Dr. Goldstein's Blog

A Secret of Plastic Surgeons

2008-10-08T19:42:00.000-07:00

I just saw yet another patient with an open wound and instructions to keep the area dry with clean gauze. I will now reveal to you a long kept secret that will probably expel me from the American Society of Plastic Surgeons. Just Joking. We, as plastic surgeons, have always viewed ourselves as teachers not just technicians, and therefore have been trying to teach our colleagues in other branches of surgery and medicine our experience with healing. We are the ones that are called upon to close wounds that no other service can heal. We arrive and miraculously patients' wounds heal within days. The secret...... none really, just common sense. The internal environment of our body (that is anything below the level of the superficial skin) is moist! Therefore when trying to heal an open wound keeping the environment moist will provide the normal biologic rapid cascade that leads to contraction and epithelialization better known as a healed wound. Wounds that are kept dry only form a biologic crust that was once live tissue. A layer of live tissue is necrozed (killed) everytime an open wound is allowed to dry. Healing is inhibited by a scab of dead tissue that is a wonderful breeding- ground for bacteria. Wounds that are kept moist will practically heal themselves if allowed. So next time a friend gets hurt on vacation..... cleanse the wound with soap and water, apply ointment liberally as often as necessary to moisturize and you too will be hailed as a hero. Psst.. don't tell anyone!

Impusle buy

2008-09-27T12:28:00.000-07:00

I have experienced many occasions where potential patients book surgery on their very first visit with me. While I feel slightly flattered by this event, I feel that a time out is usually worthwhile in order to digest the consultation and brochure information. Almost invariably booking surgery on the initial visit results in postponement or cancellation when the person has had time to take many other factors into consideration such as events, people and other obligations as well as the procedure(s). Impulse buying in other situations has fewer consequences (such as unworn shoes in the closet) but aesthetics are more permanent and require more resolve.

Who is a "Cosmetic Surgeon"?

2008-08-06T03:48:00.000-07:00

Once again another example of bad and unsafe cosmetic surgery presented itself in my office. We, as real plastic surgeons, are asked to "fix" other people's mistakes and, as is the usual case, the patient and plastic surgeon are "behind the eight ball". Results and life would be better if people were educated to seek consultation with a BOARD CERTIFIED PLASTIC SURGEON. This means a surgeon who has specifically trained in plastic surgery programs and has been tested (written and oral exams with presentation of their surgeries) and certified by the AMERICAN BOARD OF PLASTIC SURGERY. This is the only board recognized by the THE NATIONAL BOARD OF MEDICAL SPECIALISTS. Since the "cosmetic surgeon" scene is so confusing for the lay person, I recommend that the only question to ask that will get to the heart of the matter is: Is the surgeon certified by the AMERICAN BOARD OF PLASTIC SURGERY? This is a serious case of public safety not a matter of competition between equally qualified specialists, because they, in reality, are not on par.

Liposuction "Urban legend"

2008-07-16T16:44:00.001-07:00

I have to interrupt my discussion of different laser treatments in order to address a horrible grievance against liposuction. It was made apparent to me that liposuction (liposculture, etc) is "the most dangerous cosmetic procedure" because of several horror stories that have been reported by the media. I agree that liposuction can be very dangerous, but only when used by the wrong hands.People with some minimal surgical training will look at liposuction superficially and think it is an easy procedure. They take weekend courses and start operating on unsuspecting patients. Unless they have had proper and extensive anatomical and surgical experience, these untrained non-board certified money-hungry charlatans will kill you when blindly probing their cannulas through existing hernias, abdomens, diaphragms and lungs because of poor knowledge and even poorer or no preop exams. These type of mishaps would not happen if only appropriately trained and certified plastic surgeons were allowed to perform these procedures. Then people would realize the benefits and excellent outcomes from well thought out surgeries.

