A mini tummy tuck is a hybrid procedure, part tummy tuck and part liposuction, and for the properly selected patient, it offers the best of both worlds.

Liposuction by itself can remove disproportionate fat from many areas. For the tummy it works extremely well if the skin is tight and the underlying muscle is firm. If there is redundancy and looseness of the skin or muscle; however, a tummy tuck provides superior results. A tummy tuck can tighten and improve the skin and muscle laxity, which is commonly seen after pregnancy and weight loss.

When the looseness is confined to the area below the belly button, a mini tummy tuck may suffice. While a mini tummy tuck cannot improve muscle or skin laxity in the upper abdomen, it can be combined with liposuction to provide additional contouring.

The question I usually ask my patients is, “Are you happy with the area above the belly button?” If so, a mini tummy tuck can provide an easier and more cost effective method of correcting lower abdominal laxity. If not, a mini tummy tuck may still be a good choice, if the upper abdomen can be adequately improved with liposuction. On the other hand, if the problem is loose skin or lax muscle in the lower and upper abdomen, than a “real” tummy tuck is needed.

While the above cannot substitute for a consultation with a Board Certified Plastic Surgeon, it does provide a framework for discussion. It is especially important that cosmetic plastic surgery be tailored to the individual. While general rules provide for safety and predictability, individualization can be the difference between a good and a great result. I you would like to take the next step, please call (925) 943-6353 for a personalized consultation.

If you would like to get your questions answered on air, send me an e-mail today.

The Bay Area’s New Station, KRON, Channel 4 has a new show - “Body Beautiful.” The show is all about the latest trends and treatments in cosmetic surgery. I will be appearing on Monday, November 5, 2007, at 10:00 AM.

The segment will be dedicated to cosmetic plastic surgery, and a portion of the segment is dedicated to answering viewer questions. If you have questions about plastic surgery, you can always send me an e-mail via the DrMele.com web site and get a personal response. If you have a question you would like answered during the “Body Beautiful” television show, please mention it in the e-mail. You can remain anonymous, but if it is okay to use your name or initials during the broadcast, please let me know. Alternatively, you can also call in during the show.

The show is live, and will be available after broadcast via web cast. The live aspect of the show was what hooked me. The most important part of my job as a Board Certified Plastic Surgeon is to provide information to my patients. The question and answer format of the “Body Beautiful” is a natural extension of what I do daily on an individual basis for my private patients.

Full lips are a sign of youth and fertility. The lips tend to be ample in youth, and slowly shrink with age. Many options exist for plumping thin lips, so it is important to choose the option that is best for you.

The most common cosmetic procedure for lip enhancement is by way of an injectable filler. Since the 1970’s, Collagen® has been available off-the-shelf for wrinkle correction and lip enlargement. It still provides a very precise means to augment the lip and fill in pucker lines. While Collagen® provides better definition than some of the new fillers, there are several downsides.

Collagen® has a shorter duration of correction, so there is an increased need for repeating treatments. Collagen® is suspended in solution, so initial overcorrection is needed. Collagen® is white making is visible if the injections are too superficial. Last, and certainly not least, Collagen® use is associated with a 1-3% incidence of allergic reaction. To help avoid the reaction in patients who are allergic, a skin test and a waiting period of four weeks before use is required for the initial treatment and if you have not had Collagen® recently.

Products have been designed to avoid the last problem, Cosmoplast® and Dermaplast® are two. These products do not have a Bovine source, so the collagen fibers in them are much less likely to cause an allergic reaction.

More recently hyaluronic acid products have received FDA approval. Hyaluronic acid (HA), like collagen, is normally found in the skin and joints. Brand name products include Restylane® and Perlane® distributed by Medicis and Juvederm®, Captique® and Hylaform® distributed by Allergan. Each has subtle variations in firmness and longevity. It is important to choose a professional who can explain the differences and choose the product the best suits your needs. In general these HA products last two to four times as long as Collagen® and are softer to the touch. There is no need for a skin test, and since the gel is clear, it tends to be less visible than it predecessor.

