Plastic Surgery Newsletter
  September 2010

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Terry L. Hand, M.D.
 
In This Issue
Ask The Doctor
A Great Choice For Simple Monthly Maintanence
Saline Vs. Silicone, The Battle Continues!
Motivation, Expectations and Making The Decision To Undergo Surgery
Interesting Procedure: Cheek Implants
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Schedule your no charge consultation with Dr. Hand by simply sending us an e-mail to this link or by giving us a call at
415-461-6742.

Ask The Doctor

What cosmetic
surgery procedure(s) do you think require the greatest amount of artistic skill? 

When I considered my answer for this question, I reflected back on the procedures that I see most often for another surgical opinion regarding   correction of a prior cosmetic surgery procedure.  I also considered the procedures that I personally find to be the most individually challenging that require careful and meticulous surgical technique, while constantly reevaluating variations of individual anatomy. 

The three procedures that I am most often asked to review and revise are eyelid lifts, rhinoplasty and liposuction.  I take great pride that the procedure I perform most often is blepharoplasty (eyelid lift).  As with all surgeries, great technique, surgical planning and the experience of actually doing hundreds of prior procedures is absolutely mandatory. The proper amount of skin and muscle to resect, the suturing technique, the placement of incisions and the amount of lift and fat resection all contribute to the surgical result.

Rhinoplasty made my list because rarely do I see 2 noses that are identical.  Each nose will have different issues (wideness, droop, thickness of skin, size of the nostrils, etc.)  Again, surgical experience with careful procedural planning  and patience are imperative for the surgeon.  I am continually amazed at the current trend where a surgeon takes a picture, morphs it on a computer and presents it to a patient as what the implied result will be. The surgeons skill level is the only thing that counts, not his slick computer program.  The nose is the one area of the body where a millimeter of healing or surgical change makes a huge difference.

I included liposuction because careful planning must be done to achieve symmetrical correction of not only the area that is to be corrected but also that it blends with the adjoining areas.  Great care must be taken during the procedure not to overresect the underlying fat thickness. My goal is to always create a smooth, symmetrical result as one would see in nature that blends with the rest of the body.
A Great Choice For Simple Monthly Maintenance

AHA Peel with dermaplaning: An AHA (alphahydroxy acid) peel is a procedure that the majority of our patients utilize as an avenue to refresh the skin. As a result of this peel, fine wrinkling, areas of dryness, uneven pigmentation and acne can be treated. At our office, this peel is combined in a 3 step process. The initial step is a five minute physical exfoliation of the skin by a process referred to as dermaplaning. An instrument is used to remove the micro-thin top layer of the skin. During this process, the top dead cellular layer is removed along with proteins that may inhibit the chemical peel process. A 30 percent AHA is then applied for a short duration of time. The patient may experience a slight stinging sensation that resolves after the peel is neutralized. This part of the peel helps to reduce acne related conditions by freeing impacted debris from the pores. The skin also benefits from the increased collagen response to the peel resulting in smoother and brighter looking skin. A special instrument is then used to extract blackheads and acne pimples. The third step of this procedure involves cryogenic therapy. Carbon Dioxide is applied to the face in light, circular motions. Immediately, the coolness causes an anti-inflammatory response while the surface of the skin becomes smoother. It is recommended that this peel be repeated monthly for optimal results. Unlike a facial, most patients will notice a positive change in the skin right away. Makeup can be applied immediately after the procedure. Improvements after an AHA peel are very subtle; most patients will see an improvement in skin texture and a healthier, vibrant glow to the skin. Home care products are available to compliment the prescribed skin care regime.
The cost for this procedure is $75.00 and most patients return at 4 week intervals.
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Carecredit#1

2010 has brought new government rules regarding financing.  CareCredit has refined it's programs and has a new option that will benefit most of our patients.  In the past, our office offered a 3 month same as cash option for payment.  CareCredit has revised the program so that the repayment period is now extended to a 6 months, same as cash! There is no longer a minimum charge amount to qualify for this offer.
 
Credit lines up to $25,000 are available with instant qualification and credit availability. A payment plan that gives you 6 months to pay for your procedure with no interest charges may be selected. A secure CareCredit application may be found on the financing page link below. Click on the "Apply Now" button or use our payment calculator as a means to determine your monthly payments.  Most applications are approved in several minutes and a line of credit is established that may be used over and over.

Please let Cheri or Lisa know if you need any further clarification regarding the current financing options with CareCredit or would like some assistance in completing an application. 

