My Plastics Life

Oh, Venezuela!

2011-03-15T22:21:00.000-07:00

My favorite quote from this article in the New York Times today:

“I’ve never seen more silicone anywhere else,” Mireia Sallarès, a filmmaker from Spain who focuses on feminist issues and is working on a project about Venezuela, told the newspaper Tal Cual.

I can't imagine.

Rain, rain go away

2011-02-18T15:17:00.000-08:00

Ugh, this rainy, cold weather is really getting me down. Being cooped up inside with windows full of dreary grayness is no fun.

After we moved down the Peninsula (and then even further to the South Bay), my husband often claimed that he missed the misty coolness of living in the Outer Sunset. I was happy to claim a new Bay Area microclimate... but where's that Northern California sun now?

"Bargain plastic surgery". . .

2011-02-01T21:03:00.000-08:00

. . . three words that shouldn't be seen together.

Dr. Weintraub forwarded me this article, and I continue to be equally fascinated and horrified not only by what some medical "professionals" out there continue to do, but also by the poor men and women who are susceptible to such fancy phrases and rock bottom price promises.

As a Bay Area plastic surgeon, I want to believe that our community is too well-educated and informed to fall prey to such things, right?

Why, hello again.

2011-01-29T16:28:00.000-08:00

Wow, has it been a while. 2010 disappeared in a hurry, leaving me grasping at the beginnings of 2011. So let's give this another try.

A few plastic surgery-ish things in the news lately (although lately is probably being overly generous):

Cosmetic foot surgery? As a plastic surgeon, I'm all for making things look better, but really?
Following up on the freaky contact lens craze, some other ways to "enhance" your eyes - some slightly more conventional things, like surgery, Restylane, and Latisse.
A very matter-of-fact opinion on improving how you look and feel. Contrary to what some of the plastic surgeons out there would have you believe, not everyone needs plastic surgery, and not everyone should. I guess I'm just conservative for a plastic surgeon...
Men admitting to wearing makeup (more here too, with a hunky shot of Don Draper to boot). Finally.
So I guess Latisse (and all the other products out there) aren't just for women anymore. Eyelashes for everyone!
One theory on why plastic surgery and cosmetic surgery were suddenly everywhere and everything. To blame? Reagonomics, of all things.
Plastic surgeons aren't all just boobs and Botox; we get called to sew up all sorts of things. I love Martha; I hope she's doing okay.

Regarding the FDA's recent breast implant news

2011-01-27T11:51:00.000-08:00

The headlines sound alarming; anything with "breast implants" and "cancer" in the same line certainly catches my attention. Anaplastic large cell lymphoma (ALCL) may have a possible association with breast implants.

But if you read the FDA communication, you learn that although there is cause for heightened awareness regarding this unusual cancer, thankfully, it seems to be relatively rare. ALCL has been formally reported in 34 of the approximately 5-10 million women worldwide who have had breast implants.

Relatively rare, of course, is meaningless, if it's you; thus the recommendations for monitoring your breast and implant health with self exams, mammograms, and MRI (if you have silicone gel-filled implants).

The Best of Silicon Valley

2010-08-25T16:18:00.000-07:00

Go Duet! Thank you to everyone who nominated us for the "Best Plastic Surgeon in Silicon Valley 2010" - what an honor.

Vote for us here!

Bab(i)es, Botox, Brouhaha

2010-08-13T16:36:00.000-07:00

Probably too young for Botox... Photo courtesy of Maggie Smith

We saw last month the first inkling of the young Glee star admitting to using Botox, now fleshed out into a broader story in this week's NY Times article. Does this represent the early days of a growing trend: cosmetic procedures and surgeries for teenagers becoming commonplace? I think it's interesting how casually some folks are reacting to the news, even comparing it to teens who wish for and receive rhinoplasty (and that's a whole other can of worms...).

And over here, the actress Teri Hatcher (of Lois and Clark and Desperate Housewives television fame) apparently tired of the criticism that she had too much Botox and plastic surgery, posted photos of herself grimacing delightfully in her bathroom mirror.

