Author: Morgan Cosmetic Surgery

Question-  Can saline implants be deflated if I don’t like them?

Answer – Yes, saline implants can be deflated.  This is a procedure done in our office with local anesthesia.  It is an easy, but a temporary measure.
The usual reasons for implant deflation are:
• One implant has deflated, the other has not and you don’t have time to replace or remove the implants.
• The implants are too large, causing neck and back pain, but you don’t have time to replace or remove them.
• You are having the implants replaced, but do not know what size they are.

Implants can be partially deflated to match the size of one that has deflated, but one or both implants will usually deflate completely within a few weeks.

What happens when implants are deflated?  You may be able to feel the implant shell and it may in time be uncomfortable, rubbing on your ribs.

What is involved?  It is surprisingly easy.  Dr. Morgan makes a small injection of local anesthetic over the implant.  A needle is placed through the numb skin and through the implant shell.  A cannula (blunt plastic tube) is passed over the needle into the implant and saline is removed with a syringe.

Usually, it is better to replace your saline implants with the same or different sized implants, if you have time or money.  This can be done with local anesthesia in the office, but it takes at least a half-day and a busy woman may find it hard to find the time.

Some women just want implants out – this can also be done in the office.  However, reshaping breasts after implant removal requires a breast lift – this is not an office procedure, but rather one that needs to be done in the OR under general anesthesia.

So if you are having problems with saline implants, you do have a range of choices.  Let us know if we can help you.

Question:  My 14 year old son has just developed what look like breasts.  He wants surgery so he doesn’t look “like a girl”.  Isn’t this something that goes away on its own?

Answer:
Yes, you are right, but he has a good point as well.

Young men at puberty will often temporarily develop breast fullness as their testosterone hormone balances with estradiol hormone.  The breast enlargement usually is gone in 18 months or by the time your son is 15 or 16.

His condition is called gynecomastia – it is the term for when a man’s breast tissue becomes too large.

However, gynecomastia in a teenage boy does not always go away.  If his does not, he should definitely have surgery.  Teasing by classmates can be merciless and damaging – especially if he is involved in sports or gym is required at school.  Many sports team uniforms have snug spandex tops that make a boy’s gynecomastia hard to hide.

Surgery is usually straight forward: an incision inside the areola (dark skin around the nipple) leaves a scar that often becomes unnoticeable in time.  Through this incision the excess breast tissue is removed – taking care to leave enough to support the nipple so it doesn’t sink in.

Although this surgery can be done with local anesthesia in the office, it is better for a teenage boy with this condition to be asleep for surgery.  It is an outpatient procedure, which means he can go home an hour or so after surgery.

Unfortunately, he will not be able to play sports for 4 – 6 weeks, but speed walking and lower body weights may be alright after 2-3 weeks, if everything has healed well.

This is truly a marvelous procedure which can stop the damage of teasing and turn a young man’s life from one of intermittent misery to confidence and peace-of-mind.

Question:  I have a depression in my skin under my cheek bone.  What is causing it?  What can I do about it?

Answer:
This is called the submalar depression.  It appears as tissues over the cheeks, which sit very high when we are young, slide down a bit.  As tissue slides down, the tissue below them is folded in.
Today we have a wide range of treatments starting with filler, usually Voluma, over the cheeks to a mid-face lift, a cheek implant, or both.  Voluma is a hyaluronic acid filler (it can be dissolved with an enzyme called hyaluronidase) which is very stiff and thick.  It is designed specifically to add volume to this area, which is why it’s called Voluma.  Surgery and Voluma have the same purpose – to support the tissues that are sliding down.
Most people start with Voluma because it is done in the office and is easier and less expensive than surgery.  Injecting Voluma raises the tissues, and a little is put directly under the depression as well to support it.
Dr. Morgan suggests that you start with 1 cc of Voluma to be sure you like the result.  However, 1 cc is often not enough.  Many people need more to get the result they want.  It can take anywhere from 2 – 5 ccs of Voluma, depending on how much support the cheek tissues need. When more than 3 ccs are needed, it is time to consider surgery instead, because the cost of the temporary filler will add up to as much as surgery.  On the other hand, Voluma is a no-down-time office procedure and for many people, that still makes it preferable to surgery and the 1-2 weeks of recovery that it requires.