Many other fillers and implants exist, but the above are all FDA approved for lip enhancement and the correction of facial wrinkles. Some fillers claim to be permanent, but as anyone who has come across a picture of themselves from five or ten years ago knows, the face continues to age. Regardless of the permanence of the filler, further correction will be necessary if the effect is to be maintained.

Surgery has been used to enhance the lips for many years. Plastic surgeons transplant fat and dermis into the lips to provide fullness using the patients’ own tissues. Dermal-fat grafts are still the gold standard to which all other fillers are compared. While fat alone can sometimes give a lumps, the dermal-fat grafts tend to give a smooth and soft result. I frequently use this trick to enhance the lips, and to fill deeper facial wrinkles to enhance the results of a facelift.

Local “flaps” can also be used to enhance the lips. Rearranging the lip itself can help to enhance a normal lip, restructure an misshapen lip or completely reconstruct a lip lost to cancer, trauma or birth defect. These procedures are more specialized and require a careful consultation.

When considering lip enhancement, you will want to explore the various procedures and find the one that is best for you. It is important to consult with someone who is familiar with all the options so that you can make an informed decision. When choosing an off-the-shelf filler, stick to FDA approved fillers. Ask to see the box and syringe. Manufactures use holographic safety seals to assure you that it is the genuine product and that it has not been tampered with. Products licensed for the US should include the words “FDA Approved.” It’s going into your body. You deserve the best.

Despite all the controversy, breast augmentation remains one of the most popular cosmetic plastic surgery procedures. With hundreds of thousands of American women receiving breast implants every year, the need for breast augmentation revision surgery is also increasing.

Breast implants, like hip replacements or pacemakers, are not considered a lifetime device. Many patients have the idea that breast implants need to be changed at ten years. As a general rule during the first ten years after surgery 25% of women receiving breast implants have implant revision surgery, and this is the focus of ongoing research.

Sometimes breast augmentation revision surgery is volitional. Examples include exchanging implants to change their size. One of the most common revisions performed is to replace the breast implants with larger breast implants. Breasts continue to change as we age, with or without breast implants, so sometimes an adjustment is necessary. Less frequently implants are changed to reduce size, and this may also require a breast lift.

Sometimes breast augmentation revision surgery is not so volitional. Examples include implant deflation and capsular contraction. If an implant deflates, it needs to be replaced with a new implant. The two major American breast implant manufacturers (Allergan® and Mentor®) back up their products with a lifetime warranty. That is, if the implant deflates a new implant is supplied at no cost. If the implant deflates during the first ten years, they also supply funds to defray the costs of the required surgery. Both companies offer enhanced warranties with additional features for an additional fee.

Capsular contracture means that the normally soft scar that secures the implant becomes tight and firm. This can lead to a firm breast or a displaced implant. Revision surgery removes or modifies the scar and repositions the implant. Research is ongoing as to the exact mechanisms responsible for capsular contracture, which it is hoped, will lead to non-operative therapies.

Breast implant revisions are more common with breast reconstruction (after mastectomy or radiation) than with primary augmentation. It is important to know the facts prior to having breast augmentation surgery, and equally important to know what treatment is available. In most cases breast implant revision surgery is less invasive than the original surgery.

If you are undergoing breast augmentation surgery, you can help decrease the need for breast augmentation revision by participating in ongoing clinical research. The requirements are minimal, and consist of filling out an online form once a year. The current studies are designed to give us ten years of follow-up information. Since breast implants continue to advance, most of the number we now quote are based on older breast implant models. The current implants are manufactured under tighter quality control and with advanced techniques.

I ask all my breast augmentation patients if they would like to volunteer to participate in the breast implant follow-up studies. I feel it is my responsibility as a physician and Board Certified Plastic Surgeon to do everything I can to assure the safety of my patients and the predictability of the procedures I perform. Breast augmentation revision patients are eligible to participate if new implants are needed. If you are considering breast augmentation for the first time, ask your doctor if they are participating in the ongoing effort to improve breast augmentation. As the techniques improve, as smaller percentage of patients should require breast augmentation revision.

