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| Click on a frequently asked question to learn more. |
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Will I have scars? |
What kind of anesthesia will my procedure involve? |
Why do different doctors perform breast augmentation in so many different ways? |
How do you decide the right size of breast implant for me?"> |
Neck Lifts, Turkey Gobblers, Submentoplasties and Zorroplasties |
Photodynamic Therapy (PDT) with Blue Light and Aminolevulonic Acid (ALA-BLU-U) |
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Scarring in Plastic Surgery
Because cosmetic surgery is always elective, any complications are particularly distressing to both the doctor and the patient. Long after the surgery has healed, the patient will live with their incision. Since it is my wish to have a happy, successful result, I always ask if the patient has thought about the scars that may be associated with cosmetic surgery. I am often surprised to hear a patient tell me that they did not think scars occurred with plastic surgery. This is simply not true, for some degree of scar forms with every incision or injury to the skin of all races.
I always ask to see any scars the patient may have, whether caused by surgery or by accident. When I examine these scars, I usually get two predictable responses. If the scar is very fine, the patient usually attributes the result to the fact that they are not scar formers (90 percent), or that the doctor did a good job (10 percent). If they form poor scars, most often they say that the doctor was a butcher (90 percent), or that they are poor scar formers (10 percent). I suppose this is human nature, because there are so many factors which they do not understand and it is easier to criticize the doctor.
It is well known in the scientific and medical professions that the quality of healing is linked to genetic characteristics and cannot be predicted. It is also true that plastic surgeons have, through trial and error, over many centuries, discovered where to place incisions to that they are not as noticeable to the average person. But every incision, wherever placed, produces some degree of scar. Without scar, there would be no healing. I do not know any doctor who does not desire a successful outcome from any surgery. All of the doctors I know make a genuine attempt to create a perfect result with every incision. The reality is that few patients have completely successful results every time or form perfect scars every time!
A considerable body of scientific research exists on the modulating factors responsible for scar formation. In well controlled experimental human studies, in which there was meticulous wound closure in all experimental incisions, at least five common factors play a vital role in the healing process.
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Age: Older patients almost always heal with finer scars than younger patients. Without a doubt, the worst age is during the puberty growth spurt.
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Heredity: There are known scar formers amongst all races, but it is well known that the fairer the skin, eyes and hair, the better the scar. Practically speaking, Scandinavian and British Islanders heal far better and faster than Asians or Hispanics. It is common knowledge that poor scars (keloids) are more prevalent in blacks. Yet, amongst my six children, the one with the bluest eyes, the blondest hair and the fairest skin formed scars with every fall, chicken pock and surgery. I absolutely cringe every time she shows up in the office with an injury.
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Location: The face is the most privileged part of the body and facial incisions heal far better and with finer scars than other parts of the same body.
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Thickness of the skin: The eyelids (e.g., in blepharoplasty) form the most predictably fine scar anywhere on the body. The areolar skin of the breast is also privileged, and that is why I prefer this incision in breast augmentation. Even when comparing eyelid incisions, a person of Irish descent may look almost perfect in two weeks, while Asians may show noticeable stigmata for many months. A scar on the thicker skin of the abdomen (for example, in tummy tucks) often takes one to two years to look acceptable. Fortunately, this scar is placed below the panty line.
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The amount of tissue removed: In breast augmentation or rhinoplasty, for example, we simply make an incision to gain access to a deeper area and no tissue is removed. In more than 1000 nose cases I have never had a complaint about the scar. In a breast lift or a tummy tuck, huge amounts of skin and tissue are removed, and the resultant wound closure is under significant tension. Predictably, 100 percent of these patients get some degree of scarring.
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Time: It is often said that time heals all wounds, and while most of us think of emotional wounds, I am sure that the etymologists can trace thissaying to the wounds of the body. It is certainly true that time will improve all surgical scars. One hundred percent of abdominoplasty incisions will look better at five years than at one year, and at one year the results are far better than two months after surgery. Many times on the thin eyelid skin I cannot find a scar that I, myself, created many years earlier.