If you are seeing those submalar creases – call us for more information.

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Question – With foreign surgery so much cheaper than surgery in the USA, it’s tempting to go abroad for surgery, but is it safe?  What are the risks?

Cheap surgery is more likely to be poor surgery, although not always.

Here are the problems with surgery abroad:
1. Catastrophic infections.  People have returned with rare and incurable forms of tuberculosis from surgery done in dirty and contaminated foreign operating rooms.
2. Poor surgeons.  This is less likely if the surgeon is US trained and US Board Certified in Plastic Surgery.
3. Poorly done surgery.  Since the surgeons know their patients will be leaving and can’t sue them, they may become sloppy.
4. Complications.  Significant complications affect 10% of major surgery.  These complications usually appear 5 days after surgery or later. Most will have returned to the USA by then.  If they have a complication, they find themselves sick and scared with no one to treat them.  This leads to large bills for emergency care and later reconstructive care by a US Board Certified Plastic Surgeon.  The result can be much much more expensive than if they had had the surgery in the USA.

After seeking many complications from people travelling abroad for surgery – and talked to many people who had had surgery abroad and had great experiences, here is our advice.  Major surgery abroad can be reasonable if:
1. You speak the language fluently
2. You have friends or family in the area to help
3. You know the surgeon by local reputation or through friends and family
4. You can stay for at least 5 days
5. You have arranged a Board Certified Plastic Surgeon in your home town to care for you after surgery.

Most people travelling abroad don’t meet these criteria – they may get lucky and end up fine.  If that does not end up being the case, they may come home with poor results, catastrophic infections, major complications and major expenses.  It is therefore essential that you think things through before trying to save money with cheap surgery abroad.

Question –
How good is Restylane Silk?  I know it is a filler.  What makes it better than all the others?

Answer –

What is Restylane Silk?  It is a new form of Restylane and is a clear gel made of hyaluronic acid.  This acid is found in our skin and joints.  The FDA specifically approved Restylane Silk for people over age 21 looking for subtle lip enhancement and smoothing of the wrinkles and lines around the mouth.

What makes Restylane Silk better than other fillers around the mouth?
The lines around the mouth are one of the hardest to treat.  Phenol peels smooth the lines, but permanently blanch the skin.  Lip implants don’t improve the lines and can feel unnatural.  Botox smooths the lines, but too much makes the lip droop.  The ultra-soft filler Belotero only lasts a few weeks and up to a few months if you are lucky.  The firmer gels, Restylane and Juvederm can look hard and unnatural and may even leave visible lines on occassion.

So, enter Restylane Silk.  It can be directly injected into the skin without leaving lines.  If injected into the pink lip, the result is a soft, natural look.  We tried Restylane Silk on one of our staff.  Her verdict, “It’s subtle.  Definitely subtle.  But it left no lines or lumps, and I am happy with it.  I would get it again.”

How long will Restylane Silk last?  Here is the FDA data:
98% of patients had improvement at 2 weeks, but only 77% of patients had improvement at eight weeks – so in 21%, results were temporary.
At 6 months, almost all of these 77% had visible improvement and overall 59% still had their original results.

So results vary – some people absorb filler faster than others.  Restylane Silk is ideal if you have thin lips, want a subtle result and know that for the majority of women, it will last at least 6 months.

Can everyone have Restylane Silk?  Yes unless you are allergic to lidocaine, have had medication allergies that landed you in hospital or if you are allergic to gram-postive bacteria.

Are there any side-effects: Swelling, bruising and soreness can occur during and after injection.
For a natural result, no more than 1.5 cc is injected into each lip and no more than 1.0 cc into the lines around the mouth.

Who makes the product?  It is manufactured by Galderma – a skin product company founded by Neslte and L’Oreal, but now wholly owned by Nestle.  In the USA Restylane Silk is distributed through Valeant.

Question:  I was told to cover a recent scar with sun block for 6 months.  Why?