The question of needing a breast lift comes up often during consultation for breast augmentation. Though the two procedures influence each other, in most cases breast augmentation alone cannot eliminate the need for a breast lift.

The determination is made at the time of consultation. After evaluating where we are starting from and determining where we would like to be, a brief exam is all that’s needed. Experience helps make the determination, but at the risk of over simplifying, here is a quick trick that may provide some clarity.

Place your hand in the fold under the breast. The palm should face forwards. The tips of your fingers should be pointing to the middle of the collarbone and they should be at the junction of the breast and the chest wall. This is called the inframammary fold (literally the under the breast fold). Hint: It may be easier to check the left breast using the right hand.

Once the hand is in position, point your thumb at your fingertips. If the nipple is above the level of thumb tip then a lift is probably not needed. If the nipple is below the tip of the thumb then a lift is probably needed. If they are at the same level you are on the borderline.

Like every good rule there are exceptions. Sometimes a lift is used to change the shape of the breast even when the nipple is not low. Conversely, sometimes an implant is placed lower on the chest and a lift is not needed even when the nipple is low.

There are several ways to do a lift. My goal is always to do the smallest amount of surgery that can give us the best result. If there is a small amount of sagging, then a lesser lift with a smaller scar will usually suffice. If the nipple is pointing south, then a more involved lift is necessary, otherwise the nipple will be low, even with a breast implant.

Contrary to what some patients believe, when I do a breast lift I do not remove the nipple and the areola (the colored part around the nipple) and then replace it on the breast where it looks good. Except in the unusual circumstances, the nipples remain attached to the underlying breast tissue. The goal is to leave the nipple attached to its blood supply and nervous supply to try to maintain circulation and sensation. Too much information?

Do you need a breast lift? Clearly, it’s elective surgery, but when considering breast enhancement a lift is always considered. It may be quickly discarded, but will it help? Only your plastic surgeon knows for sure.

An issue that comes up often in evaluating the belly is the decision between liposuction and tummy tuck. I am all for using the smallest hammer possible to make the abdominal wall look good. A smaller procedure usually means a faster recovery, less risk and less expense.

Liposuction is an excellent procedure for removing localized disproportionate fat. It makes use of small, usually hidden, incisions and allows the body to be contoured with minimal changes to the skin. It works best in patients with discreet pockets of fat who have good skin tone.

Loose skin is an indication for a tummy tuck. While liposuction can remove fat, a tummy tuck can remove fat but additionally tightens the skin and the abdominal wall. Removing the excess with a low abdominal incision tightens skin. This also removes previous low abdominal scars and stretch marks on the lower abdomen. Placing sutures into the tough lining in front of the anterior abdominal wall muscles tightens the abdominal wall, like an internal corset.

Which procedure is the correct one for you depends on many factors, and the decision is best made during consultation with a Board Certified Plastic Surgeon. For some people a compromise between the two procedures, or a mini tummy tuck may suffice.

In general the following rules usually apply. If your skin tone is good (tight) and there is a localized area of fat on the abdominal wall, liposuction can often help. If your skin is redundant (folding over) and the underlying muscles are lax (commonly from weight loss or pregnancy), then a tummy tuck will provide superior correction.

Additional notes: Pain pumps can help decrease postoperative discomfort, and speed recovery for tummy tucks. Liposuction, tummy tucks (abdominoplasty) and mini tummy tucks all work better if you are near your ideal weight and a non-smoker. Smokers have a greatly increased risk of wound healing problems when matched with their non-smoking counterparts.

