GENERAL CONSIDERATIONS

If the surgery is reconstructive in nature – that is to improve health or correct a severe deformity – a person is never too young to have surgery. For instance, if a child sustains a laceration, the parents may decide that the child needs stitches even if the child cries in protest. A similar situation arises for a child who has a cleft palate or a cleft lip. Surgery is appropriate. A slightly trickier situation is that of a 5 year old child with prominent ears. The parents believe that the child will be teased by their classmates when they begin to attend school and want to have the ears surgically set back. This would make it a reconstructive operation and I believe that the parents would be acting appropriately.

These cases involve decisions by parents for young children. What about a teenager who wants to have cosmetic surgery like breast augmentation? First of all, any patient in the state of California who is under the age of 18 must have their consent for surgery signed by a parent or guardian (who will hopefully exercise good judgment in the matter!) The law also states that silicone implants cannot be used until the person is over 21. Even if this law was not present, I think that it is important that the person be sufficiently mature to make a decision about changing a body part that may influence them to engage in inappropriate behavior. The American Society of Plastic Surgeons of which I am a member has an official position against breast augmentation for most teens under 18. I would add that cosmetic surgery at such a young age may encourage a person to develop an unhealthy preoccupation with their bodily appearance.

What about liposuction? Although there is no law governing the minimal age at which it can be done, I would again be concerned that cosmetic surgery at such a young age may encourage them to have an unhealthy preoccupation with their bodily appearance. There have been recent media reports of young girls undergoing liposuction at the request of their parents to correct areas of excess fat. I think that unless this is medically indicated, this type of thing encourages surgical body shape alteration that would be better done by life style alteration that includes more exercise and attention to proper dietary habits. Furthermore, the body of these pubescent females is changing and liposuction may be found to be unneeded if additional time is allowed for physical maturation. In these cases of young women considering cosmetic surgery, I also think it wise that their pediatrician or mental health provider also be consulted as to the wisdom of surgery.

PROCEDURE SPECIFIC CONSIDERATIONS

Let’s look at some specific procedures and age considerations.
• Breast reduction for young women and gynecomastia excision for young men are often requested. My opinion is that not only should the patient be sufficiently mature to make a decision, but several years should have elapsed since any significant growth of the breasts has occurred.
• Nasal surgery should be avoided until facial bone growth is complete, something that has usually occurred by the mid to late teens. Earlier surgery can damage the growth centers in the nose that can lead to significant nasal deformities.
• Breast reconstruction in young women who have major degrees of asymmetry between the two sides should normally be deferred until the patient’s breasts have stopped growing for two years. Otherwise the patient may find that her breasts continue to grow after surgery and the deformity returns! This surgery will usually involve a combination of augmentation and lifting. Unless the deformity is severe, I think it wise that the patient be of age 18 or older for the reasons I mentioned above.

What do you think?

Should you have any further questions, please contact my office.

George Sanders, M.D.

A recent blog on NewBeauty.com (4/26/12) listed 5 breast implant myths. These are “truths” about implants that have crept into the public mind and that are generally believed to be true. The reality is that most plastic surgeons would consider them to be untrue. Here are the myths. What do you think?

1. Saline filled implants are safer than silicone filled implants.
2. Under muscle is more natural than over the muscle.
3. You cannot breast feed after breast augmentation.
4. Natural breast augmentation with fat is better than breast implants.
5. You need breast implants for a breast lift.

There is a certain degree of truth to each of the 5 implant myths listed above. Let’s examine each:

#1 Saline is safer than silicone – It all depends what you mean by safe. If you never want to have an MRI or wonder if your implants are leaking (since a saline implant will disappear from view if it does leak), then you might consider this to be true. The FDA, however, considers both types of implants to be safe, an opinion that has been borne out by years of scientific investigation. The current silicone implants are made of a very cohesive gel that causes the silicone to stick together, even in the event of a leakage. As a result, silicone spreading throughout your breast or body after a leak is highly unlikely.

