Buttock Augmentation with Fat Transfer (Brazilian Butt Lift)

Contouring the buttocks has fast become a hugely popular procedure in my practice.  We enjoy doing this procedure because we see amazing results.  It is true that this is an ethnically driven procedure.  In another words, certain ethnicities, such as Latina and African American women, enjoy this transformation perhaps more than others.  Regardless, it is very popular.
This procedure is done by removing fat from certain areas and then transferred to the buttocks.  This is not random by any means.  A patient's own fat is the best option to do this because there is no rejection problems.  The fat is transferred artistically with the vision to augment areas that will enhance the appearance of the buttocks without looking like there was something done to it.  This takes an appreciation of the normal aesthetics of the buttocks, not unlike a sculptor.
The best part of this procedure is that the patients will get liposuction of other areas of the body.  This is also done artistically to contour the body so that the buttock becomes the focus of attention.  This is one of the most desirable aspect of the procedure.
When a patient comes for a consult, it is my job to help them understand all the nuances of the procedure.  I make sure that they are good candidates for this procedure so that the outcome is nothing short of artwork.  

Otoplasty- Ear Pinning

This month we have focused on otoplasty in our practice.  Many patients struggle with this as a social issue and this can be a major source of embarrassment for many.  In most patients this is a relatively minor surgery to correct this and typically done in our offices.
In general, there are two issues that makes the ear protrude.  The first is conchal excess.  This is the cup part of the ear that is in excess and therefore protrudes too far from the head.  This often needs to be reduced and gets pinned to the head using permanent sutures.
The second issue is the flaring of the helical rim and the loss of the antihelical fold.  This is the upper part of the ear that flares too far out.  This often also needs to be pinned and the cartilage that creates this problem needs to be shaped and bent back on itself.
All of this can be done with an incision located in the back of the ear.  These incisions heal quite well and are hidden from view.  We can do this in the office with only minor local anesthesia and takes about 2 hours.  After the surgery, I typically recommend patients wear a head wrap for about 7 to 10 days to keep the ear pinned and covered at the same time.
Patients find this to be remarkably easy and very satisfying as a procedure.  I have seen this procedure change a patient's perception of themselves and improve their self-esteem.

  

The Use of Drains in Plastic Surgery

During my consults with my patients, I often introduce the concept of placing drains in the site of the surgery towards the end of the discussion.   This by no means diminishes the importance of their function.  Whether drains are left in place after facelifts or tummy tucks or even large body lifts and contouring procedures, they help patients by removing post operative fluid that is produced after these surgeries.  These drains offer a window to what is going on at the site of the surgery and help manage post operative issues like bleeding or fluid accumulation (seroma).  These drains are your best post operative friend as I have been known to explain to my patients.

Question that is often asked is how long do the drains have to be left in?  The answer is..it depends.
Depends on many factors, but the main concept is that I like to wait for the drainage to be below a certain threshold before removal.  Generally speaking the drains are removed anywhere from 5 to 7 days after surgery but this is not a rule written in any text book.  Right after surgery as your body is making this fluid, it cannot absorb the fluid fast enough.  Until the body can catch up to this absorption process, the drains allow an outlet for this fluid.  So my answer to that question is that the drains are removed at the most PERFECT time after surgery as determined by me!       

The Unlikely Smile Maker

As I finished surgery on a beautiful ten year old girl from a local orphanage with a secondary cleft lip deformity, I did not realize how this tiny little Philippino girl was about to humanize me and my entire team involved in her care.  When I met her the day before with her caretaker from the orphanage, it was obvious that she had a beautiful disposition.  But like a technician, I came to the Philippines to perform cleft lip and palate surgeries to restore form and function, not get emotionally attached.