As always, our office continues to accept Visa, MasterCard and personal checks as well. 
 
View the CareCredit payment calculator and application



THANK YOU!

 Once again, thank you for reading our newsletter!  As always, subscribers to this letter are free to come into the office for a no charge consultation regarding surgical or cosmetic procedures.  Please give Lisa or Cheri a call for any questions or if you would like to meet with Dr. Hand.  We will look forward to hearing from you!

Schedule a consultation With Dr. Hand

 
He's back!  Love it or leave it, the newsletter is back after a great summer.   Fall usually brings our practice back to simple maintenance procedures such as Botox, dermal fillers and lasering those pesky summer freckles away. Typically, this is the time that many patients consider surgical planning for fall and winter procedures so that they are recovered for the holidays. 

This month I am including an article that  reviews the decision making  process when considering cosmetic surgery and the motivations and expectations that are realistic and those that may be less realistic when considering a procedure.  It is the policy of my practice to thoroughly educate my patient, myself, from the initial consultation regarding what I can and cannot deliver.  My staff is well versed in most procedures but I am the one that is performing the surgical case, so I should be the one that reviews, discusses and prepares the patient for reasonable expectations for every procedure. Many practices will have a surgical coordinator that "sells" the procedure, with a cursory drop in by the MD to say "Yep, you need surgery!"   I elect to skip that entire sales gimmick.  You are either a surgical candidate or not, which mandates an ethical office to sometimes discourage a procedure that will not benefit a patient. That being said, I also understand that studies show that less than 20% of what a doctor says is retained at any given time for many reasons, including information overload and stress.  I encourage any patient that is considering a procedure to take home the information I provide, thoroughly go over it and return for follow-up consultations to revisit any questions that may still be unanswered.  In my many years of practice, I have found that  good patient preparation and follow-up for almost any procedure, improves cosmetic outcome and post surgical satisfaction and comfort. 

Breast augmentation has continued to be a popular procedure with the  current trend being a return to silicone implants over saline implants.  As I review later, I prefer the shape, feel and general look of silicone and can see no reason other than surgical expense to return to saline implants as the preferred choice.

Cheek augmentation with an implant is a beneficial procedure if done with an artistic eye for facial balance.  I find that my patients that have simple aging facial changes but have never had any issue with their facial balance, can generally be corrected with a midface lift that is performed at the same time as a lower lid blepharoplasty.  If cheekbone projection was always a facial quality that the patient felt was lacking, a reasonable sized implant often makes a profound difference.  The goal is always to create a natural appearing, balanced face. Later on I have included detailed information regarding this procedure.


All the best,

Terry Hand, M.D.
 Saline Vs. Silicone, The Battle Continues!

breasts in bra photoWhen I started my plastic surgery practice, I used one type of breast implant that  contained elements of both saline and silicone implants.  The base was silicone and there was an empty chamber that could be filled so that the difference in volume  of each breast could be individually changed to achieve symmetry. Most women do not have 2 identical breasts so that the option to change small nuances in volume and shape came in handy.  Breast implants continued to evolve though  and  those implants were removed from the market because the  shell occasionally ruptured. The plastic surgery world then embraced different implants over the years, some textured, some anatomically shaped.  I tried them all and found one universal truth.  I could predict that 5% of my patients would encounter contraction of the capsule surrounding the implant and there seems to be no difference in saline vs. silicone regarding contracture.   And the big prediction, I could not predict what my individual patients preference would be.  The final choice often seemed to be one based on budget vs. my recommendation for the better implant.

Connie Chung came along and announced that breast implants were bad, bad, bad.  The result of her sensational reporting was silicone breast implants were removed from the market, copious research and studies were performed, and multiple lawsuits were filed by industrious legal firms.  Saline implants were immediately branded as the "healthy" choice and silicone implants were demonized.  Then the scientific controlled studies came in, multiple studies showed that there was no truth to the vigorous and untrue reporting Ms. Chung initiated and silicone implants were once again available with all implantations tracked and studied for complications.  Both silicone and saline implants were available except for this time they were 4 times more expensive and several of the manufacturers stopped producing implants.

So now where are we? Breast implant shells have improved tremendously over the years with very few implant ruptures in the current generation.  I have patients that have had ruptures within 5 to ten years of implantation and I have patients that are 20 years postimplantation that still have soft, natural breasts.  The companies that are currently producing implants have extensive warranties for implant replacement. I do recommend that any patient considering this procedure recognize that the initial implants will probably need to be replaced sometime in the distant future. 

