Plastic and Cosmetic Surgery in the Atlanta Area by Dr. Kumar

An article in today’s Wall Street Journal refers to skin tightening procedures using either a velasmooth or a thermage. This is an excellent article which references statements from dermatologists who are either support or refute the claims. I would like to point out to the claims made by the manufacturers of these machines, minimal to no scientific basis to support the marketing claims, as well short term duration of the results (6 months). These expensive treatments are a latest marketing phenomenon to the earlier endermologie. I would like the public to consider whether there expectations will be met (short term as they are not a cure) with these expensive treatments which may also be painful.

Similar claims for cellulite treatment have been made by physicians and nurses performing lipodissolve and liposuction. The underlying “pathology” is the abnormal placement of fat close to the skin with skin attachments which cause it to compartmentalize and give it the characterisitic appearance. Lipodissolve, liposuction, endermologie, as well as the above mentioned treatments may cause short term improvement by causing swelling and the skin appearance to change. As the swelling subsides in 6 months, the cellulite will most likely return. In my opinion, the only and best treatment is for skin excision to tighten the skin. Liposuction will not achieve this as it is risky to perform close to skin due to contour abnormalities and it will not break thru the attachments of the skin to the underlying tissue. While this does entail a surgical procedure with longer scars and greater risk of complications, it also best attempts to meet a patient’s expectations (an important aspect of any procedure). The physician does have to screen the patient for smoking history, diabetes, heart disease, risk of Dvt’s, etc to make sure that it is a safe procedure also.

I recently obtained a free subscription to Men’s Outdoors magazine. I guess they want to increase their subscription by sending it to physician’s offices since patients may often wait a long time for the physician. I mention this as I saw an article on six pack abs or abdominal liposculpture for men. The article touts only one machine, the Vaser, for this procedure and interviews only physicians who use this machine. It gives me the impression that it is a paid advertisement by Vaser. I wonder if the author or the magazine received money or free treatments. While I do not refute the results, similar results can be obtained by other liposuction machines. Similar marketing pitches have been made by Laserlipo. Again, this is an expensive machine and guess who is paying for the extra expense of the machine. The patient. I will efer readers to my earlier blogs where I have discussed that in our discussion at a local hospital among the plastic surgeons on staff, the general consensus was that the different machines were great for marketing but similar results could be obtained by a basic liposuction machine used in conjunction with tumescent fluid and an experienced plastic surgeon.

In returning to the article, I will caution readers again to view such marketing material with a critical eye. Also, there is no mention of risks, complications, and recovery time is a snap. While this is often true with regular liposuction, there are still chances of complications and there is actually increase risk of complications with an ultrasonic machine. Also, the claim regarding skin shrinkage with Vaser also holds for a regular liposuction machine. Even postoperative bruising, swelling, as well as recovery time is similar for different types of liposuction machines. In conclusion, the marketing claims for the liposuction also hold true for a regular machine liposuction which is much cheaper. Please do research, consult with a board certified plastic surgeon, stay clear of marketing, and use your own critical judgement.

Recently, one of our patients who had been undergoing infertility workup underwent liposuction. During the consultation, the patient stated that she had once before become pregnant following liposuction procedure and was hoping to repeat it again. During the consultation, I did state that I am unable to make such a claim or any guarantees. After discussion with an infertility specialist, I was told that liposuction can cause a decrease in insulin as well as androgen hormones. This can be more pronounced in a patient with polycystic ovarian syndrome. Again, I was advised that while this is theoretical, it is difficult to put it to practice. In this case, the patient was extremely excited.

As per a recent Dear Abby column in the Atlanta Journal Constitution for Women’s Health Week, the FDA assistant Commissioner for women’s health has a letter with free offer of a Health an dBeauty Kit with information about making informed choices about cosmetics and other beauty products.  It is available from either www.pueblo.gsa.gov or Health / Beauty Iformation Kit, Pueblo, CO 81009 or 888-878-3256 8-8 EST.