#2 Under muscle is more natural looking than over the muscle – In a slender patient, this is usually true! What are my colleagues thinking?? An implant in front of the muscle tends to give a flat look in the upper chest that then suddenly juts forward where the implant starts. On the other hand, if the implant is behind the muscle, the upper portion of the chest fills out a bit more and the transition to the lower area where the implant sits is far more natural. There is also less wrinkling of the implants when they are under the muscle that results in a more natural look. More importantly, most doctors who interpret mammograms would consider the under muscle location to be superior for mammographic interpretation. Many believe that you’ll miss fewer breast cancers that way.

#3 You cannot breast feed after breast augmentation – This is false. Most patients who can breast feed before surgery can also do so afterwards. The fact is that many patients cannot breast feed before surgery! You maximize your chances of being able to breast feed after surgery by opting for an incision other than the one around the areola. The incision beneath the breast is the most popular option.

#4 Natural breast augmentation with fat is better than implants – This could be considered as true if you want to avoid implants at all costs. The reality is that fat injection for breast augmentation is a new procedure that may have problems of which we are not yet aware. For starters, 50% of the fat tends to dissolve. Furthermore, fat injection tends to produce a relatively flat and wide breast, something that many patients do not like. They prefer the narrower and more projecting look that implants can produce.

#5 Breast implants are needed for a breast lift – A breast lift alone will usually not produce the desired degree of upper breast fullness on a long term basis that a breast lift plus an implant allows. If upper breast fullness is not a priority for the patient, an uplift alone may work beautifully! On the other hand, many patients find that with an implant only, there is still some lifting of the breast, and they can still have some lifting and avoid the additional scars that an uplift requires.

Should you desire further information, please contact my office.

George Sanders, M.D.

Lips are a focal point in a beautiful face. Women have been enhancing them since antiquity by both surgical and non-surgical means. Lipstick, lip liner, lip tattoo, and lip augmentation with injectables are all non-surgical, whereas lip implants and lip lifts are popular surgical treatments. Although the non-surgical means are well-known, let’s look at the surgical options.

Lip implants of today look like giant, but very soft, toothpicks. Currently I am using PermaLip implants that are made of a very soft and pliable rubbery material called Silastic. These are permanent and do not need to be touched up every few months like Juvederm injections. In the past a variety of substances were used for lip implants, including injecting silicone liquid or your own fat, as well as inserting Alloderm (from cadaver skin) or GoreTex (a fabric-like material). PermaLip implants seem to be a much better solution to the need for lip enhancement than these other options because of their softness and permanence.

Lip lifts can be done in a variety of ways. One of the most popular techniques shortens the upper lip with a small scar hidden in the natural crease at the base of the nose. As aging occurs, the upper lip will lengthen, covering up your upper front teeth. By taking out some skin at the top of the upper lip and hiding the scar in the crease at the top of the lip, a rejuvenated look is obtained.

Another way of lifting the lip is by taking out a snippet of skin just above the corner of the mouth. A downturned corner of the mouth can be lifted, giving the person a cheerier look. Although a small scar results, this is usually well hidden in the natural crease line in the area and allows you to avoid something as major as a facelift that also lifts up the corner of the mouth. Botox injection into the depressor anguli oris muscle located just below the corner of the mouth decreases the downward pull of the muscle on the corner of the mouth, allowing for an uplifted look. The injection is only of several months duration, however, and can sometimes alter the smile in an unattractive way.

Should you desire further information about any of these procedures, please contact my office.

George Sanders, M.D.

Do remember the TV ads of the 60’s and 70’s when Madge, the manicurist, soaked her clients’ hands in Palmolive dishwashing detergent before she did their nails? The soap’s bright green color was unmistakable as was the message – “As you wash the dishes, your hands benefit from Palmolive’s amazing rejuvenative powers!”

There is no question that hands are one of the areas that women wish to keep looking as young as possible. They are involved in handshakes, displaying important items of jewelry, and holding the hands of special people. Moisturizing creams, sun screens to block harmful sunlight, and lasers to fade away brown spots are all part of the arsenal that medical science has put at our disposal.