Answer:  The sun can damage recent scars in 3 ways:

1. Disrupting collagen in the skin.  This will make a scar thicker and wider.
2. Damaging the veins in our skin – red scars have lots of tiny veins that are part of the healing process.  These veins disappear when healing ends, but sun on these veins damages them, so they may not fade and may permanently widen.
3. Darkening the scar – this is a real problem in any dark scar.  We want a brownish scar to fade, but it cannot if it is exposed to the sun.  The UV rays of the sun will increase the activity of the melanocytes which are making the scar dark.

What to do?  The easiest approach is to put a tinted zinc oxide/titanium dioxide sun block over any recent sun-exposed scar from spring through the fall.  Since the sun can reach scars that are under our clothes – especially the thin white and light colored clothes we wear in the summer – apply the sun block under your clothes if you go to the beach or on a cruise where you’ll be in the sun for hours at a time.  Here’s a hint for dark scars – hydroquinone does not fade scars easily after surgery. However, 100% cocoa butter soap really can help. It is sold on-line and is the only cream that Dr. Morgan has found effective.

Question:  What is Kybella?  Will it really dissolve fat?  Is it safe?  Does it replace liposuction?

Answer:
Kybella is an injection that destroys fat cells.  The FDA says it is safe.  It is unlikely to replace liposuction except in treatment of small areas of excess fat.  Here is what you need to know:

Kybella or ATX-101 is deoxycholic acid, an acid produced in our bile to emulsify fat.  When injected into living fat, it kills fat cells.

Kybella was approved on April 29, 2015 by the FDA as safe and effective for reducing fat under the chin.  Since deoxycholic acid has been used for years in mesotherapy to destroy fat cells, Kybella will most likely be used from the start “off-label” for other fatty areas.  In effect, it is FDA approved mesotherapy.

Kythera Biopharmaceuticals, which makes Kybella, was unprepared for approval.  As a result, it is now hastily setting up programs to sell the product and train doctors to use it.  This will begin in June 2015.  Treatment will mean 6 sessions of injections – up to 50 at a time – spaced a month or more apart.
Bile acids are powerful and not surprisingly, deoxycholine injections can destroy not only fat, but skin, nerves and muscles so treatment is not risk free.  Some studies show that all patients have some kind of side-effect, typically swelling, bruising, pain, numbness, redness and hardness.  Permanent skin, nerve and muscle damage can also occur.
Not everyone responds to treatment.  In one ATX-101 study of 363 patients given 4 treatments, only 65% of people saw any improvement.  In another study, after 5 treatments, 75% saw improvement, but the average improvement was minimal.
Any injection of a powerful acid is a compromise between ultra-safe injection with minimal response and aggressive injection with serious complications.  This has always been the problem with mesotherapy, but with the FDA approval and standardized treatment, Kybella and other forms of deoxycholic acid will be an option for people with excess fat to whom the risks seem acceptable compared to the improvement they want without surgery.

Finally, what does Kybella mean?  It is the name of an ancient and overweight mythological goddess of fertility, Kybele.  The company that makes it, Kythera Biopharmaceuticals of Westlake Village, California is named after the Greek island which was the mythological home of Aphrodite, the ancient Greek goddess of beauty.

Lip Lift Question:
I am considering a lip lift, but I can’t tell if I would benefit from one.  Also, if I do get a lip lift, how do I avoid my lip being too short afterwards?

Lip Lift Answer:

You can try a “do-it-yourself” test at home with a small ruler.

If your white lip – as measured from the base of the nose to the mid-upper lip – is 15 mm, you may benefit from a lip lift.  The change would be 3-4 mm, subtle, but for a young person, that may be all you need.

If your lip measures 20 mm or longer, your lip is close to double what it was when you were young.  In this case, you can definitely benefit from a lip lift.

To avoid having your lip end up too short after a lip lift, your surgeon should preserve at least 75% of your lip.  For instance, if your lip is 20 mm long, a 5 mm reduction is appropriate.

Right before surgery, I always mark the lip reduction based on precise measurements and on the “look” the patient and I discussed during their consultation.  Then, I show my markings to my patient.  This way, together we can adjust the lip reduction precisely to meet the goal of the patient.