While I am not sure about the contents of the kit and am sure that most of the information is available on the web, it is still nice to have information in an organized fashion.  For interested readers and consumers, this is a good toolkit for further information to help in the decision making.

As spring is passing us and summer is almost here and we are enjoying the outdoors, please be careful and protect your skin.  Although this is also true if you are into winter sports such as skiing, more people are involved in summer sports including activities by the pool, lawn care, etc.  While the first step is sun avoidance, this is difficult and the next step is to use sun block.  While it is difficult to go into the details of different active ingredients in sun block, please use sun block religiously as it is much easier to prevent  sun damage than to reverse it.  Sun damage can be viewed with a wood’s lamp and most dermatologists and plastic surgeons have the lamp available.  Some may even have fancier contraptions for the same purpose.  Recently, Wall Street Journal and Consumer Reports have had great articles and recommendations and I will try to find them to summarize over the next few weeks.  Also, if you are outside, please cover your skin with clothing, caps, and visors along with sunglasses for your eyes.

For those with sun damaged skin, a good regimen to follow is to use gycolic acid to exfoliate skin and Retin-a (vitamin a ) to improve skin vasularity.  Over time, this regimen has been shown to work well athough some may find that retina is irritation to the skin.  It should be used at night, even at the lowest concentration and started every other night, along with a sun block during the day time.  A variant to this is the Obagi skin care system which does have its proponents and also has shown to work well over time.  Obagi also works well only with Retin-a (iso tretinoin ) and does do a decent job of reversing sun damage.  Other adjuntive treatments include chemical peels, lasers, dermabrasion for skin resurfacing.  Last but not least is to stop smoking if you do smoke and also avoid second hand smoke.

Recently, we had a plastic surgery meeting at a local metro-Atlanta to evaluate liposuction machines.  Although the reps were there for the ultrasonic , laser, and power assisted machines, we were unable to test all the machines.  Most of us had experienced with the the regular, power assisted, and the ultrasonic machines and agree that we can obtain excellent results with a regular machine and benefit from the ultrasound machines when dealing with scar tissue or tough breast tissue.  The latest machine is the laser liposuction machine which is very expensive.  We were unable to appreciate whether the extra expense to the patient (any increased costs for machine is passed on to the patient) will be worth the benefit to the patient.  We did realize that it will be a great marketing tool for the patients as patients have increased information and marketing available but are unable to discern whether the new technology shows clinical improvement or is plain marketing.

Since the meeting, there was an article in the Wall Street Journal(March 4, 2008) regarding the same topic and titiled “Laser Liposuction Lacks Clear Advantage.”  The journalist interviews both the chief executive of the laser manufacturer as well as physicians and one does quote that is is a “marketing gimmick to get people through the door.”  A study quoted in the article in which the physicians performed laser liposuction in one leg and regular liposuction in another leg did not demonstrate improved results.

I advise the public to be critical of new technology till there are good studies performed to show a clear benefit and not to get caught in the marketing hype.  Besides the increased expense of the procedure, I do not know of any disadvantages of the procedure.

I hope that this information is helpful in providing insight into laser liposuction, and marketing of new technologies.  I would recommend regular liposuction unless performing liposuction in the areas mentioned above.

Recently, I was made aware of a New York Times article (January 2008) regarding a group had filed a petition with the FDA for a stronger warning label as well as a letter stating its potential risks be given to patients. I will like to make two points regarding this NYT article.

Botox is presently being injected by most medi-spas with heavy competition as well as marketing. This can be experienced in most large metropolitan cities including New York, LA, Dallas, Houston, Atlanta, etc. Most of the clientele are healthy individuals and thus the market would dictate that any complication will come to light and shine in media. In the New York Times article, the Botox was injected near the esophagus causing eating difficulties and in patients with other neurologic deficits. This is different from the cosmetic patients where a previous neurologic condition is a contraindication to treatment with Botox. Most of the complications from botox can be either asymmetry due to migration or allergic reaction. Even blindness is only rarely reported and hopefully stays that way. Patients getting botox for cosmetic reasons have a high satisfaction rate with many coming back every three to six months for repeat injections despite the ever increasing costs of Botox cosmetic. The injections can be painful but results are remarkable and noticeable with in 1 to 3 days and thus the reason for the popularity of Botox.