I am located in the East San Francisco Bay Area community of Walnut Creek (about 20 minutes for San Francisco). The majority of my patients live within a few hours of my office; however, thanks to the Internet, I get inquiries from around the world. Since it is difficult to be exact about any procedure without performing a focused history and physical examination, I usually recommend a consultation appointment for anything other than general information. At a consultation appointment you are provided specific answers to your questions. Initial consultations gives you time to get your questions answered and me time to formulate a plan tailored to your needs. In my practice there is a charge for the consultation, and this is applied toward the cost of surgery should we decide to proceed.

I am happy to be found, and my office can help make arrangements for out of town guests. However, if I am too far away, you might wonder how to find a Plastic Surgeon in your local area.

One way is to try asking your friends, family or family physician for a recommendation. Word-of-mouth referrals tend to quality recommendations, but this isn’t always an option.

If you are starting from scratch, the American Society for Aesthetic Plastic Surgery (ASAPS) at www.surgery.org and the American Society of Plastic Surgeons (ASPS) at www.plasticsurgery.org have doctor locators on their sites. The doctors on these sites must be Board Certified Plastic Surgeons and have had further credentialing.

When you are investigating a doctor you should check their Board Certification with the American Board of Medical Subspecialties (ABMS) at www.abms.org. If it does not say “Plastic Surgery” then they are not a Board Certified Plastic Surgeon. There are many “Boards” out there, but the ABMS is the recognized authority for subspecialties in medicine. Some boards may sound like plastic surgery (some even sound better) but they are not ABMS recognized boards.

You should also check the doctor’s license on you local states medical board web site. For example when you Google “California Medical Board” you will find: http://www.medbd.ca.gov/ listed in the number one slot. Click on the “Check Your Doctor Online” box to check the status for the doctors license. Any actions against the doctor’s California Medical License will be listed here. If none are found it’s a good thing.

I hope you find this information useful. There is no substitute for a face-to-face visit for both doctor and patient, but the above is a good starting point. For those of you in the greater San Francisco Bay Area or Northern San Joaquin Valley, if you would like to take the next step with me, the easiest way to schedule a consultation appointment is to call (925) 943-6353. We are open weekdays, 9 AM to noon and 2 PM to 5 PM.

Joseph A. Mele, III, M.D., F.A.C.S.
Certified by the American Board of Plastic Surgery
Walnut Creek, CA 94598
(925) 943-6353
www.DrMele.com

I am frequently asked by patients, reporters and market researchers about the latest trends in plastic surgery. Most new technologies promise surgical results with no recovery time. I like to keep up with what’s new, but listen with a critical ear. At the recent American Society of Plastic Surgery Meeting I had the opportunity to speak with several vendors of new technology, and it struck me that many plastic surgery procedures are hard to beat in terms of efficacy.

For example, there are several new(ish) technologies claiming to provide liposuction results without the need for surgery. A few have clinical research to show that the technology is safe and effective. When comparing to surgical liposuction, these alternative procedures have a shorter recovery and lower cost per treatment; however the degree of effectiveness is debatable and the number of treatments required can outstrip the lower cost per treatment advantage. The clinical studies that do exist show that noninvasive methods can result in hundreds of cc’s of fat reduction (up to a pound of fat) and repeated treatments are common to achieve the desired results. Compare this to surgery which can remove thousands of cc’s at one time (up to eleven pounds). Upper limits depend on the amount of fat available to be removed.

This is not to say that there is no roll for these types of more limited procedures, and if they improve, one day they may indeed replace liposuction. I am excited about being able to move in this direction, but more effective treatments are needed before they can truly compare to liposuction. There is a reason that liposuction is the most frequently performed cosmetic plastic surgery procedure — it works. Like with any procedure, careful patient selection is key.

No matter what the topic, it pays to ask critical questions. I am always suspicious of oranges that claim to be as good as apples. New procedures have the connotation of better, but old procedures that persist have withstood the test of time. The strengths and weaknesses have been defined leading to increased safety and predictability. We can’t make progress without change, but if something sounds too good to be true…it probably is.