SkinTyte

2008-06-11T17:36:00.000-07:00

New technology from Sciton makes skin tightening possible. Of course it does not take the place of a face, neck lift or a tummy tuck but it does work for early loose skin. The treatment is derived from thermolysis which heats up the dermal skin while cooling the surface. This provides comfort and safety to the patient. There is no downtime. A series of 2-3 treatments is typical, usually a month apart. It can be combined with other procedures. Full results often require up to 4 months so that collagen can build up and strengthen the skin. Areas that can be treated are face,neck,abdomen, and even arms. No specific after care is needed. You should always use sunscreen though. This is a nice technique if you are not quite ready for more extensive work.

MicroLaser Peel

2008-05-18T15:58:00.000-07:00

The first of many treatments with laser that are available is the microlaser peel. This is perfect for people who are too busy for any significant "downtime". This is an intra-epidermal laser peel or as I rather like to call it: "resurfacing". The laser precisely ablates (removes) a portion of the epidermal skin (outer layer) to smooth out the surface. It is performed with just a topical anesthetic and requires only a normal office visit. The downtime can be predicted by the depth of the peel. Redness lasts usually only 1-2 days. Repeat treatments help deepen the resurfacing process for a smoother, healthier and youthful skin. This treatment is available in the Madison,CT and Providence,RI offices.

Laser Advancements

2008-04-03T19:18:00.000-07:00

I am happy to announce that there are lasers out there that really work with minimal downtime. There are also non-ablative techniques that, of course, have little to no downtime but actually are effective. I personally have had a ten year experience with one company's laser and feel that it has provided good results that were consistantly reliable. The number one concern, as always, is safety which this laser has built its reputation on. I therefore recently aquired a new version of the laser which has allowed me to resurface skin more effectively, quickly, painlessly, safely and with little downtime. The laser also has a non=ablative feature in the form of BBL (broad band light) treatment of brown and red spots, hair, acute acne, superficial vessels, and loose skin. There is virtually no downtime with this new advent. I will discuss each treatment modality in the coming blogs and in the procedure portion of this web site.

Mommy Makeover

2008-03-15T14:26:00.000-07:00

A popular new combination of surgeries has hit the late 30's to 50's crowd. Women finished having babies are looking in the mirror and noticing saggy breasts and abdomen. These are areas that naturally age and with the added physical stress of pregnancy can look in need of some rejuvenation to help with uplifting the spirit as well as the body. Breast augmentation and/or lift can now be combined with tummy tucks in most otherwise healthy individuals safely. The combined surgery is performed in 4-6 hrs with an overnight stay. The process saves money as well as takes off years of wear. For more details check with your favorite board certified plastic surgeon.

Medical Clearance for Elective Surgery

2008-03-02T15:27:00.000-08:00

There is a reason why medical histories and exams are obtained at good plastic surgery offices. This is appropriate medical practice where people with significant medical problems are identified and treated and/or prepared so that medical surprises (read... medical emergencies) are avoided as much as possible. Pre-operative blood work and EKGs also help identify potential problems or even prevent serious complications. Recent well-publicized "plastic surgery " related disasters involving high profile people should make every person appreciate the concern and care in their pre-operative evaluation offered by real plastic surgeons.

Planning

2008-02-04T12:10:00.000-08:00

I often come across (happened again today) patients seeing me for the first time and expecting their procedures booked within a limited time period. The usual outcry would go something like this: "I can only do it in the next three weeks, otherwise it will have to wait a year." Well....... why not plan the visit to my office a little more ahead so that self imposed deadlines are not an issue! Good aesthetic procedures cannot be sandwiched. They require planning for good results and patient safety.

Individuality

2008-01-27T09:36:00.000-08:00

Many potential patients compare possible results to other people's outcomes. Unfortunately that is not always the best method to decide on procedures. As an example I have many women wishing to have the same "cup size" as their friend. That will only happen if the two people are exactly the same chest circumference with the same shape, trunk length, body length, weight and tissue firmness. Its best to look inside you to see what you would like to see on the outside. All you need is a mirror.

