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

A recent Wall Street Journal article on Tuesday, August 19, 2008 titled “The Latest Cellulite Treatments Sound Too Smooth to Be True” may be correct in its play on words. I have many patients that come in for other procedures but always ask regarding cellulite treatments and which ones may be the best. As the article points out, quite a few of these new and expensive treatments are getting FDA approval but clinically ineffective longterm. Even the FDA spokeswoman interviewed for the article mentions that they do not have any data on how long the treatment lasts. NBC, People Magazine, or CBS will not tell you this on their promotional shows. The clinical trials themselves are performed by the investigators with financial ties to the manufacturers. During my plastic surgery training, I did research endermologie which is also marketed for cellulite. This procedure involves a machine with rollers which is supposed to loosen the connective tissue attachments of the skin to underlying tissue. These connections are supposed to cause cellulite or the appearance of it. Endermologie treats this short term by causing swelling in the skin and decreasing the appearance of cellulite. However after 5-6 months, the swelling resolves and the appearance of cellulite returns. I would caution to stay away from the marketing claims of the new machines whether they are for liposuction, cellulite, skin resurfacing, etc. Many of these treatments cost thousands of dollars and the criteria a consumer should use is whether your expectations will be met. If the answer is 15-60% then you may not be happy with the result whereas a rate of greater than 70% will most likely meet your expectations and make you happy. Often, the pictures as well as the claims may not be accurate. Finally, the treatment that may work best but not liked by many consumers is actual skin excision to tighten the skin and reduce the cellulite. This does result in scars but also treats the condition.

I see quite a few patient’s express during consultation that they are not sure of what choices to make in deciding cosmetic procedures.  This is perfectly normal.  As a cosmetic surgeon, my first question usually is “What brings you in?”  If a patient has a list, I will usually focus on the things that affect the patient most and go over the entire list during the remainder of the consultation.  Most surgeons could discuss different procedures, risk, complications for hours.  So to improve communication and decrease confusion, I feel that I should focus on the main issues or concern that brings a patient to the office.

Next, I try to find out what a patient’s expectations are regarding the change desired with cosmetic surgery, recovery time, pain, and any planned trips or vacations.   Following my examination, I will provide information regarding the  procedures which will meet patients desired goals.  This discussion includes the technical procedure including why I think it will work, risks, recovery time, pain level, and return to work.  I try to give several options as I feel that everyone is different and a single procedure will not work for every person.  Prior to departure, a financial estimate is provided.

During the visit, our purpose in the office is to fulfill our customers needs by providing the most up to date information customized for the the specific person without any pressure or marketing tactics.  I strongly believe that by providing the best service and meeting patient’s expectations is the only way to ensure a happy patient.  I also advice anyone considering cosmetic surgery to please meet your plastic surgeon, check their credentials to make sure that they are board certified, and finally the surgeon should make you feel comfortable.  They should listen to your goals prior to making recommendations.  I have mentioned above the main principles I try to follow so that I can provide the best service for my patients.

The article appeared recently in Wall Street Journal,”Europeans Take Beauty Trip to U.S.,” touting the advantages for  Europeans, mainly price, as the dollar is much weaker than the Euro.  I want to point out disadvantages and advantages for prospective clients.  First, the disadvantages:  You will need to travel by air to a distant place and stay with either relatives or in a hotel.  You should discuss with the surgeon prior to emarking on the trip regarding the procedure that you are interested in and even emailing pictures for a telephone consultation.  While this may not be the deciding factor, it can help the surgeon know your expectations and also acquaint you to the surgeon’s thinking.  The recovery will be also at a different place and the length depends on the planned procedure.  Of course this can vary if there are complications.  None of the surgeons will harp too much on this prior to the procedure but they do sometimes happen.  Follow up may require another trip, and the length of stay again can depend if any touch ups are needed.

There are several advantages also.  I say this because the medical system in the United  States is geared towards full disclosure (transparency) which seems to be different than the South American or even the European system.  This may be due to the liability issues and most surgeons feel best about relating to the patient both the limitations as well as any complications of the procedures.

A big advantage is the availability of plastic surgeons certified by the American Board of Plastic Surgery which only accredits surgeons who have had adequate plastic surgery training, kept up with continuing education, and are ethical.  The criteria is even more rigorous as new standards are put in place.  Thus I encourage everyone to use this criteria as the main guiding point for selecting a plastic surgeon.  Another criteria to use is where the surgery will take place.  This should be preferrably in a hospital based surgery center or the surgeon should have an accredited facility.  Longer procedures should be performed  in a hospital based center with the availability of other services if the need arises.  Anesthesia should be performed by an anesthesiologist.

Other advantages include cheaper travel, hotels, and food in the United  States.  Certified nurses as well as other help is also available readily over the past 5 years.  With  the mortgage turmoil, I am sure that house rentals are also increasingly available.

One advice to offer to prospective patients is to stay clear of marketing gimmicks such as different lasers or newer procedures which have fancy names invented for marketing.  While minimally invasive surgery is preferred, I would ask the advice of a board certified plastic surgeon regarding your expectations and which technique is best suited.  Many other medical specialties are performing cosmetic surgery and call themselves cosmetic surgeons and are boarded by different board specialty.  But make sure to check out their board with the american board of medical specialties (ABMS).

Lastly, I would like anyone considering plastic surgery to consider  Atlanta as it does have the busiest airport in the world with direct flights from Europe.  My office is located in Johns Creek, GA which is about 45 minutes north of Atlanta but with an international population as many of the major international corporations are based in this region.  I am director of Plastic Surgery at Emory Johns Creek Hospital and perform all aspects of facial enhancement, breast surgery, and body contouring.  Lodging, food, nursing, as well as domestic help can be easily arranged.  I have had patients from Germany and England who have been satisfied.  I also have some testimonials on youtube as well as my web page.  For any questions, concerns, comments, please email me at info@riversidepsc.com

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.