But what about the backs of hands that have lost the pleasing smoothness of the fat of youth? Virtually everyone will find that they lose fat over the back of their hands as they grow older. As a result, the veins and tendons become much more noticeable, giving an aged look. By injecting the area with filler, there can be an excellent filling in of the hollows, giving a significantly rejuvenated look. Of all the fillers, Radiesse is my favorite because of its duration. The injection is very well tolerated and the results last for one to two years in my practice. Very little bruising and swelling is encountered since only a single point is injected with the Radiesse and the Radiesse is then massaged so that it fills in the entire back of the hand.

Fat injection is another alternative filling technique, but this involves a minor surgical procedure with fat being taken from a donor site and then being injected into the back of the hands. I find that there is more bruising than with the Radiesse injection and that the fat may not last any longer than the Radiesse since fat does not last as long in areas where there is a great deal of motion such as the hand.

Should you have any further questions, please contact the office.

George Sanders, M.D.

When a woman becomes pregnant, there is usually significant stretching of the skin of the tummy and breasts. Depending upon skin elasticity, the skin either shrinks back into shape or sags after pregnancy. There are also changes going on beneath the skin surface – the breast tissue may shrink or enlarge, and the abdominal region may suffer from a stretching apart of the muscle that produces a perpetual pooch and/or fatty accumulations may occur.

All of these issues can be addressed with surgery and which one(s) a woman chooses to address will determine what procedures are needed to restore her to her pre-pregnancy condition. This surgery is termed a “Mommy Makeover” and may include liposuction of the hips / pubic region / sides of chest, tummy tucks of the limited and traditional variety, breast augmentation with or without uplifts, breast uplifts alone, and even breast reduction. Depending upon which procedures are chosen, a woman can choose to look just like she did before children or to improve on what she started with. Most “Mommy Makeovers” will involve both breast and tummy surgeries since both of these areas are affected by pregnancy.

When is the right time to consider “Mommy Makeover” surgery? Once the woman has stopped losing the weight she gained with pregnancy and her breasts and tummy have stopped changing, surgery may be considered. That may occur in as little as 2 or 3 months after childbirth. It’s also a good idea to plan for no more children for the foreseeable future. That’s a good time to visit with the plastic surgeon and discuss goals for surgery and make plans for any additional weight loss before going through with the surgery.
Depending on which surgeries are selected, the recovery process usually requires about 2 weeks for recovery at which point that the woman can drive a car and care for her children. Although heavy lifting should be avoided for 6 weeks following a tummy tuck if it involves muscle tightening, women can carry and hold children by 2 weeks after surgery in most cases.

For further information please contact my office.

George Sanders, M.D.

A California appeals court ruled last month that Certified Registered Nurse Anesthetists (CRNA’s) no longer need to be under the supervision of an M.D. This was a clear victory for CRNA’s, as well as rural hospitals in California that have complained that requiring physician supervision of CRNA’s added unneeded costs and limited the range of surgery services they could provide. This was also a further recognition of the fact that CRNA’s are so well-trained and that the current anesthesia delivery systems so “precise” that CRNA’s are able to deliver extremely safe and unsupervised anesthesia without input from a supervising M.D.

Just to make the difference between a CRNA and an anesthesiologist clear, a CRNA is a Registered Nurse who completes their nursing training and then does several years of additional training in anesthesia. On the other hand, an anesthesiologist is an M.D. who has graduated from medical school and who then does additional training in anesthesia.

I am very comfortable with the use of CRNA’s as anesthesia providers in my office surgery center. For the past 26 years I have had a wonderful experience with the excellent group of CRNA’s who have provided anesthesia for my patients, including my own family members. From time to time patients request an anesthesiologist, and my experience with them has been equally excellent. If a patient has significant medical issues, I recommend that their surgery be done in a hospital and that an anesthesiologist provide the anesthesia. But for the patients in my office who, by my choice, are all in good to excellent health, I personally believe that either a CRNA or an M.D. anesthesiologist is an excellent choice.