Another point is about the petition for more labeling as letters detailing risk. This is where the provider need to convey to his or her patients. In our office, we go by the consent provided by the American Society of Plastic Surgeons, an organization of Board Certified Plastic Surgeons. This consent itself takes me 5-10 minutes to discuss with patients and lists in more detail than most physicians would normally discuss by themselves. It almost scares the patients from obtaining the injections were it not for their previous experience at a different place. Most of my patients come because of dissatisfaction with their previous injector and is usually word of mouth referral. During the consultation, the consent is covered in detail by me and includes all contraindications such as allergies, pregnancy, neurological disorders as well as potential risks. A copy of the consent is also provided to the patients. Once the patient does not have any further questions, the procedure is performed and the patient is asked to follow up for any reason that they are not satisfied. Again, in a competitive market where the price cuts are aggressive, the patient has to be cautious. Injectors may not spend enough time to explain the consent in detail and to patient’s satisfaction and the consumer had to make sure that they are happy with the explanation as it is a mild toxin that is being injected into their body. All my patients have voiced that they would rather I cover the consent in detail and a few have stated that the last place of injection did not handle the consent in a responsible manner.

In conclusion, the actions of new warning labels as consent letters to patients stating risks of Botox are already the actions performed by Board Certified Plastic Surgeons for their cosmetic patients. As a service to the public, further labeling may enhance the safety concerns but the public has to be wise and consider Botox Cosmetic to be an injectable drug and separate it from a product bought at a mall cosmetics counter.

Tips For Patients:

1. Discuss the risks, complications, alternatives (surgical options are available) and pricing prior to injections. Obtain a copy of the consent form for later reference. Ask if followup as well as touch up is included in the initial price.
2. Discuss your goals and what bothers you. Do not get caught caught in marketing and try with areas of face that cause most concern to you. Botox works for moving wrinkles and lines caused by muscle contraction. It may not affect deep lines or static lines which may require fillers to fill in the defect.

3. Avoid aspirin, NSAIDs, high dose vitamins, and herbals for 10 days prior to the injection to decrease the risk of bruising.

4. Icing the both before and after the procedure may help in reducing the bruising or if bruising does happen, icing will shorten its course.

Dr. Kumar,

There is some questions that have been bugging me every since I learned about the “brazilian butt lift” procedure. If you can liposuction fat and inject it into the buttocks for a rounder shape, etc. can you also inject fat into the breast for a similar result instead of using silisone or saline implants? I ask because, I would love to have larger breasts, but I don’t like the idea or implants. Also, does breast lift make breast look bigger? Or just more perky? How soon can I go back to work if I get breast lift and gluteal fat grafting? What does a consultation consist of? Will I be “pressured to buy”? Will I be treated rudly if I decide not to get the procedure or if I decide not to get it right away? will I need to lose weight before surgery? I’m sure as I go along I will have more questions. Thank you for responding to my initial query so quickly. Hope to hear from you soon.

Answer your questions:
1. Fat grafting can be performed to the buttock area since there is no problem with cancer in the buttock region in women whereas fat injected in the breast region can look line cancer on mammograms and cause confusion or even require unnecessary biopsy. The psychological impact of not knowing is huge and not worth the procedure. It is a highly controversial topic and I will not recommend fat grafting to the breast.

We have advertised these specials in Creative Loafing and would like to place it on my blog also. These expire on 12/31/2007

Botox $200/ area

Breast Augmentation (Saline) $3700 (Silicone) $4785 (includes surgeon’s,or,anesthesia fees and implants) The surgical procedures are performed at fully accredited hospital surgery centers: Emory johns creek or Gwinnett hospital to ensure patient safety.

