Author: Morgan Cosmetic Surgery

Question:  I hear the FDA recently issued a bulletin warning that fillers can be dangerous in some parts of the face. Is this true? Can the risk be reduced?

Answer:

Yes it is true. And yes, your risks can be reduced.

This is not news for any plastic surgeon. The FDA warning follows new studies done by plastic surgeons on the risks of fillers.

Here is the issue –  the forehead, between the brows and around the eyes can form deep lines, but there are important blood vessels underneath these wrinkles. So filler can end up being injected into these blood vessels. This plugs up the blood vessel. Since these blood vessels are near the eye and the brain, blindness and stroke can occur. This is very, very rare, but it is important to understand it can occur.

It does not occur with Botox because it is a liquid that does not block blood vessels. It is safely injected in these areas.

Does this mean filler should never be injected in the forehead? No – Dr. Morgan will occasionally do such injections, but only with important precautions.

Many health practitioners doing filler injections  – nurses, PAs, dentists and podiatrists – don’t have the training or experience of a plastic surgeon. They often do injections in these areas, not understanding the risks. What seems safe to them may in fact not be safe.

Here is what to do if you want the safest possible facial filler injection in risky areas:

1. Have a plastic surgeon do the injection.
2. S/he will first inject local anesthesia with epinephrine to shrink the blood vessels.
3. A cannula, not a needle, is used. Cannulas are designed to avoid injection into blood vessels.
4. Vitrase – a filler-dissolving enzyme – should be immediately available.

With these precautions, injections in these areas is still more risky than elsewhere, but can be done with the lowest possible risk if filler in this area is important to you.

Watch in this video as Dr. Morgan explains all you need to know about fillers:

 

Question:  Is it reasonable to get a chin implant and a nose operation at the same time?

Answer:

Yes, a rhinoplasty to make a large nose smaller plus a silicone implant to make a small chin larger is a common dual operation. The reason is that having a nose too large for the middle face and a chin too small for the lower face is often seen together.

So – doing a chin implant at the same time as a rhinoplasty is often an excellent combined operation.

However, this combination isn’t a good idea if you like your nose and aren’t sure you want to change it. For instance, let us say you are a man who wants a strong chin. You have a large, straight nose already. But you are having a large chin implant put in place. You may want to leave your nose alone because your new chin implant may be in proportion to your nose. What you want to avoid here is having your large nose made too small – for your masculine face and for your new, large chin. Not sure? Just wait 6 months after the chin implant. You are likely to end up thinking you need nothing more done.

On the other hand, you may be a petite, feminine woman with a delicate face, a tall, thin, curved nose that dominates your entire face and a slightly too-small chin. In this case, your nose definitely is the major operation – but even with an excellent rhinoplasty, your nose may still end up slightly dominating your face. So placing a small or extra-small chin implant can finish your new look by giving your face balance.

But many women aren’t bothered by their chin – they don’t want to be ‘sold’ a chin enlargement that they weren’t expecting to need. What to do? It’s easy. Just have the rhinoplasty. If at 6 months, you like the final look, in front and profile views, do nothing more. But if you say, “Actually, my chin is a little too small. I can see that now,” – no problem. A chin implant can be done in the office with local anesthesia. You still made the right decision to wait until you were sure.

If you are having both procedures, just remember that your face will be swollen at first from your lower lids to below your chin. Not to worry – the swelling subsides at the same time. By one week, most people can get back to work and school. By two weeks, the swelling should be improved to the point that you are aware of it, but others tend not to notice.

So if you are considering nose surgery, chin surgery or both – be sure you discuss your surgery in detail with your surgeon, so you are confident you make all the right decisions!

Watch in this video as Dr. Morgan explains what you need to know about chin implants:

 

Question:  I hate my stocky lower legs and fat ankles.  Can I have liposuction for this? Is there anything else that can help me?

Answer:

You can definitely have liposuction of the calves and ankles – if excess fat is making your legs stocky. Results can be lovely. However, liposuction here is different from liposuction in most other areas. For example:

• In muscular legs, it can be hard to tell in advance how much of the shape is from bulky muscle and how much is from excess fat.
• Removing too much fat can leave calf skin loose.
• Ankle fat is embedded in nerves and arteries and may be hard to remove.
• Swelling including ankle swelling lasts longer, because it has nowhere to go.
• Recovery includes 1-2 weeks of pain from irritated muscles and nerves.
• The network of nerves at the back of the calf may react to liposuction with weeks, even months of numbness, nerve pain or strange feelings in the lower leg and foot.