This girl was just one of many on a long list of patients in the middle of a busy week.  My responsibilty was to create a smile only on her face, but little did I know, this little orphaned girl’s simple innocent actions the next day would be responsible for creating smiles on an entire team of doctors, nurses, surgical technicians and countless others with whom she came in contact.  I have heard many times that I am a miracle worker, that our team is miraculous in what we are doing.  This could not be further from the truth as this little girl was about to teach me.   

I glanced over at the table next to me and saw my colleagues Scott Mosser, MD, a San Francisco based plastic surgeon and Raquel Redtfelt, MD, an ENT surgeon from Arizona working on another girl roughly the same age.  This is a typical scene on our medical missions to the Philippines, two operating beds in one operating room.   We were working to correct a cleft lip, a congenital deformity where the structures of the lip do not completely form leaving a defect in the face.  Over the past few years, Scott and I have done hundreds of cleft lips surgeries as part of Destination Hope, a non-profit organization started and maintained by him. 

This year Scott assembled the best of best from the US, who traveled to the small town of Tarlac City in northern Philippines from January 20-24, 2014.  Aside from us three surgeons, our plastic surgery team comprised of Drs. Vernon Huang and Susan Wong, two amazing anesthesiologists from the Bay Area in Northern California.  Also included were Dr. Lawrence Lipana, a meticulous compassionate pediatric resident doctor from Southern California, Tania Di Re, Elizabeth DeGuzman, Alberto Enriquez, and Juyon Yi, amazingly gifted and most kind-hearted OR nurses from Northern California.  I took a moment to appreciate this fine collection of like-minded professionals dedicated to their craft and dedicated to help those with less.  Soon thereafter, I noticed Scott and Raquel finished surgery on their little girl. 

Both the girls had no problems after surgery.  The three of us were pleased with the outcome of the surgeries on these girls.  They did well during their immediate recovery phase and were admitted to the hospital for overnight observation.  The following morning we made rounds to check on the patients that we operated on the day before.  This is a routine mundane, but necessary, part of what we do as surgeons.  This involves an entire entourage of doctors, nurses and all ancillary staff, including translators, who go from room to room, patient to patient, to make sure they are recovering. 

Our two older girls from the previous day, though strangers to each other, were placed in the same ward in adjacent beds.  As we approached their beds, I saw that they were already interacting with each other as if they knew each other.  They did after all share a common problem, which connected them beyond any ordinary bond.  In general our patients are babies ; these two girls were older.  They were able to appreciate the events that brought them to this point in their random lives.  This was a meeting point for these two strangers, who shared a common bond that they could not have imagined the day before.  These two strangers were about to touch me and my entire team in a profound way.     

As I watched the two children interact, I felt the sudden urge welling up that no surgeon likes ; I was struggling to hold back my tears.  Surgeons don’t get emotional, we are technicians who put things together without getting emotionally invested.  These two kids were old enough to realize the monumental change that had just occured.  I handed each girl a hand-held mirror so they could see the change for themselves.  Where there once was a shapeless hole in the middle of their face, now there is tissue and structure.  Where once they looked like outcasts, monsters, now there is a normal looking face staring back from the mirror.  Where once there was no smile, now there is a gorgeous warm infectious smile.  They now looked like all their friends.  Perhaps now they can leave their home to wander outside, perhaps now people will no longer stare, perhaps now they can live a normal existence. 

The two girls smiled at each other staring into the hand held mirror exchanging small sheepish glances with each other and with the rest of the strangers standing around them.  Then the two girls turned the mirror simultaneously towards each other’s faces to show the other her new face.  They were gleaming in excitement, as I felt emotions welling up again.  I glanced at my entire team and noticed they were all smiling in admiration and appreciation.  I reminded myself, surgeons don’t get emotional. 