Finally, there is a substantial number of patients (usually young) who have never had any surgery, injuries or stitches. They do not know if they have a scar-forming tendency and, like many young people, have a tendency to believe that even if this is possible, it simply will not happen to them. I am always very careful with this group of patients lest I do not meet their expectations. I certainly do not wish to hear them explain that their scars are poor because the doctor (me) was a butcher.
If you cannot accept any scar, or if you believe that because a plastic surgeon is doing your operation no scar will form, then you are not informed and you should not proceed with any cosmetic surgery.
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Anesthesia Information |
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Patients want to feel safe when undergoing a surgical procedure. Our operating room staff is second-to-none in insuring patient safety, listening to patients' concerns, maintaining their dignity and being sensitive to fears and anxieties. At Cosmetic Plastic Surgery Center of San Diego, both general anesthesia and conscious sedation with local anesthesia are used, though 90% of our procedures are performed with the latter.
Conscious Sedation
Conscious sedation is achieved via an IV that Dr. Splinter will start himself. All vital signs are closely observed to ensure safety as we administer medications painlessly through the IV. Upon reaching a "twilight" state (described by our patients as "the most relaxed I have ever been in my life", or as an "incredibly pleasant sensation"), Dr. Splinter then injects a local anesthetic similar to that used in the dentist's office into the appropriate region for the procedure. It is this local anesthetic that completely blocks all pain reception to the brain.
This technique is incredibly safe and has greatly reduced the risk of postoperative nausea and vomiting (PONV), as well as the prolonged drowsiness and disorientation associated with general anesthesia. When the procedure is finished, patients are able to walk under their own power to the recovery area.
We refer to our conscious sedation technique as multimodality anesthesia. By using a select combination of medications, we can utilize the synergistic relationships between medications, thereby reducing the total amount of anesthetic drugs that we administer. This results in greater patient comfort, improved safety, and quicker recovery. Our incremental dosing of medicines guarantees safety by tailoring medication levels to each patient's unique tolerance level.
We have been developing and refining this technique for the past 28 years and have performed thousands of procedures using these principles. Other than a low incidence of PONV, we have never had an adverse outcome. For those patients with a known risk for PONV, we have developed a supplemental technique that has dramatically decreased the incidence of PONV in even this highly susceptible group.
General Anesthesia
Some procedures, including full tummy tucks, can only be performed under a general anesthetic. Here, too, our Board-Certified anesthesiologists are employing the most progressive anesthetic and analgesic techniques to make the operation safe and the recovery comfortable and uneventful. We our very proud of our flawless safety record and our patients' positive experiences.
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Breast Augmentation Techniques
There are many different breast augmentation operations because no single operation is perfect for everyone. This can be very confusing to patients who have so much information available to them on the Internet. In fact, there is so much information available that we often reach information overload. Your doctor should be patient and logical in explaining his approach to breast augmentation.
It is not uncommon for a patient to tell me that they want 450 cc implants, placed under the muscle, through a belly button incision. "Why?" I ask. "Because my friend, Susie, had her operation done this way and they look great." The fact that Susie is 40 pounds heavier and 6 inches shorter doesn't seem to matter.
The fact is, all of my patients are different and there are many different subsets of breast augmentation candidates. The classic case is the 30-year-old mother of two or three who has progressive breast involution with each additional child; there is also the thin, flat-chested 18-year-old female who doesn't have and never will develop any breast tissue; the 45-year-old recent divorcee; there are the Colorado River girls, the gym enthusiasts, the dancers, etc. Each of these has a different idea of what is beautiful, and a successful result will be different for each of these people.
What is difficult for most patients to accept is the reality that the final outcome of breast augmentation depends mostly on what the patient brings to the table; specifically, three main variables. (1) Chest wall deformities (i.e., the shape of your rib cage); (2) Tissue coverage (i.e., how much breast and/or muscle tissue you have to place over the implant); (3) Immunocompetence (i.e., how your body's immune system will react with the implant material).
Surgeons have developed different operations which are designed and tailored to address the many different variables in the anatomy that our patients bring to us. I would be personally cautious of any doctor who has only one way to perform breast augmentation. In my office, for example, we may suggest placement of the implant above the muscle (subglandular), below the muscle (submuscular), or a dual-plane approach (a hybrid of the above two operations). We also offer several different approaches to the placement of these implants.