 

There are also technical considerations. Dr. Morgan uses 2 and 3 micro-cannulas- to avoid the nerves and blood vessels in the ankle. She does not use laser liposuction, which can permanently damage nerves, tendons and skin.

 

Recovery takes time

• Because of the swelling, you need to keep your feet up all the time for 1 – 2 weeks.
• You need to wear compression knee high stockings for 6 full weeks.
• No exercise for 6 weeks – although walking on springy surfaces is fine in 2 weeks.
• Someone else has to walk your pets for at least 2 weeks.
• You need patience! The swelling means that it may take 6 – 12 months to see your final result.

 

What about other treatment? Intermediate and advanced level ballet will reshape legs – it is the only sport specifically designed to do this. But if you start as a beginner, it will take years to see results.

 

For heavy muscles, Botox injections and muscle resection can work – but Botox is very expensive (about $1100 every 4 months) and muscle resection can permanently affect how you walk.

 

So for practical reasons, liposuction is the popular treatment for reshaping heavy, stocky legs.

 

Question:  Can neck liposuction be done in the office?

Answer:

Liposuction is often done in the office by inexperienced doctors who do not understand how risky it is.

The neck can be compressed by bleeding during or after liposuction or just by the tumescent fluid that is injected under the skin. This can make it hard to breathe. So what starts as a “simple” procedure, can suddenly become and emergency, or a tragedy.

 

Air way control – that means, someone doing the breathing for you – is essential for most neck procedures.

 

Sadly, catastrophes involving breathing do happen when there is no airway control. The celebrity, Joan Rivers, died having a quick little neck procedure in her doctor’s office without airway control. Neck liposuction should definitely be done in an accredited operating room – for your safety.

 

Neck liposuction and small neck lifts are easy to have done, don’t take long and your recovery is speedy. Just give us a call and let Dr. Morgan help you arrange this.

 

Question:   What is the best kind of chin implant to have?

Answer:

This is a very good question. There are 4 considerations in choosing a chin implant – type, size, shape and material.

1. Type – you should have an extended chin implant, not an onlay. Let me explain why. The original chin implants were placed directly over the chin prominence. These are on-lay implants, they just sit under the prominent soft tissue of the chin. Experience has taught us that these don’t solve the problem well. Chin implants need to go over the full length of the front part of the jaw bone – the lack of bone thickness here is what causes a small chin.
2. Size of implant – as a general rule, women should have small implants, men large ones. What if you are a woman, and you aren’t sure if a medium or a small implant is better? Have the small one. Women have delicate faces and too large an implant can look heavy or even masculine. But let us say you are a man and you can’t decide between a large and an extra large implant? Assuming it will fit your face, choose the extra-large. Most men want to look very different from the look women have in mind – it is masculine to have a large, assertive, dominant chin. These rules don’t apply to everyone, but they are a helpful guide.
3. What kind of shape? Chin implants have different shapes for different looks. Some have squared chins, some curved. That is a personal decision, but your surgeon will guide you.
4. Finally – material. There are two kinds of chin implant material – those to which your body doesn’t attach and those to which it does. In the past, many surgeons used materials to which the body attached, a common one being Medpor. But wait!! People’s faces and preferences change with time – what if you don’t like your Medpor implant? It is difficult to remove. So the trend is moving away from attaching implants. Today the preferred implant is made of a soft, solid silicone, tradename Silastic. They can be held in place with a suture – or a tiny screw. There is no need for the body to attach to the implant. This makes changing an implant easy – if you ever need it done.

Chin implants have truly gone from good enough to excellent.

Watch in this video as Dr. Morgan explains the different types of chin implants in detail.

 

Question:  I want breast implants, but I am afraid of capsular contracture. Is there any way to prevent it?

Answer:  Yes, there may be a way to prevent capsular contractures.

Capsular contractures are tight scar that your body forms around an implant – any implant – that it finds irritating. After a breast implant, you have a 1% risk each year of developing a capsular contracture.