With this simple gesture, these girls succeeded in creating smiles in all those standing near them.  It was a pivotal moment, the jolting realization that for this moment I was not a surgeon, I was a fellow human being sharing in the private joy of these two little girls and their care takers.  I was part of that great moment for this orphan, who I just met yesterday, but will not forget for the rest of my life.  She reconfirmed for me why I do this every year.  In a moment of clarity, behind my concealed tears, I realized something even greater.  This little orphaned girl from a remote village in the Philippines was the miracle, she was the teacher, she was the technician who knew how to create smiles better than any surgeon.  She was our unlikely smile maker.

Sculptra – For Deep Facial Volume Restoration (Liquid Facelift)

One of my favorite fillers is Scultpra (L-Polylactic Acid).  I often tell patients that when they look at photographs from their earlier years, they will notice that their face is fuller.  This fullness is what gives a more youthful appearance to the face.  The key assumption is that the skin overlying that fullness should still have good elasticity.  If this is the case, then deep volume fillers like sculptra can be very effective. 

Sculptra works by inducing collagen production.  The collagen is what does the "filling".  It is a deep injection but is done in the office with only topical numbing medicine applied to the face.  I typically prefer to treat the whole face, but we can also inject specific areas as well.  This is what I discuss with each patient to customize their treatment plan. 

Also, I typically prefer to combine this procedure with re-surfacing of the skin as well.  This may involve an abltative laser or even an IPL(intense pulse light) procedure to give an optimal enhancement of the face.  Below is an example of this treatment.  This patient underwent sculptra injections to the face.  She has a nice result with a rejuvenated appearance.  Notice there is more fullness in her face.  It is just as powerful as fat grafting in my opinion. Her jowls are softened and there is almost a lift, hence the term "liquid facelift".

How do I know if I need a Facelift? What is a facelift?

Patients often ask me "Do I need a facelift ?" This then goes into the second phenomenon that I describe in the aging process, namely the loss of ligamentous support.  As we age, along with losing volume as I have described before, the tissues that "hold up" our face begin to lose strength as well.  Take a look at the image below to understand how the face ages.

This is where you begin to notice deeper lines and wrinkles around the naso-labial folds and jowls.  This is also very evident in the neck region as the tissue gets loose and just cannot « stay up » any longer.  The platysma muscle in the neck, which is contiguous with the SMAS (muscle soft tissue of the face), begins to droop and patients will notice banding of the muscle ( the so-called turkey gobbler neck).  It is at this point that the patient will likely need some surgical intervention to reverse these changes.

Once these changes begin to occur, a patient needs to consider facelift as a solution.  Facelifts have many different connotations for patients.  I think this is because there are so many different techniques and approaches that you all have heard about.  Mini-Facelift, Short scar facelift, LifestyleLifts (strong TV marketing), SMAS facelifts, Twilight lifts, Smartlifts, Deep Plane Facelifts just to name a few and I probably missed a couple in there !  The main goal of any of these procedures should be to restore the laxity that  and ligamentous support.  When I evaluate a patient, I take all these factors into consideration before deciding which technique fits that patient.  It is a mistake to try and fit one technique to all patients that walk in.  I try to be versed in all these techniques to assure natural results and long term results.

Lipoatrophy- What does it mean?

So lets break down our earlier blog and discuss more specifically the changes I talked about.  Lipoatrophy represents, in my opinion, one of the changes that aging brings.  It is a term that we use to describe loss of fat or volume in the face.  When a patient says to me that they "looked so much younger" in old photographs, what they are looking at is volume.  Their face simply has more volume as compared to present.
The simple answer to this problem is to restore lost volume.  We can do this in many ways and with various techniques available to us.  The first "filler" was fat and it still is today.  Sometimes we do fat grafting independently or we can combine it at the time of a facelift.  Other fillers that are available on the market like Restylane, Perlane, Juvederm, and Sculptra also play a significant role in facial volume restoration.  In the last 10 to 12 years, the advent of these fillers has made these procedures very popular.  My goal when I meet a patient for facial aging is to find the right treatment option.  The art, of what I offer, lies in the proper assessment and treatment. The ultimate goal is to achieve the most natural appearance for the patient.