plasticsurgeryblog

New Website

I've finally started updating borud.com which was sorely out of date in terms of, well, everything.  I'm asking viewers to be patient, as new material is being added every week.  My practice is now about 80% body contouring, mostly after weight loss.  There's much to blog about, so much happening in our field that will benefit patients.  Check the blog from time to time for new posts.

Welcome to our Annual Meeting!

Our largest national organization, the American Society of Plastic Surgeons, started its annual meeting today in Chicago.  Most members of the public really never get an inside view of events like this, so I thought I would make some comments on my impressions of the convention.  OK, I so I admit it's not like blogging the democrat national convention, but here goes.  I'm here with my office manager, Jennifer Forgione, and many other members of our team at BIDMC and Harvard.  Today, the meeting was convened by Dr. Scott Spear, who has been the ASPS president for the past year.  Our keynote speaker was Justice Sandra Day O'Connor, who spoke about the history of the court and some of its more flamboyant figures.  Tomorrow is the real first serious day, and I'm sure there will be much to report.  Big topics this year are war-time plastic surgery in Iraq, post-bariatric body contouring, face transplants, and new cutting-edge technology. 

HIV Lipodystrophy

Certain anti-retroviral medications commonly used for HIV treatment can cause significant alterations in fat distribution.  No one really knows for sure exactly how this works, but some areas tend to atrophy and others tend to hypertrophy.  Some areas on the face, including the nasolabial fold area and other parts of the cheek, frequently are plagued by lipoatrophy - that is, wasting away of the fat, which can cause an emaciated, ill, or notably unusual appearance.  It's hard to treat this with collagen and most other "fillers" because large volumes are needed, and they are temporary - lasting 3-12 months.  We are now starting to use AFT (autologous fat transfer).  In other words, we use the patient's own living fat - taken from the abdomen or elsewhere - and then transplanted to where it is needed.  The drawback is that only a percentage of the fat survives, and only a relatively small amount can be transplanted in one sitting and be expected to survive.  Thus, multiple stages are required.  The positive is that whatever fat survives is permanent - at least, we think so.

On the left are photos before AFT.  On the right is one year later, following three rounds of AFT.

Closing a Big Hernia

Sometimes, after gastric bypass and other abdominal procedures, a large hernia can result.  This is an uncomfortable bulge in the abdomen around the previous incision.  Most methods of fixing the hernia use prosthetic (plastic) mesh of some kind.  Although this is OK, the mesh can sometimes get infected, extrude, or become palpable or uncomfortable.  It can also move or tear away from the native abdominal wall muscle, resulting in a recurrent hernia.  So, in about 1990, some plastic surgeons devised a way to close the hernia by expanding the native abdominal wall - which contains 3 muscle layers.  One of the muscle components is separated from the deeper two, which are left intact.  I've adapted this procedure a bit and have developed a special technique for use in gastric bypass hernias.  Many patients of mine have been asking how this works, so I filmed a recent case, and am putting some video clips on the blog to illustrate.

Download CompSepForWeb.wmv

Breast Augmentation Without Breast Scars

The use of video- assisted endoscopic surgery is widespread in many areas of medicine. For example, very few gallbladders are removed the "old fashioned" way through large incisions. Large incisions in the abdomen can be avoided with more minimally invasive techniques. We are now applying these techniques to cosmetic surgery to allow us to place scars in more favorable locations. In the past, breast implants usually meant scars on the breasts themselves. Now, some plastic surgeons are placing breast implants in the usual position (i.e., under the pectoralis muscle) through small incisions in the axillae, thereby avoiding any scars on the breasts. Because the endoscope provides such an excellent view, placement of the implant can be very accurate and can occur with minimal bleeding even though the incisions are in the armpit areas. The two photos on the left show postoperative results from a recent patient of mine using this technique, compared with preoperative views on the right.

Off Shore Plastic Surgery

This afternoon, we just saw a patient who had complications from an abdominoplasty done in the Dominican Republic. Today, the New York Times is reporting a series of infections in just such patients - those going offshore to obtain cut-rate cosmetic surgery. Sure, complications happen everywhere. But some of the outcomes that I've seen from off-shore surgery demonstrate very unusual complications that are more a reflection of incompetence than bad luck or bad protoplasm.