If you are considering a lip lift or some other lip rejuvenation, consult a Board Certified Plastic Surgeon.  If your surgeon recommends a radical lip reduction or more than you have in mind, get a second opinion.  With this operation, more can always be removed, but once a lip is too short, there is nothing that can be done.

Blog Question –
What are the benefits of cannulas for facial fillers and why do so few doctors use them?
Blog Answer
Cannulas are a real technical advance in filler injections.
I always use them except in those rare areas where a needle is necessary.
However, there are reasons other doctors avoid cannulas.  Let me explain.

Since 1980 when fillers were first used, most injections have been done with needles.
Needle injections almost always cause mild bruising – severe bruising lasting weeks is not rare.
Things began to change about 5 years ago when the use of cannulas for filler injections was reported.

What are cannulas?  They are blunt, not sharp.  Facial injections require specialized cannulas.  They are long and thin like needles but flexible and strong.  The filler comes out an opening on the undersurface, not at the tip like a needle

The first cannulas came from Japan – and were very expensive.
Now excellent cannulas are made in the US and sold at a reasonable cost.  What makes using cannulas better?

1. Safety, safety , safety:
-Needles can inadvertently inject filler into a small artery or vein. Filler in a blood vessel can kill overlying skin, causing permanent scarring – even worse and fortunately rare, filler injected into a blood vessel can travel to the eye and cause blindness.
-Cannulas, being blunt, don’t easily pierce blood vessels – instead the blood vessel blocks the cannula which is then re-directed.
-In addition, filler does not come out the tip of a cannula making it very unlikely that filler would be injected into a vein, even if the cannula pierced it. So the risk of serious complications caused by filler injection is greatly reduced.
2. Bruising: Since cannulas don’t pierce blood vessels like a needle, bruising is rare and mild.

Why don’t all doctors use cannulas?
Because it takes time to learn how to use them and needle injections are faster.
It takes only 15 minutes to inject filler with a needle.  It can take twice that time with a cannula.

So a plastic surgeon won’t use a cannula unless s/he is willing to set aside more time to do filler injections.  For me and for my patients, the extra time is much less important that the greater safety and much less bruising which cannulas provide.  So, if you want filler injected by cannula, just call us!

Blog Question:

When I get Botox, how do I know if it’s really Botox?

Blog Answer:
This is an excellent question because Botox looks like water.
(A patient of mine was sure another doctor had charged her for Botox but used water.)
It helps to be informed.

Here’s where the problem starts – and 5 tips to stay safe.
Botox is the only USA-made FDA approved neurotoxin.
It arrives within a day of a doctor placing an order.
Other neurotoxins such as Dysport and Xeomin come from abroad.
Transportation and customs delays can mean a week or more before foreign products arrive.
During that time, they decay unless they are kept frozen.
So in the USA, Botox is the most active, most reliable neurotoxin.

Being a fairly expensive product, there are many underground salesmen offering people “cheap” Botox. This type of Botox, is either stolen or fake.

So who buys from these underground salesmen? Anyone, from an unethical doctor to people with no medical training or license who make money giving illegal injections. Beauticians and photographers are common culprits.

The FDA recently issued an alert that a dangerous fake Botox is being sold across the USA.

So here are the 5 tips on how to avoid being a Botox victim:
1. Ask to see the Botox vial. Real Botox vials have a lot number on every vial. If there is not a lot number on your “Botox” vial, it is a fake injection. Walk out!

2. The vial isn’t available for you to see. Maybe the excuse is that pre-filled syringes are used. Botox doesn’t come in pre-filled syringes. Walk out!

3. The price is too good to be true… Botox regularly priced at or below $8 a unit is not likely to be real Botox – because one can’t cover overhead at those prices.

4. Get treated at a medical clinic, not a salon or spa. Ask to see the medical license of the person treating you (It should be a licensed doctor or a nurse or PA working under the supervision of a licensed doctor).

5. In an ideal world, only get your Botox injections at the office of a Board Certified plastic surgeon, facial plastic surgeon or dermatologist. We are the only doctors actually trained in cosmetic medicine – and the ones who best understand how to use it and the dangers of using fake product.