The effect of a capsular contracture varies – your breast may feel just a little firm or it may become hard, painful and misshapen. The usual treatment is re-operation to remove the thick scar and place the implant in a new position (e.g. over the muscle if the contracture occurred under the muscle). However, once a capsular contracture forms, a new one may form even after surgery.

The good news is that a recent study from Brazil reports that the risk of capsular contractures can be reduced by taking montelukast (Singulair) before a capsule develops.

 

Montelukast is a leukotriene antagonist  – it stops the release of chemicals that cause our bodies to be hypersensitive. It does have side-effects – headaches, fatigue and a stuffy nose are mild and common. Rare effects such as depression, tremors and severe skin reactions of course require the medication to be stopped.

 

But for women who have surgery for a first capsular contracture, who are anxious and want to reduce the chance that they ever get one or who develop early signs of a contracture and don’t want it to progress – Montelukast gives you an option that you didn’t have before.

Watch in this video as Dr. Morgan explains capsular contractures, why they occur, and what can be done:

https://vimeo.com/106929413

Question:  Is there anything new for treating wrinkles and skin depressions?

Answer:

Yes, one advance is immediately available. Another is on the horizon.

The advance available now is a skin treatment called microneedling. We use the SkinPen which is a medical grade machine.

The treatment on the horizon is reported to make tissues regrow (very exciting) which may be very  popular once the FDA approves basic Fibroblast Growth Factor for clinical use, but this will of course take time.

How does the SkinPen work? The hand-held machine is passed over your skin to make thousands of tiny skin punctures, which stimulates the skin to grow new collagen. It is much more aggressive and effective than a glycolic peel or microdermabrasion, but much less aggressive than a CO2 laser resurfacing or deep TCA peel, both which have risks and about 2 weeks of healing.

SkinPen is an office treatment and can be painful, so numbing medicine is applied. Treatment takes about 30 minutes. You will be red – often very red – for several days and can be mildly bruised. But it does change the skin, filling in superficial acne scars, reducing the depth of deep lines, improving skin texture and at times, may reducing pores – which are notoriously hard to treat. SkinPen can be used anywhere on the body – it is not limited to the face.

Our experience suggests that SkinPen treatment makes therapeutic skin products more absorbable. We suggest patients start tretinoin (generic Retin A) or vitamin C 1-2 weeks after treatment. There are also specially formulated topical products that may improve the skin thickening even more. This is a big advance for office treatments. Although one treatment should lead to improvement, it takes 3 treatments a month apart to get your best result.

The other treatment, which is not yet available, but being talking about, is basic Fibroblast Growth Factor treatment. It will be more expensive, but an office treatment that may replace fillers. This treatment first takes a sample of your blood and separates the Protein Rich Plasma (PRP). This alone has no effect on wrinkles. But once the PRP is separated, it is mixed with bFGF and injected into areas of depression, lines and wrinkles. It stimulates growth of new tissue over the area of injection. Improvement takes 60 days to appear and increases for 6 months. Results are dramatic and, it appears, permanent. They are evident years later, despite natural aging. If this treatment proves as good as reported, it will be very popular indeed.

In the below videos, Dr. Morgan discusses PRP and microneedling.

We proudly provide personal, high quality cosmetic surgery and office treatments.

Call us now to learn more so we can help you.

 

Question:  Is out-of-town surgery safe? If so, how can I prepare for it?

Answer:

Out-of-town surgery is more challenging than having surgery near home. Once you leave your surgeon’s city, you don’t have direct access to her/his care. This makes many people anxious. It also makes it difficult for your surgeon to help you, if you have a complication.

However, the demand for out-of-town surgery has risen, because of the internet and two other reasons:

1. People search the world for the cheapest surgery. This is risky. As a result, we have seen poorly done surgery, rare, untreatable infections and serious complications.
2. People search the world for surgeons with special expertise that surgeons at home don’t have. This is a reasonable reason to travel for surgery.

Here are some reasons patients have travelled nationally and internationally to see us –

• A second face lift, after a poor result from a first face lift.
• Breast implant, because of our careful approach helping patients select the right implant.
• Lip lifts, because local surgeons don’t do the procedure.
• Calf implants, because local surgeons don’t do the procedure.