Post-Gastric Bypass Radical Body Contouring

When I was a general surgery resident in the early 90's in Los Angeles, I assisted on some of the early gastric bypass procedures for weight loss. At that time, I remember thinking that we had a lot of surgical complications, and that the anesthesia seemed dangerous. The procedure was thought of as "radical", and was undertaken in only the most extreme supermorbid obesity cases. I really never thought it would catch on. Well, I was wrong. Since then, advances in surgical technique and anesthesia have made it a common, everyday procedure at many hospitals with a fairly acceptable complication rate. More importantly, it's no longer perceived by the public as some radical, extreme measure and has gained widespread acceptance in many communities. Pop singers like Carnie Wilson have undergone the procedure with great success. Over 100,000 such procedures were done in the US in 2003. Sure, it's still a real operation with serious risks, and there are the occasional well-publicized disasters.

In my experience, patients lose weight for about 1.5 years, and then plateau at a new "set point," and fail to lose any further substantial weight after that. This is the time for plastic surgery consultation. When I'm taking their histories, I'm always astounded at how the procedure has changed their lives. "I'm not on those blood pressure meds anymore and my diabetes has gone away" is a frequent scenario for these patients. So what about all of the excess skin left on the now-shrunken body? That's where plastic surgery comes in. Last year, over 52,000 post-gastric bypass body contouring procedures were done. These kinds of procedures are very commonly performed in our practice, and in the days ahead we will go over the "real deal" on these procedures.

Dog Bite Case

This 55 year old female suffered a dog bite from an Italian greyhound that she was temporarily caring for. The injury and the recovered segment of lip are shown in the right two panels. Sometimes tissue fragments such as ears and lips can be replanted, if it is possible to reconnect their blood supply under the microscope. Unfortunately, the amputated lip had no satisfactory vessels and we could only close the wound (2nd photo). Several months later, the scars remain (left hand photo).

Real Plastic Surgery

At cocktail parties, plastic surgeons are favorite targets for tipsy partygoers. "What could you do with my nose?" "Should I have botox?" It's evident to most of us in the profession that the public equates plastic surgery with cosmetic surgery. No wonder. Nearly every media story involving plastic surgery focuses on aesthetic procedures. So it was refreshing to see Reuters carry a story about ear reconstruction among Iraqi victims of abuse and torture at the hands of Saddam. Ear amputation was a common form of punishment, meted out to an estimated 3500 victims. Surgeons are now beginning the complex task of reconstructing these ears, which generally requires multiple stages of fairly complex procedures. I couldn't help but draw an uncanny parallel. Historically, all plastic surgeons know that the first plastic surgery operation is credited to Sushruta, an Indian surgeon from the 7th century BC, who developed a technique to use forehead skin for nasal reconstruction. Why did so many noses need reconstruction in ancient India? Infection or trauma? No. Rather, because nasal amputation was a common form of punishment in those days.

Dog Bite Awareness

When I was at Bellevue Hospital training in plastic surgery, I saw a number of severe dog bites. The most memorable was a 9 year old boy who was playing with a neighbor's pet - a dog very familiar to the child from extensive previous contact. Without provocation, the dog (a german shep) attacked the boy, resulting in severe facial lacerations and multiple facial fractures. The teeth actually crushed the bones of the midface. This led me to study dog bites in New York, which I discovered were events that all physicians are supposed to report to the Dept of Health. We are now entering the time of year when dog bites are most common, according to the study data. Children are the most common victims, and the face and extremities are the most common sites of injury. Certain breeds are frequent offenders, even when properly raised and known to the victim. A reporter from the New York Post called me about the article yesterday, so it has been on my mind. I hope that some more publicity stimulates public support for: breed-specific legislation, leash laws, criminal prosecution for violations that result in injury, as well as more public education initiatives about precautions and proper breeding. I'm considering posting some photos of dog bite injuries in the next few days.