It’s interesting to note that nationwide, studies have shown that the anesthesia complication rate is extremely low for either type of anesthesia provider. The bottom line is that the anesthetic agents currently available, the equipment used to deliver them, and the standardization of the method of delivery has made anesthesia an extremely safe venture. The overall death rate from anesthesia per year in the United States is only 1 in 5 million. That’s 10 times less than the risk of being struck by lightning!

So the Bottom Line is this: There is no such thing as a bad choice when it comes to the type of anesthesia caregiver used in an office surgery center. Of course some individuals are more skilled than others, and I make sure that our patients have only the best to choose from.

Should you have any further questions, please contact my office.

George Sanders, M.D.

As we head into spring and summer, the quest for a golden tan heats up! Not only do many people believe that it looks good, but it’s also thought to be healthy. Beautiful it may be, but healthy it’s not! A tan is the skin’s protective response to exposure to harmful ultraviolet radiation. By increasing the amount of melanin, the skin is attempting to block more ultraviolet radiation from passing through and causing damage to cells and the supporting collagen and other material. This increased amount of melanin shows up as a tan.

Is there a way to get a tan and not harm yourself?

• Tanning beds are not the answer as they are simply a man-made source of harmful ultraviolet radiation that induces a tan. Tanning beds made news headlines in October 2011 when Governor Jerry Brown signed a law that prohibits most teenagers from using tanning beds at tanning facilities in California. Interestingly, Brazil has banned tanning beds altogether!

• Spray tans offer a safe option. According to the American Academy of Dermatology, the most effective sunless tanning products contain dihydroxyacetone (DHA) as the active ingredient. DHA is a colorless chemical (it is derived from glycerin) that interacts with the amino acids in dead skin cells to produce a brown color change. Since these dead skin cells are constantly being shed, the color change produced by DHA usually lasts about five to seven days. These repeated applications could make this a rather pricey alternative.

• Sunless Tanning Creams allow you to apply a tan in the privacy of your home. Neutrogena Build a Tan, Clarins Self-Tanning Gel, and Estee Lauder Self-Tanning Towlettes are among the top rated products. Each has its advantages and disadvantages including an odd smell, rubbing off on clothing, and the several days required to reach a peak tan.

• Certain medications do stimulate melanin production. Scenesse ® is currently undergoing clinical trials in Europe for treatment of certain medical conditions that render the patient extremely sensitive to sunlight. It’s packaged in the form of an implant the size of a grain of rice that is implanted beneath the skin and apparently works for 3 months. If it is approved in Europe, it may eventually find its way across the Atlantic.

Here’s wishing you a “tanless” yet tanned look this summer!

George Sanders, M.D.

The most important advantage to these new implants is that they are available with a “form stable” silicone gel. The “non-form stable” gel implants are widely used in the United States today and include the MemoryGel Mentor Implants that I use in my practice. The MemoryGel is thicker than the gel used in previous generations of breast implants, but the gel used in the new Sientra “form stable” implants is even thicker, giving the implant the nickname of the “Gummy Bear Implant” because it feels a bit like the candy well known to many of us and our waistlines! These form stable implants are widely used throughout the rest of the world, but have not been commercially available in the United States until the introduction of the Sientra implants earlier this month.

What are the theoretical ADVANTAGES to this form stable implant offered by Sientra?