 

We recommend this approach if you are considering traveling out of town for surgery:

1. Have a consultation with the surgeon by phone or by Skype at least a month in advance.
   1. We have patient fill out the complete medical history before a phone consultation.
   2. We may ask for medical records and photos.
   3. During the phone/Skype consultation have a ruler or tape measure – to take measurements, e.g. the length of your lip, the width of your chest.
   4. Have a note pad and pen to take notes.
   5. Be sure you understand what the surgeon can and can’t tell you without an exam.
      1. For instance, the best breast implant size can be estimated long-distance, but a pre-surgery consultation is necessary for a final decision.
   6. For major procedures, if possible, travel with a friend or family member for help and support.
      1. Or ask the surgeon’s office for help finding someone for the first days afterwards
      2. Ask if you should spend the night after a minor procedure, if you are travelling alone.
   7. Ask the surgeon’s office about where to stay.
      1. We have good, near-by hotels and motels that offer corporate rates to our patients.
   8. Be clear as to the day you need to arrive, the day you can leave and your expected recovery.
   9. Be sure you get a written proposal that sets out all the costs and requirements. For instance, because of the risk of blood clots, we require out-of-town patients to have Exparel for pain if they are having tummy tucks, calf implants and under-the-muscle breast implants. Exparel is expensive, but it allows early mobility, making travel home easier and safer.
   10. Arrange someone back home to see you, if you end up needing it. Ask what you may need –
       1. You many need a nurse to remove sutures, your regular doctor to check healing, a near-by Emergency Room or Plastic Surgeon in case of infection or poor healing.
   11. Before leaving town, schedule follow-up phone visits with your surgeon and send follow-up photos. We do this one week, two weeks and six weeks after surgery.

 

With these preparations, out-of-town surgery is likely to go smoothly for you.

Question:  I am a female competitive weight lifter and want breast implants. Is it ok to put the implants under the muscle?

Answer:

I generally recommend that women weight lifters have their breast implants over the muscle. The muscle is the pectoralis major muscle. This is the major muscle of the chest. It is highly developed and very strong in weight lifters and this can lead to trouble with implants that are under the muscle. For instance,

• When you use the muscle, it may flatten the implant visibly, an odd and distracting look at the gym and during competitions.
• The muscle is also strong enough to force the implant out of position. Normally, an under-the-muscle implant sits partly under and partly below the muscle. In a weight lifter, the pectoralis muscle can force the implant out of position, either up or down, but in either case not its natural position.
• Finally, the natural breast sits over the pectoral muscle. When the implant is behind the muscle, it changes the look of the muscle which no longer lies flat against the ribs. No one would notice this normally, but again, at the gym and in competitions, the muscle position and definition may look odd.Any athlete with highly developed pectoral muscles needs to be aware of these possible problems. Swimmers for instance have strong pectoral muscles. Although the implant movement doesn’t show under water, the muscle activity can shift the implant out of position.Ballet dancers are another group to be aware of the problem. For instance, for lifts a dancer tenses her arms and chest muscles so her partner can lift her. (A limp dancer can’t be lifted.) This means that during lifts, the muscles can visible flatten her breast implants.The point to remember is that there is no right or wrong. There are advantages and disadvantages to putting breast implants over or under the pectoral muscle. You can decide which you prefer after a thorough discussion with your plastic surgeon.

Cosmetic Question:  I had a breast lift. My nipples look as though they are too low on the breast. My surgeon says that it is fine, but I don’t like it. What can I do?

Cosmetic Answer:
This can happen, but it is also fixable.

You need to wait 6 months at least before having anything done. The breast will often settle with the nipple ending up in the perfect position. If not, the nipple can be shifted upward. This is a delicate procedure, but it can be done with local anesthesia with some oral sedation in a minor operating room. When done this way, it saves you time and money.

A new position is marked for the nipple and it is shifted upward during surgery. Your new scar will be red and it can take a year or more for these scars to fade.

Ask your surgeon six months after surgery if they think you are a good candidate. Review post-op photographs with him. Most surgeons will be happy to correct this for you, although there may be a small fee. We all want our patients looking the way they imagined!

A much harder problem is a nipple that lies too high – this is very difficult to fix. So to avoid it, experienced plastic surgeons will set a nipple on the low side, even if that means you will later need a lift.