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During a conversation with a 26-year-old lady last weekend, I mentioned my profession (including my web writing for plastic surgeons) and she said, “I don’t think I’ll ever need cosmetic surgery… but maybe I’ll get Botox when I’m older.”

I wondered when exactly she would decide she was “old enough” for Botox.

That perfect age probably comes when you have disposable income and those frown lines start to become very prominent – though surely there are exceptions to that rule. According to Bay Area plastic surgeon Sirish Maddali, “many patients understand that using Botox at a younger age can be preventative and therefore start earlier.”

How many young people decide to take these early steps to preserve their appearance? Lets look at some 2008 statistics from the American Society of Aesthetic Plastic Surgery:

2,464,123 Botox treatments were performed

• 0.3 percent of patients were 18 and under
• 15.4 percent of patients were 19-34 (379,582 procedures)
• 49.1 percent of patients were 35-50
• 27.3 percent of patients were 51-64
• 7.9 percent of patients were over 65

Draw your own conclusions about these stats, but the number of treatments chosen by people under 35 is undeniably large.  Are you in that age group and have you undergone a Botox treatment?  Tell us about your experience.

Like many cancers, the treatment for breast cancer has gone through its evolution.  Surgical treatment in the beginning and well into most of the 20th century consisted of the radical mastectomy.  This procedure involved removal of the breast, pectoralis major muscle and all of the lymph nodes of the axilla or armpit through a large incision.  This was usually followed by chemotherapy and high dose radiation that left the patient severely cosmetically deformed.  This initial “cure” lead to severe upper extremity lymphedema (that was untreatable), late destruction of the chest wall ribs and death due to the initial treatment or it’s complications.

In the mid-1960’s the modified radical mastectomy came into existence. This surgery involved removal of everything that the radial mastectomy did except the pectoralis major muscle.  As minimal as it may seem this was a huge surgical advance and allowed for much better reconstructive possibilities.  This surgery was the standard of care well into the 1990’s.  But in the late 70’s and 80’s innovative surgeons introduced the skin-sparing mastectomy that removed the nipple areola complex and used a much smaller incision.

Finally, in the mid-1980’s the nipple sparing mastectomy was introduced.  However, as with many procedures the indications for its use had to be determined and therefore it was not widely used.  Finally we have understanding and indications for its use.

The nipple sparing mastectomy is the greatest advance in breast cancer surgery.  We have gone from removing everything associated with the breast and chest wall to only the breast tissue.  This leaves the nipple areola complex, an excellent breast skin envelope and all of the muscles of the chest wall.   In addition it may or may not be combined with a sentinel lymph node dissection.   The incision for the nipple sparing mastectomy can be as short as 6cm, hidden in the inferolateral inframammary fold or breast crease (see the picture).  This incision is only one centimeter longer than an incision used for a primary silicone breast augmentation!  With this surgery an immediate breast reconstruction may be done with an acellular dermal matrix and tissue expander or permanent breast implant.  I do not use a permanent breast implant in this setting because the final result will never be as good as a two-stage procedure using an expander first followed several months later by exchange to the permanent implant.

So why don’t we always do this fantastic surgery?  The reason is tied to anatomy.  Invasive ductal breast cancer means that the cancer has started in the milk duct of the breast and has spread through the duct into the surrounding tissue.  All ducts are connected to the nipple so theoretically there could be cancer cells in the nipple.  Remember this is only theory.  Therefore current dictum (and lack of tort reform) states that all of the breast tissue and the nipple areolar complex should be removed to remove any possibility of recurrence.  Therefore the current indications for nipple sparing mastectomy are really limited to DCIS (ductal carcinoma in situ), prophylactic mastectomy or non-cancerous breast disease.  DCIS is cancer that has not mutated enough to become invasive through the milk duct wall.  Given time it will.

Ten years ago DCIS was not considered cancer, but since we now know that if given time it becomes invasive cancer, then by definition it must be cancer (just not invasive).  Other researchers and surgeons believe that the nipple sparing mastectomy should be considered even for patients with invasive cancers of less then 2cm in size, located at least 2.5cm from the areola (see indications).  While this remains to be determined what is important is that we have outstanding surgeons like Dr. Virginia Chiantella, of Reston VA that are on the forefront of breast cancer surgery.  Few surgeons can perform a thorough and complete mastectomy through such a small incision.  It is this level of understanding, skill and caring that allows plastic surgeons like me to give patients, like our 31 year old, breasts that are imperceptible from normal breasts.

