Richard A. Baxter, M.D.

The Art Behind Plastic Surgery

Dr. Baxter Questions & Answers

 
 

Breast Implant Q & A

Are breast implants safe?

There is probably no product which has undergone more thorough scrutiny than breast implants. Because of allegations of health concerns, the safety question was reviewed in detail by the Institute of Medicine, which considered all available scientific data in addition to testimony from breast implant patients. It is interesting to note that, while silicone breast implants were restricted by the FDA from 1991 through 2006, silicone was still approved for injection directly into the eye for treatment of retinal detachment. It seems to me that if it is safe enough to inject into your eye then it might be OK for a breast implant.

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Are herbal supplements for breast enlargement safe and effective?

Could it be that natural herbal supplements are dangerous while silicone is safe? Several products have appeared over the years claiming to enlarge breasts using "safe, all natural" herbal supplements. Yet despite the marketing claims, no clinical studies have ever been published to verify either the safety or effectiveness of these supplements. An article published in the medical journal Obstetrics & Gynecology raised serious questions about both aspects. Since the intended effect of these products is stimulation of the breast tissue in a manner similar to estrogen, there is a real possibility that the risk of breast cancer could be increased. Only large scale, long-term studies could answer this question.

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Are "gummy bear" implants better?

There is a lot of confusion about the potential benefits of "gummy bear" implants, also known as cohesive implants, but most correctly called "form-stable" silicone implants (Allergan Style 410, Mentor CPG, and Sientra). These have been in use around the world for several years but only became available in the U.S. in 2012-2013. In order to understand the role of shaped implants, we need a little history: a while back, implants with a "teardrop" profile were introduced because that was believed to create a more natural shape. However, it was later shown that the round implants actually had the exact same profile in the upright position. Round implants, on the other hand, "behave" more like a natural breast and so become the most popular choice.

But there remained a concern about silicone gel leakage; what happens when the implant ruptures? The answer is basically nothing. That is because gel is a semi-solid, not a liquid. In scientific words, it is cohesive. The newer implants were called "gummy bear" implants, used that term to emphasize that the silicone is highly cohesive, meaning that you could slice into it like gelatin and it holds its form. (Hence the correct term "form-stable.") But the softer gel in round implants is also cohesive, just softer, so it may very well continue to be the more natural-feeling implant. And the form-stable implants have a further disadvantage of requiring a larger incision for insertion, so there is a longer scar.

But because form-stable implants are shaped, not round, they provide an option where the foundation of the breast aren't round. They provide a choice where the round implants may just not fit the size and projection that the patient wants. Bottom line is for a more natural result, you need to take into account your goals as well as the limitations of your existing anatomy, not make a choice based only on the features of the implant.

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Should implants be placed under or over the muscle?

There are several compelling reasons to place the implants under the pectoral muscle, which is behind the breast tissue: lower risk of capsular contracture, more thorough and easier mammograms, a more natural look for many patients, less visible rippling of the implants, and less sagging of the breast over time. The downside is a, high percentage of distortion of the breast with muscle flexion, called animation deformity. Using the traditional technique for submuscular placement of (dual plane), this occurs to some degree on more than 3 out of 4 cases. In order to achieve the benefits of going under the muscle without the common problems, I developed the split muscle technique:

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What is the split muscle technique for breast implant placement?

Basically the idea is to use the pectoral muscle to cover the upper portion of the implant, where it is most important. The difference between this and the dual-plane subpectoral method is that the split muscle technique preserves the normal attachments and function of the muscle by leaving the lower portion behind the implant. The reason for this is that the dual-plane method detaches the muscle from its attachment to the rib cage and this free edge of muscle then heals onto the scar capsule in front of the implant. When the muscle is contracted, it pulls on the capsule, causing animation deformity and often double bubble.

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Can deformity of the breast with muscle flexion be corrected?

The subfascial (or subglandular) technique generally eliminates this, but sometimes at the expense of inadequate coverage of the upper portion of the implant. A variation of the subfascial technique called the split muscle methodis often a good solution, where coverage of the upper portion of the implant is needed.

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Do my implants need to be changed every 10 years?

When the FDA approved silicone breast implants in 2006, they deemed them to be safe, but cautioned that they would need to be replaced every 10 years. This seemingly definitive statement is in fact misleading. Breast implants sold in the U.S. in fact have a lifetime warranty against leakage/rupture, and it seems self-evident that the manufacturers are not planning on replacing every implant for free within 10 years. The FDA points to a high re-operation rate (up to 40% over 10 years after implantation), but that is not the same as saying implants have to be replaced. Most of these re-operations are for conditions not requiring implant replacement or for simple size change request. In fact, we can expect most implants to last quite a bit longer than 10 years.

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What are the advantages of high profile saline implants?

High profile, round implants have a smaller diameter but more projection compared to the standard implants. My experience is that when the implant diameter matches the natural base diameter of the breast, the result is more natural appearing and there is less rippling. With the availability of various implant profiles – high. Moderate, low - we are now able to match the diameter with a choice of different sizes.

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Liposuction Q & A

What is the "tumescent" technique?

The tumescent method is a simple, but revolutionary technique, which has improved results and enabled faster recovery from liposuction since it was introduced several years ago. (I was one of the pioneers of the tumescent technique in the Northwest in the early 1990's.) Nevertheless, there is a considerable amount of confusion about exactly what it is. Basically, it involves the injection of a relatively large amount of fluid into the fatty tissue, which the surgeon plans to remove by liposuction. The fluid contains a small amount of lidocaine (a local anesthetic similar to Novocaine) and epinephrine (adrenaline.) The lidocaine helps to make the area numb and the epinephrine constricts the blood vessels so that there is dramatically less bruising and blood loss. Virtually, all liposuction procedures done today involve the infusion of fluid for these reasons. The confusion has to do with the use of the tumescent technique as the only form of anesthesia. This approach has traditionally been advocated by non-surgeons (such as dermatologists) who did not have access to surgical facilities. I believe that most patients are far more comfortable with additional anesthesia. Usually sedation, not general from a qualified anesthesia professional, since the injections of large amounts of fluid can be painful.