What about the pros and cons of each product?  My general recommendation is for silicone implants because they have a much more natural appearance and shape.  Particularly on women with very little natural breast tissue, the appearance of rippling is minimized and I believe the simulation of natural breast  tissue is more achievable.  The only con I would find for this product is the higher price point for the actual implant.  I am generally able to use the same incision size and  insertion point for both silicone and saline implants.  Saline implants only pro in my opinion is the lesser price.  The cons for both products are few with the risk for contracture or deflation being identical.

See preoperative and postoperative breast augmentation


Motivation, Expectations and Making The Decision To Undergo Cosmetic Surgery

There are very few factors in your plastic surgery decision that are more important than your expectations of what your surgery will mean to your life. Unmet and unrealistic expectations can be the factor with the most potential to wreak havoc on a plastic surgery patient's emotional well-being.

Physical Expectations

First, there are your expectations of the physical outcome of the surgery: Will everything look the way you envision? Are you expecting perfect symmetry (which, as any plastic surgeon will tell you, does not exist in the human body)? How much imperfection can you live with after the amount of time, money, and pain you have invested in having the procedure? Are the scars more prominent than you expected? Is the difference not as dramatic as you had hoped?

Here is where it is important to give healing a chance. Swelling is part of your body's way of repairing damaged tissue. Therefore, you will be swollen---perhaps more so in some areas than in others---which can make it difficult to have faith in the final outcome of your procedure. In fact, in some cases, swelling may keep you from seeing your final result for up to one full year. Try not to be distraught over the long wait. After all, you made it through the first 20 (or 16, or 40) years of your life with your old nose. You'll make it through the healing period with a puffy version of your new one.

As for incision site scars, contouring irregularities, and bruising---yes it can be very disconcerting to look like a hit-and-run victim, even when you have been warned and you understand that it is temporary. However, many patients aren't truly mentally prepared for the sight of themselves in this condition, and the reality can sometimes bring on painful pangs of buyer's remorse...but tough it out, and I promise, it will get better.

Psychological Expectations

Commonly stated good reasons for seeking cosmetic surgery include the following:

  • "I want to do it for myself."
  • "I look into the mirror and I don't recognize that person."
  • "I feel young, I exercise, but I don't look the way I feel."
  • "People keep telling me I look tired or angry."
Ill-advised reasons for seeking cosmetic surgery include the following:
  • "My husband/wife/girlfriend/boyfriend is leaving me. I'm looking for a boost."
  • "My husband/wife has died and I'm looking for a pick-me-up."

Here are some things to think about before undergoing surgery, so that your "after" experience can be a smoother transition:

It is very important to be honest with yourself about why you want to correct a certain part of your body. You may be doing it for reconstructive purposes, either because of congenital defect or that developed as a result of trauma or injury. Or, you may be doing it to slow the aging process. In any case, here are some questions to ask yourself about wanting cosmetic surgery and remember: be honest!

  • What is your motivation? Do you think your spouse will love you more? Or, are you doing this for yourself?
  • Ask yourself: What is it about that flawed part of my body that I want to correct and why? When did I start thinking about cosmetic surgery? Was it because I wanted to do something about it or was it because someone else made a remark?
  • What are your expectations from cosmetic surgery? Are they realistic? That is, are there just slight aging irregularities that you seek to correct, or is this a way to make up for deeper issues?

It is a plastic surgeon's responsibility to assess a prospective patient's reasons and expectations before agreeing to operate. That having been said, the best outcomes will be for the patient who takes personal responsibility for his or her own reasons and expectations. So, while you're making up that list of questions to ask your surgeon, make sure you are also taking the time to ask yourself the important questions.

Interesting Procedure:  Cheek Implants
cheek implants

Many people consider full cheeks very attractive.  Weak cheeks can make your face appear gaunt, and create an aged appearance to the under-eye area.  Cheek augmentation can restore the fullness to your cheeks if it has been lost with aging, or can create the appearance of strong cheek bones if you never had them. There are many options for aesthetic cheek surgery, depending on your particular appearance, and the look you wish to attain.  The operation adds volume to the cheek by effectively augmenting the bone structure of the cheek region, enhancing the foundation of your mid-face.

Am I a good candidate for cheek implants?