There is no magic operation that will work for every combination of variables; you will be best served by a doctor who will offer you several approaches and will work with you to decide what is best for you.
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Breast Implant Sizing
During your personal consultation, I do a careful exam and take detailed measurements, paying particular attention to body asymmetry. For example, it is the norm for one breast to be larger than the other, for one breast to sit slightly lower on the chest than the other, for one breast to sag a bit more than the other, for the rib cage to be asymmetric, for minor degrees of scoliosis to exist, for one hip to be higher than the other, for one shoulder to sit lower than the other, etc. These factors, while subtle, matter a great deal in the choice of implant sizing.
The results of the above analysis will allow me to suggest an approximate maximal diameter implant for you, and the best position for the implant (e.g., above the muscle, below the muscle, or a combination dual plane). On occasion there is more than one possible choice that can yield acceptable results.
After this exam and analysis, my assistant will help you visualize your choices in the mirror, using a variety of implant sizers and a special bra. Our method is quite accurate in predicting the final size and puts you in control in our shared decision making process.
Occasionally, we run into a dilemma when our patients want bigger implants than their anatomy will readily accept. Big implants can lead to stretching, sagging, and distortion of the breasts -- though this is not always true. While I generally prefer smaller, natural-looking breast implants, current fashion (around the country) is for larger implants. An average implant in 1980 was 250 cc, while today it is over 400 cc in my practice; and some doctors regularly use 600 cc or larger implants.
Because beauty is in the eye of the beholder, you have the right to choose what you want. Please be aware, however, that those who choose very large implants will be asked to sign a special consent form that basically says, "Dr. Splinter has warned me of the potential risks, but I choose to accept the risk of large implants anyway." After adequate explanations, and having participated in the decision making process, you will have the final say in the implant sizing.
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Neck Lifts, Turkey Gobblers, Submentoplasties and Zorroplasties
Patients with heavy necks and significant laxity of the skin have not traditionally been considered good neck surgery candidates. The problem is not the fat. Removing fat from the submentum and the neck can be accomplished quite successfully by a number of techniques, including liposculpture for the superficial fat, and direct open surgery for the more problematic subplatysmal (submuscular) fat. The real problem has always been what do to about the excessive skin. This is the so-called turkey gobbler.
The traditional treatment has been to try to reposition the skin laxity superiorly with a face lift. This can work reasonably well, but it requires what I call a "heroic face lift," -- a very extensive surgery that entails additional risk to get an often less-than-perfect neck tightening. Curiously, the person with this neck problem often does not show much facial aging, and they do not want an extensive face lift. This is particularly true for many male patients who "just want a little something done to the neck."
Much has been written, and many claims have been made about the benefits of using ultrasonic liposuction and/or laser treatment to the undersurface of the skin. These techniques just do not seem to work very well. I have seen a lot of very unhappy patients who have had these so-called "weekend face lifts" (sometimes called "48-hour face lifts") performed with these techniques. Weekend face lifts are beneficial and do have a role to play in the right patient; however, they rarely deliver what the patient expects -- a tight neck. I do these procedures myself in properly informed patients.
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Z-shaped scar resulting from "zorroplasty" surgery |
Intuitively, patients just pinch the excess neck skin and ask, "Why can't you just cut it off and sew it up?" And I should tell you that I have tried this, as have many other doctors. As I have worked on this problem over the past decade, I have developed a neck procedure that I call a zorroplasty (so called because it uses a "Z" shaped incision).
In the right person, it is a very dramatic procedure, producing a very tight neck, a reasonably fast recovery, and a good scar that is barely noticeable.
This operation seems to be mostly a "man's operation," and men choose this option six times more frequently than females. This is probably because it is not called a "face lift"; I think men are more willing to admit to a little neck surgery, but they don't like to say that they had a face lift.
To see pictures of a zorroplasty patient, please go to our face lift page and scroll down to the last three pictures sets. We will be posting more pictures shortly.