1. Hip fat is healthier than tummy fat. Fat around the hips, thighs and buttocks may work advantageously against heart and metabolic diseases. In contrast to tummy fat, hip fat burns slower, thereby releasing fewer pro-inflammatory cytokines, hormones that are linked to heart disease and diabetes. Also known as visceral fat, this dangerous fat lies closer to vital organs, whereas subcutaneous fat is situated closer to the skin and is more visually accessible. A pear-shaped body typically carries less dangerous visceral fat and more subcutaneous.

2. Better Fat redistribution is in the works. There are procedures intended to redistribute fat and turn an apple into pear.  But aside from aesthetic benefits, it’s difficult to say if doing so would allow you to realize the purported health benefits.

3. What your body wants: protein and exercise. Citing studies conducted on the effects of training on waist size, medical researches advocate incorporating at least 30 minutes of physical activity five days per week, and two days of strength training; and cutting calories by 500 to 1,000 daily. Also important is to eat 25 grams of fiber and 60 to 70 grams of protein daily. Added protein and strength means more muscle and less fat.

4. Love the curves you have and strive for your idealized self. Before and after plastic surgery, diet and exercise remain the key to maintaining your figure and your health. Combine a healthy lifestyle with body contouring and you may be able to have your cake and eat it too. Literally.

Related Links

• BBC News: Big Bum, Thighs is Healthy
• Body Shape, Fat Distribution May be Predictor of Health Risks

Today I had a consultation with a lovely couple.  The wife and patient is a  31-year-old mother of two young children.  During a breast self-exam (which I hope all women do but know they don’t so do it) she noticed something very slightly different in one of her breasts.  She saw her doctor, who sent her for an ultrasound evaluation of the breast.

Just to clarify, young women typically have very dense breast tissue.  This is why mammograms aren’t done in younger women; it’s very difficult to see any pathology or disease through the dense tissue.  If there are any concerns, an ultrasound is the first test performed.

The ultrasound was performed and read by a radiologist as normal.  Fortunately, this radiology group uses two radiologists as a sort of checks and balances system.  The second radiologist, either due to experience or intuition, suggested that the patient get a mammogram for clarification.  The mammogram confirmed the doctor’s suspicions, something irregular, was there. Our patient was then referred to a breast surgeon, Dr. Virginia Chiantella.  Dr. Chiantella (can-tell-a) is well-trained and performs outstanding breast surgery.

Now just take a minute.  Think about the whirl-wind that this woman was undergoing.  She was living a normal, happy, suburban life one day and in a very short period of time she’s going to see a surgeon for a potential cancer.

Just take a moment and put yourself in that position.

There aren’t enough adjectives to describe the feelings that would go through your mind and body.  But our patient is tough. Tough, like so many other women in this situation, because she has to be-children don’t understand when mom is sick.  And the thought of your own children having to grow up without you will drive any parent to do what is necessary.

Dr. Virginia Chiantella MD FACS, is incredibly talented, smart and caring.  She performed a needle biopsy on our patient.  This involves using a needle to take an actual piece of breast tissue.  The pathologist determined that the this tissue contained cancer, DCIS (Ductal Carcinoma In-Situ).  Now when I was a resident physician DCIS wasn’t considered “cancer” but over the course of time and multiple studies we know that this is the first stage of invasive breast cancer.  In addition, because of her young age and an extensive family history of breast cancer, gene testing was suggested.

Gene testing looks for damaged BRCA 1 and BRCA 2 genes.  These genes are in the class of tumor suppressor genes.  What they do is produce proteins that go out and repair DNA that has been damaged.  Like a power company fixing a power line-they either repair it or replace it. Damaged DNA, if not fixed or removed, will proliferate as the cell it is contained in multiplies.  There are lots of these gene in our DNA that protect us from cancer and other diseases.  The problem is that these genes, like any gene, can become damaged and not able to perform their duties.  When this happens cancer occurs.  When these damaged genes are present they can increase the possibility of breast cancer as well as other cancers AND be passed onto offspring in their damaged state.  Our patient got tested and her results indicated….