If you have lost volume in the malar region associated with aging, or if you were born with weak cheeks and desire a fuller, more youthful appearance, you may be a candidate for aesthetic cheek surgery.  Some patients have used temporary soft tissue fillers in the past to achieve full cheeks, and are seeking a permanent solution.  Patients undergoing cheek augmentation should be of good health, with a normally functioning immune system.

Cheek implants procedure techniques

Aesthetic cheek surgery can be performed alone, or in combination with other surgical procedures. Multiple shapes and sizes of implants are available to fit your particular anatomy and desired change.  Depending on the areas that are being addressed, the implants can be placed through the mouth with a small incision at the gum line, or through a lower eyelid incision if eyelid rejuvenation is being performed at the same time.  Depending on the approach and your surgeon's preference, the cheek implants can be made of solid silicone or other non-reactive materials such as Medpor.  Surgically, a pocket is made for the implant directly over the cheek bone, and the implant placed.  The implant is secured either by designing a well fitting pocket, or affixing it to soft tissue or bone.  The incision is closed, completing the cheek augmentation.  Usually the whole operation takes about 30 to 45 minutes to complete, unless other procedures are being performed in addition to the cheek augmentation.

Cheek implants benefits/options

*Permanent way to achieve full cheeks(as opposed to temporary fillers)

*May easily be performed at the time of other facial surgery

*Intraoral or eyelid approach

*Multiple implant choices to achieve desired look

Other considerations regarding cheek implants

Implants add volume to the cheek, and in doing so provide a lift.  A similar effect can be achieved with soft tissue fillers, and these can be used as a temporary way to see if you would be happy with cheek implants.  A midface-lift may be the procedure of choice for middle aged patients who previously were happy with their midface appearance, but have noted a drop of the cheek rather than loss of volume.  With more advanced facial aging, there can be a combination of factors yielding the aging appearance, including bone resorption, loss of skin elasticity, and loss of volume with fat atrophy.  The cheek region may appear deflated and jowling can be present along the jawline.  In these cases, aesthetic cheek surgery combined with a facelift procedure may yield the ideal result in such cases.

Cheek implants risks

*Sensation to the cheek my be temporarily or permanently changed by the implants.

*Implants can become shifted, especially in the early stages after surgery.  Avoid contact sports until you are fully healed. 

*With the eyelid approach for surgery, retraction of the lower eyelid is possible, which may create a dry eye sensation.

*If cheek implants become infected, removal may be necessary to clear the infection.

Cheek surgery recovery process

The usual recovery after aesthetic cheek surgery depends on the type of surgical approach utilized and if other procedures are performed at the same time.  In general, from a cheek augmentation alone, you should be active the day of surgery, but your upper lip will be "asleep" similar to a visit to the dentist.  Thissensation returns overnight, and the cheeks will feel mildly sore and swollen.  Prescriptions for antibiotics and pain medicines may be provided, and you should maintain light activities.  Keeping your head elevated helps the swelling resolve sooner.  If your cheek augmentation was performed throughthe mouth, you will be restricted to a soft diet for a few days until the gums have healed.  You will rinse your mouth after eating to keep the sutures clean, and these will dissolve on their own after several weeks.  If the eyelid approach was utilized, your surgeon will instruct you on how to rest your eyes, and utilize lubricants to prevent dryness during the post-surgery swelling phase.  During follow-up visits, skin sutures will be removed.

Will cheek surgery be painful?

Most patients do not consider aesthetic cheek surgery to be a painful surgery.  There is a period of "tightness" associated with the increased volume from the cheek implant, which is worse right after surgery due to the body's normal swelling response.  Pain medications are usually only needed for a few days, and then only at night to help with sleep.

Will there be scarring from cheek surgery?

With the intraoral approach for cheek augmentation, no visible external scars should be present.  If an eyelid approach is utilized for your aesthetic cheek surgery, scars will be present under the eyelash margin. Scars in this location are usually very hard to identify, even when you are searching for them.

What are some of the short term side effects of cheek surgery?

It is normal to have a change in cheek sensation after aesthetic cheek surgery.  Right after surgery, your cheek will be "asleep" due to the local anesthetics utilized. After your cheek "wakes up", sensations maybe heightened until sensory nerves near the implant get used to their new, tighter surroundings.

What type of anesthesia will be used for cheek surgery?

Cheek augmentation surgery can be performed under sedation anesthesia, or general anesthesia,depending on the technique utilized and the preferences of the patient and surgeon.