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Photodynamic Therapy (PDT) with Blue Light and Aminolevulonic Acid (ALA-BLU-U) |
| Blue light with a 400 nanometer wavelength by itself is not very useful to doctors for skin treatment. However, by pretreating the skin with a new class of drugs called photosensitizers, we have a revolutionary new way to treat common skin conditions such a sun damage and acne. It is simple, safe, and efficacious. Not only does it treat the real diseases of aging skin, it produces skin that is clearer and smoother.
The combination of using a sensitizing agents and its activation by a specialized light source is generally called Photodynamic Therapy (PDT). You may recall your dentist activating the restorations of your teeth with a blue light. This is a very similar process called Photoactivation. Currently there are more than 20 different brands of light sources that can be used to perform PDT.
In our office the photosensitizer is aminolevulonic acid (ALA), and the blue light source is BLU-U. We refer to the combination as ALA-BLU-U. You may see other doctors call it ALA-PDT. The only difference is that the term ALA-BLU-U is very specific, while the term ALA-PDT is generic and applies to any number of other machines.
The sensitizer, ALA, is absorbed more rapidly by abnormal skin cells than by normal, healthy skin. Once absorbed, ALA is converted to protoporphyrin-9, and when exposed to blue light, produces free radicals that selectively destroy abnormal cells. This is very exciting because it does not damage normal skin.
Sun-damaged skin is the primary indication for treatment in my practice. People with fair skins (class I and II skins, for example, English, Irish, Scandinavian and Middle Europeans) almost always have significant sun damage in Southern California. Manifestations of this are scaly, flaky skin, pre-cancers, actinic keratoses, early skin cancers, and many pigment conditions. All of these conditions caused by sun damage, as well as aging, can be effectively treated with ALA-BLU-U. Of great advantage is that one can treat the face, neck, scalp, chest, hands and arms. Because large areas can be treated at one session, it is very cost effective (about $400 - $600 per treatment). Most patients are satisfactorily treated with one or two sessions.
ALA-BLU-U is also effective in disorders of the sebaceous glands, such as common teenage acne, middle-aged female acne, the acne that accompanies rosacea, and the condition of sebaceous hyperplasia (little small, round target lesions with a dimple in the center). Rhinophyma (thick, oily nasal skin, and also a late-stage variant of rosacea), is effectively treated with ALA-BLU-U, too.
The first step in treatment is the application of ALA. The ALA contact time ranges from 30 minutes to 18 hours, and the BLU-U exposure time ranges from 5 to 16 minutes. The variation in exposure and application times varies with the condition being treated, the thickness of the skin, the age of the patient, and the known effects of previous treatment.
The eyes are protected from the BLU-U light by goggles. During exposure time, most patients experience a mild stinging sensation during the treatment, but this is usually quite tolerable. The stinging is often described as like a sunburn.
Following ALA-BLU-U treatment, we advise avoiding the sunlight for 1-2 days. Staying indoors, or wearing a broad hat outdoors will lessen the chance of reactivation of the ALA. This reactivation is not dangerous, but light exposure does seem to set off the stinging sensation all over again.
This stinging (much like the stinging of a sunburn) may last for a few days. This is usually followed by flaky skin shedding as the damaged areas heal. It is perfectly okay to wash your face and put on moisturizers and makeup during the healing process. Two or three Advil and a vitamin C tablet taken regularly every six hours works very well to speed the healing process. The erythema (redness) that follows the treatment usually resolves nicely in two to four weeks.
The results of an impressive number of studies have shown dramatic improvement in all of the conditions treated. I, myself, am most excited about sun-damaged skin. With one treatment, you can treated your entire face and neck for those flaky actinic damages, precancers and early skin cancers, and improve age spots, too. Following treatment, your skin will look clearer and smoother and makeup will go on much easier and stay on better. I think that you get more bang for your dollars with this treatment than anything else I offer.
If you are 40 years old, have fair skin, and have sun exposure (almost a certainty in Southern California), this is truly a preventive medicine for you. I, myself, am using ALA-BLU-U once per year to avoid the progressive changes of sun damage to my skin. When educated to its many benefits, patients have been very enthusiastic about this treatment.
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