To maintain their appearance, many people turned to non-surgical cosmetic treatments over the last year. The market seemed to magically respond in 2009 with new product choices and expanded FDA clearance for existing products.

The following is a guide to the most popular injectables, ordered based on their relevance.

Click on links below for related blog posts about each topic and FDA approval summaries.

Continue reading ‘Hess Plastic Surgery 2010 Guide to Injectable Treatments’

Cytori Therapeutics announced today that FDA approval was granted for their PureGraft System, an autologous fat grafting device the company says will “allow a patient’s own fat tissue to rapidly be prepared in approximately 15 minutes for re-injection back into the same patient for aesthetic contouring.”

More information on Cytori Therapeutics.com

Read more about fat grafting in Fairfax, Virginia.

Okay I have my bottle of wine, a Valium and the encouragement from my therapist who says that talking about my mother is therapeutic.  Hmmmmm.  I’m just kidding, mixing Valium and wine-that’s just crazy.  Don’t get me wrong, this is no celebrity “I blame my mother for everything,” sob story.  My mother did the best she could with the skills she had and I think I turned out just fine (but hey we all think we’re fine).

Mom grew up the daughter of a teacher/homemaker and an industrial engineer whose specialty was time management.  My grandparents were cold Germanics who ran their lives to the second and raised children to be the same.  My mother went to Syracuse University for fine arts (it was this or Home Ec. believe it or not).  She and my dad started dating in high school and got married immediately after graduation.  Ah, life in the 50’s.

My parents “wedding” story explains a lot.  Mom and dad decided to elope.   My guess is that dad had no money, mom and grandma would have killed each other and they were born in the depression so my grandfather wouldn’t pay for something that had no return on investment.  So mom and dad were driving to the courthouse and stopped at a red light.  My mother turned to my father and said, “You never asked me to marry you!”  Dad said, “Will you marry me?”  Mom replied “Yes. Light’s green.”  Do you feel the love?

During my childhood my mother and I had a close relationship which was fostered by my participation in theater (she also did a lot of community theater).  As early as age seven or eight mom had me trying out for small parts in various community theater productions.  Now don’t misunderstand this, my mother was no “stage mother.”   She was simply finding me an activity that I enjoyed and would keep me occupied for a few hours a week, I think.  And I enjoyed performing eventually getting paid parts.  But mom has a strong narcissistic personality trait that leaves little room for anyone else.

Our relationship was very good until… can you guess?  Anyone?  Yes, I got married.  Apparently this did not fit into mom’s vision for me?  Who knows, but what I do know is that the criticisms and complaints began in earnest and haven’t ceased.  But I will give credit where credit is due.  When my ballet career (yes you’ll hear of this later) was ended in a severe accident my mother, with her infinite wisdom said, “You never finish anything.”  Ah, okay?!  Yes, she saw the end of her vicarious life but that statement has driven me in every endeavor since.

I don’t begrudge my mother; she’s a product of her upbringing.  People can change if they choose to; as I have.  My father has worked very hard to show that he cares about my family, especially my children, and all of his children.  We all have that person in our lives that we hope will change.  Never give up on them.  You never know when change may come.

Q: What is Latisse?

A:  Bimatoprost ophthalmic solution 0.03% was initially developed and used for over 10 years as a glaucoma medication.  In using the medication many patients noticed that their eyelashes grew.  Many even had to trim their lashes due to excessive length.  Allergan, who owned the medication, began to market the medication for topical use in patients with hypotrichosis (small lashes).  The new medications name is Latisse.

Q: How long has Latisse been on the market?

A: Latisse has been available for over 6 months.  But its safety record, as an eye drop solution, is well over 10 years.  Any medication that is used in the eye must be very safe.

Q: Why do I need a prescription for Latisse?

A: Many women exhibit hypotrichosis or reduced amount of eyelash growth.  Latisse can result in eyelash improvement of 105% in thickness and over 25% in length.  Latisse has been approved by the FDA as a prescription medication and not an over-the-counter medication.