Urban Legend

2008-01-12T09:49:00.000-08:00

Just a quick note in regard to a vicious rumor that has been spread as truth by lay and medical people alike. There is the mistaken perception that breast implants have to be exchanged after 10 years. Nothing can be further from the truth. If there is nothing wrong with the implants they never have to be touched. 80% of patients never need more surgery after their first procedure. This is one urban legend that serves no worthwhile purpose.

Happy New Year

2008-01-03T16:36:00.000-08:00

Time for resolutions that we would like to fulfill but down deep in our hearts we know we will not. One of the main reasons for this is that we have unreasonable expectations and the first hint of slow or no progress sends us scurrying for a distraction that will make us push aside or, better yet, forget our initial objective. Maybe a realistic goal with the knowledge that results take an unknown amount of time would be more successful. Nothing happens overnight and if someone promises you just that, be very suspect that the only quick event will be the loss of your hard earned money. Plan carefully and you will be more successful and happy.

Liposuction As Incentive

2007-12-25T09:22:00.000-08:00

Liposuction in the best of all possible worlds works best on people who are at or near their ideal weight since it improves contours of the body. Nonetheless I have seen liposuction help people who are visibly overweight as long as it serves as an incentive for weight loss. The person has to be honest with him/herself as to the reality of their determination to lose weight versus fooling themselves. Some people are able to successfully hold the surgery out as a carrot after they lose weight, and others undergo the procedure first no matter how small the improvement as an incentive to go on an exercise and diet program. Either way these approaches work for some people.

Patient Safety and the Media

2007-11-24T09:08:00.000-08:00

I knew as soon as the media explosion of Dr. Jan Adams and Kanye West's mother took place that I would be inundated with phone calls from worried prospective patients. It is very difficult for the lay public to decipher the truth about professionals' credentials especially when the media itself does not care enough to find out important details such as training and true certification. The general feeling is that certification among surgeons is just a "turf battle" between equally qualified professionals. Nothing could be further from the truth. The word "plastic" should be reserved for use by people trained in the field of plastic surgery. It should not be used as a general term describing everybody who wishes to be called a plastic surgeon. The media is to blame for helping propagate the misconception that everybody is a plastic surgeon. This is not so, and IT IS A MATTER OF PUBLIC SAFETY.

Truth in Advertising

2007-11-13T10:09:00.000-08:00

Once again I have recently run into patients seeking more cosmetic and/or corrective cosmetic surgery after having these procedures performed by ENT, Dermatology, Oral Surgery and Ophthamology physicians. Every patient was surprised to learn that their surgeon was not a board certified plastic surgeon. They were board certified alright! Certified in their own field of endeavor. When physicians advertise themselves as cosmetic surgeons they should be truthful about their board certification. It continues to be a matter of patient safety as well as patient satisfaction.

Breast Augmentation III

2007-11-03T12:08:00.001-07:00

There are a variety of incisions for placement of implants. Some make sense, while others are purely a promotion ploy. The oldest incision has been much maligned in favor of newer and therefore presumably more inventive approaches. The axillary incision is good when the scar is good, but some people develope an enlarged scar in this are which becomes very visible in certain clothes. The nipple areola approach is nice at the very beginning, but as the scar matures it becomes lighter in color and in some cases cotracts causing very visible dimpling. The naval incision is at best a long run (and dangerous) for a short slide. I venture to say that this area is very visible in many of today's styles. The infra-mammary (bottom fold) approach allows good visualization for safe surgery, easy access, and excellent scars that are in the fold of the breast. My large following of exotic dancers have this incision and are very satisfied with it. Not all that is old is bad. There are reasons why this classic has withstood the test of time.

Breast Augmentation II: Above or below the muscle?