Juvederm: $450 plus free makeup kit

Restylane $400

Radiesse $600

Lip enlargement with fat graft $750

Laser Hair removal : free chemical peel and treatment with package

Hair transplant offers-$7 / follicle

Mens Breast reduction for Gynecomastia with ultrasound liposuction (best results)-call for pricing

Gift cards available

Our practice is north of Atlanta in Johns Creek area, in between Alpharetta, Duluth, and Suwanee (North Fulton County) Georgia. We have been open for 5 years and perform most of the plastic surgery procedures at Gwinnett Hospital in Duluth, Emory Johns Creek Hospital, or Northside Hospital in Forsyth. We do perform small procedures including liposuction and hair transplant in the office. We do this to ensure patient safety and the above facilities have special rates for cosmetic surgery which are better than any in the Atlanta area. The patients benefit in two ways: Safety at great prices. In fact, combined with these low rates and our low surgical fees, we are competitive with most board certified plastic surgeons in the U.S and hope to post our rates on the internet before 2008.

As for Dr Kumar, that’s me, I graduated from Woodward Academy in College Park, GA and finished my undergraduate at University of Georgia, majoring in Economics and Pre-Medical. I graduated from Medical College of Georgia with an MD, and finished a General Surgery residency at Brookdale University Hospital in Brooklyn, New York. During this time, I did a one year research fellowship in Plastic Surgery at Emory University. I finished my Plastic Surgery training at Medical College of Wisconsin in Milwaukee, WI. After returning to Atlanta and passing my written and oral board exams, I became board certified in Plastic Surgery. I have been concentrating on different aspects of cosmetic surgery and recently focusing on body contouring (breast augmentation, tummy tuck, and liposuction) and facial enhancement (surgical and skin care). Some of the other areas have been gluteal augmentation(brazilian buttock lift), contouring following bariatric surgery, and breast lifts. Our clientele span the entire range of the atlanta area including caucasians, asians, african americans, and latin americans.

Our philosopy is to keep it simple: Listen to the patients in order to meet their expectations and ensure their safety. Give the patients the information so they are comfortable in deciding for themselves and guide them with the various options and minimize the effect of all the marketing and hype seen on the television, internet, and print. Every surgeon shows their best results only and it is the surgeon’s role to guide the patient and discuss the good and the potential bad. Shopping through the web is great if you are buying a new ipod but you should interview your surgeon personally just as he or she will interview the patient during the consultation. We would like to treat every patient and offer the same advice as we would to our own family. This is the way all physicians should guide their patients. Ultimately, we are in a service business and happy patients are our best marketing tool. Please do not hesitate to call or write to us for any questions and if you are in the Atlanta area, call to shedule an appointment.

Fat grafting has recently become very popular and a good alternative to soft tissue fillers. Most of us have plenty of fat available. Depending on the amount and location where the fat graft will be placed, it can be performed under local anesthesia. We have seen good results with fat graft to lips, facial areas, and buttocks. In fact, one of the latest fads, brazilian buttock lift, relies on fat graft to increase volume and projection of the buttock region without the risk of implant infection. It is a very popular procedure and with good results.

Lip augmentation with fat graft also has a good result and can be often done in the office. The recovery is longer than Juvederm or Restylane but the results are pretty close to permanent. Bruising lasts for a few days. Other areas of the face can also be grafted.

Fat grafting to the breast region is controversial due to the difficulty in detection of breast cancer. Fat cells may produce mammographic findings similar to early breast cancer and make it difficult to diagnose and require biopsy. These were presented at the recent ASPS meeting in Baltimore, MD. Also, the results that were presented were for smaller augmentations of around 250 cc or less (per MRI) and most of the patients that I see and implants that I place are over 275 cc. Due to the controversy and smaller augmentation volumes, I am not recommending it to my patients at this time. This information is posted for patients desiring fat grafting and especially for patients in the Atlanta area looking for alternative to soft tissue filler and who are tired of paying high prices for each syringe, you may want to consider fat grafts. This can also be combined with botox. We are located in Johns Creek / Duluth / Alpharetta area.