Continue reading ‘Latisse Eyelash Enhancement Q & A With Dr. Hess’

Making a good decision about plastic surgery depends on having all the necessary information.  So before you get that long-awaited breast augmentation, tummy tuck or laser treatment, you need to get all the facts.

Why should I research my procedure?

1. You can discover which surgeries are consistently satisfying and which are not.

2. You find out if plastic surgery is truly a good fit for you by comparing the risks and benefits with your personal values and goals.

People are often looking in the wrong places for legitimate answers to their plastic surgery questions. It’s best to get scientific and objective information from authoritative sources.

Take the scholarly approach

Visit your local Fairfax public library or better yet – your university library.  The academic resources and peer-reviewed medical journals you’ll find are going to have real data on surgery complications, rates of patient satisfaction, and other crucial info.

The drawback: many of these articles and books will be written in a style that only doctors and med students understand – you might find that extremely boring.

Browse the right websites

Yes, it really is a jungle out there, but there are a few sites that publish honest, useful information about plastic and cosmetic surgery. RealSelf.com is a great start; Dr. Hess is very active on that forum. Yourplasticsurgeryguide.com is another popular resource.

The drawback: You find a great deal of conflicting (and sometimes vague) information, sometimes making your decision more difficult.

Ask plastic surgeons in your area

Visit a few before making a choice and know that board-certified plastic surgeons should be looking out for your wellbeing.  They don’t want you to have a bad experience; they want to get you the best possible results and avoid complications. If a procedure would put you at risk, a good surgeon will tell you honestly.

Email Dr. Hess if you need to.

The drawback: A plastic surgeon can tell you if you’re a suitable candidate, but only you can decide if surgery is in line with your personal values.

There’s no doubt about it, I am no “private person.”  You ask me pretty much anything and I’ll tell you.  I’m strong in my personality and convictions so I’ve got nothing to hide.

Many physicians take great care to never discuss their personal lives with patients.  And while it’s true that there must always be a professional doctor-patient relationship that doesn’t mean that we physicians can’t be human and interact with patients on a more personal level at times; I love swapping stories about children with my patients.  This is especially important with cosmetic patients.

As many of you know, my approach to patients is first educating them on the available options then working together to create the ultimate aesthetic outcome.  As part of this process, I like to know who the patient really is.  And I’ve found that without a more personal understanding of my patient it’s more challenging to determine exactly who they are and what they desire.  But maybe it should be a two-way street.  My webwife, Eva, and I were talking and we thought that maybe we should level the playing field and let my patients know who I am.  Well here goes.  If you have insomnia you can thank me later.

I was born a poor….

Okay, sorry for the only Steve Martin line, I know.

I am “the baby” of my family (this explains a lot, you’ll see).  My father, a retired chemical engineer from the oil industry has been married to my mother, a graduate of Syracuse University in fine art (remember this later), for 50-something years, God help them both.  They have four children all but one in engineering or business.

Then there’s me – the one.  The baby of the family is well known to be extroverted, spoiled, the entertainer, type A, blah, blah blah.  Is that me? Okay, ya got me.  But I’m only a product of my upbringing and I suspect a mother who was living somewhat vicariously through me.

I honestly think my mother wanted fame and fortune but she married the wrong guy for that.  My father is a very smart, hard working, minimally exciting only child who was the first in his family to go to college.  My grandfather died when my dad was only 18 so with a very small loan (interest bearing) from my grandmother and the work-study engineering program at Drexel University dad made it happen.

But I have to give my parents huge credit because they’ve lived through things I never had too.  My father’s first job in 1956 paid $100/month.  Their rent was $80/month.  Anyone who can stretch $20/month with a newborn is pretty impressive.

Of course, the apartment they lived in was more likely on the condemned list than Better Homes and Gardens.  In fact, things were so bad that my father would put the legs of my brother’s crib in cans and fill the cans with kerosene just to keep the cockroaches out of the crib.  Yeah, I get the willies just thinking about it too.   But my parents were industrious and really exemplify the saying “you make your own success.”

Still awake?  It’s later.

Then there’s my mother….