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What other techniques are available and how can I decide which is most appropriate for me?

It is important to make your decision in consultation with a plastic surgeon who has extensive experience in state-of-the-art techniques. There are several new technologies in liposuction, and these are often introduced with so much marketing hype that it can be difficult to separate truth from fiction. Remember that all of the current methods use the tumescent technique. So in and of itself, the tumescent technique is not really a specific method.

"Traditional" method: With the traditional or standard method, suctioning is done with a small instrument called a cannula. This is a blunt-tipped instrument about the diameter of a cocktail straw, with holes near the tip. After the area is infused with tumescent fluid, the cannula is connected to suction and the tip is inserted through a small incision in the skin. The cannula is moved continuously until the desired amount of fat has been removed and the planned contour change has been achieved.

Ultrasonic-assisted liposuction (UAL): Ultrasound is high-frequency sound waves, which can help to soften and liquefy fat cells, making it easier to achieve good results in areas where the fat is more dense (such as abdomen, hips, back, and chest.) The internal UAL method uses a specially designed probe to deliver the ultrasonic energy directly into the fat compartment. The most widely used type of UAL is called VASER. Most UAL procedures employ a combination of ultrasonic and traditional techniques.

Laser-assisted liposuction: Out of all the new procedures that have appeared over the last several years, this one has undoubtedly received the most hype. But does it really offer any advantage over traditional techniques including ultrasound? The procedure still involves injection of anesthetic fluid and requires the use of a suction cannula just like regular liposuction. The only difference is the use of a laser, which is supposed to soften up the fat and stimulate the skin so that it might tighten better. Although some studies show a measurable increase in skin shrinkage, it is not likely to be clinically significant and the use of laser adds expense and the risk of burns and scarring. Paradoxically, laser lipo has been advertised as being less invasive and safer.

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How much fat can be removed?

Keep in mind that liposuction is a body contouring procedure, not a weight-loss shortcut. And, even though the use of tumescent technique enables larger amounts of fat to be removed because of the reduced blood loss, infusion of large amounts of fluid creates a physiologic strain on the body. For these and other reasons, the American Society of Plastic Surgeons has recommended that outpatient liposuction procedures remove no more than 5000cc (about 5 quarts of fat.) Very large volumes of fat removal are much less likely to result in either long-term weight reduction or satisfactory contours.

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Are fat cells removed permanently?

The number and distribution of fat cells is believed to be determined at an early age as a manifestation of genetics. With adult weight gain, there are not more fat cells, but rather the cells expand. Also, fat cells in different parts of the body respond differently to diet, exercise, and hormonal changes. That is why the usual liposuction patient has discrete problem areas such as the outer thighs that are out of proportion to the rest of the body. Liposuction does remove cells, permanently reducing the fat "storage capacity" in specific areas. Normally, this results in more even distribution of body fat.

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How long is the recovery time after liposuction?

Generally there is relatively little discomfort after liposuction, although everyone's experience is unique as with anything else. I recommend light activity for the first 5 days, followed by gradually progression to normal routines over the next 2 weeks. Compression garments are highly recommended to be worn for 3 to 4 weeks, in order to control swelling and hold the skin smooth.

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Facelift Q & A

I don't want that "pulled" overdone look. How can you make a facelift look natural?

The best work never looks obvious, but there are several specific things that help accomplish that goal. First, it is helpful to understand that a facelift is more than pulling skin tighter. It's really a 3-dimesional operation that reshapes the face in a youthful way. The layers under the skin, needs to be elevated in a vertical direction. If you look at the oblique view of a "before & after" you will notice the S-shaped curve of the cheek that results.

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How can recovery time be minimized?

Most people are simply too busy to hide out for weeks after a facelift and don't want to have to explain to everyone they see that they had "a little work" done. Facelift techniques have improved a lot, but one thing that remains true is that a longer operation always means more swelling. The reshaping of the deeper tissues, as mentioned above, needs to be done with precision and minimal manipulation. You will still need to "hide out" for a week, but by the end of the second week, most patients are comfortable being out and about. Perhaps with a little camouflage makeup.

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I don't want visible scars. Is a short-scar technique an option?

A facelift isn't just one operation done the same way on everyone. Just as an artist has a palette of colors, there is a menu of techniques and variations that enable the facelift to be customized. All of these are designed to have very inconspicuous scars but as a general rule, the shortest and best-hidden scar that gives ideal results for that specific patient is used. Some of these have clever-sounding names, implying that they are some kind of dramatic improvement and render the 'standard" facelift obsolete. There are indeed some great improvements, but I would advise an extreme degree of skepticism regarding trademarked facelifts, which may have more to do with marketing than anything else.

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Is there really such a thing as a nonsurgical facelift?

In a word, no, but that hasn't stopped the term for being widely used. That's because a true surgical facelift is a reshaping operation, not simply tightening skin or adding volume with injections. There are some good options that don't involve surgery, they just do something different and calling them a facelift tends to inflate expectations.

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What is the best age to have a facelift, and how long does it last?

Of course there's no simple answer to this, but when done in younger years (40's to early 50's) the skin is generally in better condition and so the results may hold up better over time. Also for a younger patient, the change isn't as obvious to everyone and more often a short scar technique is a good option. On the other hand, for someone a little bit older, the change is more dramatic and some may find that more worthwhile. As for how long it lasts, a facelift isn't really a temporary benefit. Think of it as turning back the clock.

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