• Shape – “Non-form stable” fillers such as saline and standard silicone gel will change shape according to the forces placed upon them by the breast when they are inserted for breast augmentation. In contrast, form stable fillers will maintain their shape and in so doing, change the visible shape of the breast.
• Folds and Rippling – An implant consists of FILLER such as silicone or saline that is contained within an elastic, rubbery, clear cover called a SHELL. Since the thicker, form stable gel doesn’t shift around inside the shell like regular silicone gel, we don’t see the type of folding and collapsing of the implant shell that occurs with the older style of implants. This makes for less rippling that can be seen or felt with this newer type of implant.
• Decreased Leakage – As just explained, these newer implants don’t seem to fold as much owing to the form stable gel. Since most leaks are thought to arise from cracks in the shell that occur along folds in the implant shell, it would logically follow that one would expect to see a lower leakage rate in these form stable implants. This is what has been found in scientific studies, including one involving several thousand patients in Sweden. Even if the shell does crack, the “thick” nature of the form stable gel holds the gel together, making migration of the gel away from the implant and into the surrounding tissues less likely.
• Capsular Contracture – Some patients with breast implants will develop scar tissue contracture around their implants, producing a firm feel to the implant that may be uncomfortable and deforming. This occurs less often with the form stable implants according to studies performed in countries where these implants are used.

What are the theoretical DISADVANTAGES to these form stable implants?

• When a relatively stiff implant such as these form stable devices is placed within the breast, the implant may not contour to the shape of the underlying rib cage as well as do the traditional silicone implants. As a result, the edge of the implant may tend to lift up off the rib cage and produce an edge that can be felt or seen along the inner edge of the breast.
• Excessive Firmness – Because these are firmer implants, the breast may feel firmer with them in place. How firm will depend upon things such as how much breast tissue overlies the implant and how large of an implant has been used relative to the amount of breast tissue.
• Rotation – Textured implants are more apt to rotate than smooth implants because the body tends to produce a layer of fluid that surrounds the implant. If a shaped implant, also known as a “tear drop” implant, is being used, this rotation can produce an odd look. One can avoid this problem, however, by using round implants.
• Illness? – As I discussed in my February 2, 2011 blog (http://www.drsanders.com/blog/?p=13&replytocom=6321),
there is concern over the rare development of ALCL in certain women with breast implants. As studies go on, it would appear that virtually all of these women have textured implants in place. Furthermore, women with textured implants seem to be more prone to develop fluid around their implants that may require aspiration or even implant replacement.

As these form stable implants are used, more information will become available which will clarify the situation. I will be revisiting this topic in future blogs.

Should you desire further information about this topic, please contact me at my office.

George Sanders, M.D.

“We have nothing to fear but fear itself,” is a paraphrase of what Franklin Roosevelt actually said in his 1st inaugural address after winning the 1932 presidential election. He actually said, “The only thing we have to fear is fear itself.” The United States was in the midst of the Great Depression and Roosevelt acknowledged the existence of these serious financial difficulties, but his point about fear was that folks were preoccupied with the financial problems, yet their solution was easily within grasp.

What do people fear most today? 200 years ago, hell, the plague, and rabid dogs would have probably topped the list. With a decline in a belief in the reality of hell and with the introduction of antibiotics and vaccines, other fears have arisen. A 2001 Gallup Poll lists the top 10 fears as follows:

1. Snakes
2. Public Speaking
3. Heights
4. Being Closed in a Small Space
5. Spiders & Insects
6. Needles & Getting Shots
7. Mice
8. Flying
9. Dogs
10. Thunder & Lightning

I’m relieved to see that doctor visits were only #12! It’s also interesting that the fear of dying is not on that list. I guess that death doesn’t seem that immediate for most of us.

What do folks who come to a plastic surgery office fear most? I have compiled my own list based on 26 years of patient interviews.

#1 “ I will look unnatural “– Patients base this on the appearance of certain celebrities who have had plastic surgery and who look very unnatural. They reason that if these folks who can afford the best look the way they do after surgery, what on earth is going to happen to the ordinary person!
My reply – Look at the person who referred you to the office or at my before and after photos available on line or in the office. Do any of these people look unnatural? Quite frankly, it also puzzles me as to why some of these celebrities look the way they do after surgery. The reality, however, is that the plastic results you notice the most are the poor ones. The good ones look so natural that they are difficult to detect!