2007-10-29T18:56:00.002-07:00

Placement of the implant depends on the anatomy of the individual. I like to place the implant where it will do the most good. If a person has no breast tissue, then the implant is placed under the pectoralis muscle so as to cover the implant with more than just skin. This placement is best because the patient literally has a breast created for her that will never droop since there was no original breast tissue to begin with. In most cases the patient does have some breast tissue or even a fair amount of breast but wishes to enlarge. This situation is best approached with placement of the implant under the breast but above the muscle. Here we are trying to enlarge an already existing breast and even possibly lift it. The best results are achieved when the implant is placed as close to the breast tissue as possible. This gives the most natural appearance.

Breast Augmentation

2007-10-14T18:10:00.000-07:00

Breast augmentation is a wonderful procedure for those that wish to augment their figures. It is a subject that has many urban legends and has been misunderstood. I wish to simplify this area for everybody and thus make everyone aware of the only differences from this procedure compared to other cosmetic endeavors. Breast augmentation requires the use of a mechanical device made by human beings. As a mechanical object it has the same properties as any other such device such as a car, toaster, glass, etc. They all require maintenance and the probability of repair or replacement. The same is true for breast implants, but the likelihood of replacement of breast implants is much less than with other mechanical devices. When you buy a new car, the chances of replacing that vehicle in the future is 100%; while the need for implant replacement is 15-20%. To put it another way, 80-85% of women with breast augmentation will never need another procedure. Clearly the surgery is not for everyone but for those, that after a thorough consultation, can make that choice for all the right personal reasons.

Policing the Medical Field

2007-10-04T20:04:00.000-07:00

I have already discussed the importance of real certification for judging competence and safety. Sadly I have come to the realization that physicians are not ethically able to control themselves when it comes to self promotion for financial gains. I am in private practice precisely because I fiercely believe in being independent, but over the years incident after incident has lead me to the conclusion that we as a professional group need a federal body to police and discipline physicians. I welcome a thorough review of every physician's training and clinical competence so that the public will enter medical offices with the confidence that their safety and health is not compromised.

Certification: Competence and Patient Safety

2007-09-23T19:01:00.000-07:00

I recently saw a young lady for breast augmentation who at the time of her physical exam admitted to having undergone liposuction of the abdomen and flanks just one week earlier. Asking her why she did not see her surgeon for breast enlargement too, revealed the fact that he did not perform breast surgery. It turns out that he is board certified in Ear, Nose and Throat Surgery and not Plastic Surgery. The post operative care for this patient did not include the standard of medical practice which consists of compression garments for at least three weeks. She was not informed of this crucial part of the procedure and her exam revealed bruising and swelling that could have been avoided and would have sped up her recovery. Also the exam showed that minimal liposuction was performed leaving her with residual large amount of fat that will require another procedure. She states that the surgeon informed her that he was certified and she assumed that he was a plastic surgeon. I have run across too many such situations involving other specialties passively allowing patients to ASSUME that they are in the hands of a board certified plastic surgeon. The American Board of Medical Specialties only recognizes the American Board of Plastic Surgery and not the many self proclaimed boards such as American Board of Cosmetic Surgery or American Board of Facial Plastic Surgery. These boards were established by dermatologists and ENTs who wish to perform cosmetic surgery without the rigorous training involving 6-8 years of post medical school learning, operating, research, and teaching that culminates in written and oral exams that are needed to be certified as a plastic surgeon. The plastic surgeon has the competence and lengthy experience in cosmetic surgery. Cosmetic surgery is rightly associated with board certified plastic surgeons. Unfortunately many other physicians want to carry the title without the same level of training. Do not be intimidated; ask your potential surgeon by what board he/she is certified. It is important for best results and your safety.