Are you thinking about getting a tattoo in the near future? One in six tattoos are no longer desired. What if someone could offer you durable and removable ink? Or ink with a set life span? The number of inquiries I receive about tattoo removal has been going up. On the long list of technologies I would like to have at my disposal, somewhere near the top would be a skin eraser tool. Something that would allow me to smooth the color of the skin is needed badly. When it comes to tattoo removal a company named Freedom-2 may have the solution.

You may say, Dr. Mele, this technology already exists. We have creams to fade pigmentation, lasers to erase vascular changes and tattoos, dermabrasion to smooth contours, chemical peels and the list goes on. Well that is a sign of the problem. The reason there are so many choices is that there is no one single answer. No one modality will work all the time for all the people. This is part of the reason that Plastic Surgery training takes so long.

The options are always changing. Lasers have outshined the competition for tattoo removal, but I do not perform laser tattoo removal. I prefer techniques that are more predictable. If someone has a small tattoo, it can be excised. This leaves a scar, but it’s predictable. Different colors of ink require different lasers, and different people require different energy levels and precautions. The tattoo may be removed but the skin injured permanently in some cases, and this is not predictable.

If you or someone you know has tried to have a tattoo removed, you know that lasers are helpful, but not perfect. Even if the tattoo is only one color, it usually takes several treatments to fade. If there are multiple colors, the time and cost increases into the thousands of dollars.

So why am I blogging about laser tattoo removal if I don’t do it? Because that may all change soon. Not because there is a new and more expensive laser being produced in 2007 — though I am certain several will be available. The change comes in new ink, and it comes in two flavors. One flavor will allow one laser to remove the ink more predictably for less than twenty percent of the cost of current less effective laser treatments. The second is programmed to dissolve at a set time, without the need for a laser at all. Like henna with color options.

The ink is packaged inside small polymer sphere that can be made to self-destruct after being hit by a laser, or simply fade with time. Sound too good to be true? It may be. The technology has not seen widespread use and things happen when large groups of people are involved. The ink will cost about four times the price of the inks currently used, will only hit about a dozen tattoo parlors early in 2007. For more information check out Freedom-2’s web site at: http://www.freedom2ink.com/

Coming soon under New Technology — Liposuction Without Surgery.

Although silicone gel have always been available qualifying women, yesterday the FDA further eased restrictions. This means that now silicone implants are an available option for breast augmentation for the majority of women. Saline implants will continue to be available, and will still be the best choice for many patients.

Along with approval come some additional restrictions. Here are a few items identified by the FDA:

1) While saline implants are available for women age 18 years and older, silicone gel implants are only available for women age 22 and over.

2) To detect “silent” leaks in the implant an MRI of the breast is recommended at three years after the initial surgery and every two years after that.

3) Recommendations may change as long term data continues to be collected, and to facilitate follow-up, a patient registry will be established.

4) Because of concerns with damaging the implants, silicone filled implants should not be placed transumbilically or with the TUBA technique.

Additional information can be found at http://www.breastimplantsafety.org and on the FDA web site http://www.fda.gov/cdrh/breastimplants/index.html

When considering whether to proceed with breast augmentation it is import to discuss the risks, benefits, procedure, alternatives and recovery with a Board Certified Plastic Surgeon. Many of the risks associated with saline and silicone filled breast implants are similar; however, there are some differences between saline and silicone gel filled implants.

Future note: Some of the problems specific to silicone gel filled breast implants are linked to leakage. The “Gummi-Bear,” form stable implants are soft solids — more like Jello® than a liquid. The upside is, they can’t leak, so MRI’s may not be required. For reconstructive patients (after mastectomy) the implants can be made into a larger variety of shapes. The downside they require a larger incision for placement.

News on these next generation silicone gel implants will hopefully come soon. These implants have been used in Europe for many years. It should be noted that it took Europe less than one year to lift restrictions on silicone gel implants, and this is really is what allowed the advancement to form stable implants. Canada approved the “Gummi-Bear” form stable implants last year. Maybe next year for the US?