#2 “ I won’t wake up from surgery and who will take care of my kids then! “
My reply – The most dangerous part of your operation is the drive to the office on the morning of surgery ( Assumption: the average drive is 20 miles). This is not to disparage your spouse’s driving abilities, but is simply a fact when you consider the death rate from traffic accidents versus the death rate from anesthesia. That’s for all anesthetics for all patients. The anesthesia I employ in the office is very light and our patients are much healthier which will further lower the rate of anesthetic problems. The overall death rate from anesthesia per year in the United States is 1 in 5 million. That’s 10 times less than the risk of being struck by lightning! I think that helps to put things in perspective!!
(http://www.meretrix.com/~harry/flying/notes/safetyvsdriving.html , http://www.videojug.com/interview/general-anesthesia-2)

#3 “ I won’t like the result.” – This is a variation of #1.
My reply – I believe that information is the answer to this. I use imaging techniques as well as verbal and visual explanations to help the patient gain an idea of how their desired change is apt to turn out. Of course, I don’t have a crystal ball, but experience helps me give the patient what is usually an accurate idea. Sometimes patients decide that the surgery is not for them based on these discussions. That is a very good thing to find out ahead of time, I believe!

#4 “I will lose my job after surgery and will need the money to live on!”
My reply – Fortunately that sort of thing is fairly rare, although the recent recession does give one pause! The good news is that folks who are the most attractive have the most success in landing good jobs. So go for the surgery! If you need to find a new job, your chances will be even better!!

What are some reasons that you, your family, or friends fear plastic surgery? Let me know by clicking on the link below.

As a plastic surgeon, I am quite familiar with the fundamental importance of involving the patient in surgical planning to make sure that the surgical result agrees with the patient’s idea of beauty. If the patient is not happy with the final appearance, then all is for naught! An article in the March 2012 edition of Plastic and Reconstructive Surgery explores this issue in those patients who are of Indian heritage (not the Native American kind) and who seek to have cosmetic nasal surgery. Often times these Indian patients wish to retain a bump over their nasal bridge. In a series of 316 patients, only 10 complained of their hump, far less than one would find in a similar series of American patients of Northern European heritage. An Indian surgeon explained, “In our country [India], a large hump may be well accepted but even a slight depression in the dorsum is a major concern. The stigmata of a depressed nose and leprosy is still deeply rooted in the minds of the general population.” Leprosy destroys the tissues that support the nasal bridge, resulting in a depressed “saddle-nose” deformity. Lepers are social outcasts because of the fear people have of contracting leprosy, and thus individuals considering nasal surgery wish to avoid the appearance of one who has the disease at all costs!

There are other reasons why ethnic patients seek to preserve certain aspects of their appearance that are common to members of their ethnic group but may not be considered attractive by most people. A prominent nasal hump is an excellent example. In my experience, the primary reason for this hesitation to remove the hump is that preservation of it allows the patient to look like and thus identify with other members of their ethnic group. What some may consider as an unattractive nasal hump is preserved to allow the Indian patient to continue to look Indian. Removing it may give the impression that the patient no longer wants to be thought of as having an Indian heritage. Even if the patient wishes to remove the hump, familial pressure often persuades them to retain it lest they look as though they are rejecting membership in the family and ultimately reap the ill will of their relatives. “Ill will” may become removal from the will!

To allow me to understand the patient’s desires, I will sometimes ask the patient to bring photographs or drawings to illustrate their desired changes. In the past I’ve often used what artistic talents I have to draw a picture of what I understand to be the desired result to make certain that the patient and I agree on our goal. The use of photographic imaging to morph the patient’s current photo into the desired result is a newer technique that makes use of imaging technology to accomplish the same outcome. I have made use of this technology for the past 15 years and find it to be invaluable in making certain that the patient and doctor agree on what is the surgical goal. As opposed to a patient bringing a photograph of a person whose nose they like, I alter their nasal photograph with the aid of the computer to allow them to make sure that what they are asking for looks good on their face. It’s a bit like trying on a dress to make sure it looks good before taking it home as opposed to seeing the dress on a mannequin and putting it in the bag without seeing how it fits! Imaging makes it much easier to insure that the final result is indeed, “Beautiful in the eye of the beholder!”

Should you have any questions, please contact my office.