Botox and Fillers

2007-09-16T14:51:00.000-07:00

Many people are under the misconception that Botox and facial fillers such as Restylane, Juvaderm, Radiesse have the same action or purpose. This is a short note to set the record straight. Botox is a neuromuscular inhibitor that prevents motor nerves from exerting action on muscle, thus preventing contraction which in turn prevents wrinkling. Fillers, on the other hand, provide mass to concavities to elevate the furrows and thus make them less deep. In certain situations the end result may be the same, such as forehead frown lines, but in other areas such as the deep nasal lines (naso-labial folds) only long lasting fillers such as Radiesse will help. Remember that all of these treatments are temporizing measures, before one is ready to commit to more invasive but more permanent solutions.

Combination Procedures

2007-08-20T19:08:00.000-07:00

There are several occasions where surgeries can be combined under one procedure. The opportunity to do this depends on length of the overall OR time, health of the patient and anatomical proximity of the areas to be operated upon. Of equal importance is the infection category of the wounds created since cross contamination of one site to another should always be avoided. Examples of good combinations are: face lift and eyelid surgery, liposuction and fat transfer, tummy tuck and surrounding liposuction, tummy tuck and breast surgery, brow lifts with other facial lifts. Procedures that have possible problems are face lift and thigh/buttock lift, rhinoplasty(nose surgery) and breast augmentation. Many times it is better to separate long surgeries to obtain faster and healthier (fewer complications) recovery. Make sure you have all your questions answered prior to embarking on a multiple surgery voyage.

Cosmetic Surgery and Safety: A Word to the Wise

2007-08-10T15:03:00.000-07:00

Safety is the most important factor in medicine and surgery, especially when elective procedures are involved. When choosing a cosmetic surgeon make sure that he/she is board certified in plastic surgery and has admitting privileges at a local hospital, even though the surgery may be planned in a private operating room suite. The reason for this is that hospitals do not give privileges to physicians who do not show competent full training in the area of surgery they wish to perform. This is important when problems or complications occur that may require hospital based care, which of course should be continued care by the surgeon. One should not perform any task that one cannot finish, no matter what the obstacles. That is the type of training provided by certified surgeons operating in their field of expertise. Other specialties are trying to perform cosmetic surgery; make sure your surgeon can carry out the job to completion.

Preparing for Surgery

2007-06-21T14:22:00.000-07:00

All invasive cosmetic procedures require preparation even so-called "weekend " surgeries. In order to effect a permanent change invasion of the tissue has to be made which results in a typical inflammatory response along with bleeding. The combination can lead to swelling, bruising and even blood collections (hematomas). As the saying goes " an ounce of prevention is worth a pound of cure". It is so very true in surgery. Nothing that I can do during or after the procedure will influence the course of recovery as pre-operative preparation. I therefore give my patients a list of things to do and not do and go over each specific point. #1- No aspirin or aspirin type products, which includes basically all anti-inflammatory meds other than Tylenol. Tylenol is OK everything else is not, like: Advil, Nuprin, Motrin, Naprosyn, Excedrin, Alka seltzer, Alieve, Midol, etc,etc. #2- No Vit E or herbal medications such as St. John's Wart, Saw palmetto, Black cohosh, etc. No fish oil, Co-Q10, flax seed oil, etc. #3- No alcohol. All of the above need to be stopped for at least two weeks. In the case of Vit E, I like one week stoppage per 100 units ingested daily. The reason for this Vit E rule is that it prolongs bleeding: and storage in body fat is dose dependent. Why rules 1&2? Same reason, the products cause bleeding which leads to blood and fluid collections, tissue swelling, bruising, and finally prolonged healing. #4- No protein drinks/bars from health/athletic facilities and no fat burners. Why? They interfere with normal blood clotting or severely potentiate the effects of anesthesia which could lead to vascular/ pulmonary compromise. #5- Day of surgery, no gum or breath mints since the act of sucking or chewing will cause stomach acid secretion which potentially can wind up in the lungs leading to a potentially lethal chemical pneumonia. #6- Nothing to eat or drink for 6-8 hrs before surgery: reason, as above. These basic instructions will make a difference in your surgical experience and healing process, guaranteed.