Botox: it's not for everyone.

News, news

2010-08-12T17:58:00.000-07:00

Like I've admitted previously, I am entranced by news/stories/articles/books about beauty and its perception. This series of special pieces in Newsweek about that exactly makes for some fascinating reading.

It's not just the ugly Americans

2010-07-22T13:28:00.001-07:00

A flurry of plastic surgery and beauty-related news from foreign lands lately:

Is Taiwan Asia's next one-stop plastic surgery shop? Who knew? I just visit for the food...

Indian students flock to plastic surgery to get ahead. I think this happens here in the US as well, but people tend not to be so frank about it (and we're not just talking about the citizens of Hollywood, either).

Vaseline skin-lightening app stirs debate. Now this isn't a new phenomenon in Asia; many East Asian women are quite fastidious about sun avoidance and a number of creams/lotions/potions/treatments promise to lighten or brighten are directly marketed at them. But the app seemed to take it one step too far.

Plastic surgery bits and pieces: roundup

2010-07-21T14:00:00.001-07:00

Wow - just when I was starting to get worried that celebrities had given up on plastic surgery...

Experts: Lindsay Lohan Got Filler in Her Lips Before Jail. Not exactly a peer-reviewed journal, but fascinating nonetheless. Was it Restylane? Or Juvederm? The world holds its breath...

Teenage singer Charice gets Botox for 'Glee' debut. I admit, I really have no idea who this young Filipina is (am I showing my age?), but I hear that Glee is quite a popular show. I understand one wants to make a good impression, but why did this beautiful 18 year old think she needed Botox???

Vampire facelifts: Cosmetic surgery's crazy new trend. Ditto for the whole Twilight phenomenon. But the plastic surgeon's responses in this Salon interview are pretty entertaining.

Don't rule out plastic surgeons yet. That's right. No dinosaurs here.

And finally, I leave you with this heartwarming story that has nothing to do with plastic surgery (but yes, there is still some surgery involved).

News bits and pieces in the plastic surgery world

2010-07-15T08:41:00.000-07:00

Not too much going on out there, save for the usual celebrity plastic surgery speculations and denials. Maybe everyone's on summer holiday.

Cosmetic surgery, Hollywood style. From the LA Times online, putting the blame on TV/mass media for the current plastic surgery "craze". Make of it what you will.

12 ridiculous plastic surgeries. A rather entertaining slideshow of "crazy" plastic surgery-type procedures. There are some valid procedures in the mix here; I'll leave it up to you to figure out which ones. And over here, some snarky OC commentary.

The new face of surgery. Not everything in plastic surgery is nip/tuck. This sounds like a great development for victims of facial trauma everywhere.

Frenchwomen's secrets to aging well and 10 ways to age like a Frenchwoman. My favorite bit from this NY Times Style section article is the quote from a Paris plastic surgeon: the point of plastic surgery in France is “to keep the natural beauty and charm of each individual woman, not to fit some current ideal of beauty.” My thoughts exactly - and that's how Dr. Weintraub and I approach every patient at Duet Plastic Surgery.

Friday Figure Fix: Next installment, coming up

2010-07-09T21:16:00.000-07:00

Never fear, Friday Figure Fix will be here... Give me a little time to work on the next "boob"-related topic. I think what we'll tackle next is the challenge of making breasts that are too big (headaches, neck strain, back pain, shoulder grooving, social discomfort) more manageable.

Friday Figure Fix: Making them bigger, part 3

2010-07-02T11:55:00.001-07:00

This week's Friday Figure Fix wraps up "Breast Augs 101" for all you rabid MPL fans out there. We covered some common questions, the technical aspects (and more), and today we'll discuss some of the complications of breast augmentation. With this kind of surgery, in a skilled plastic surgeon's hands, complications are fortunately uncommon; but they do happen. This week's post is not necessarily to scare anyone off, but to be realistic, provide you with as balanced a picture as possible, and help you become a better informed consumer.

To begin with, breast augmentation (as I keep harping) is still surgery, so all the common risks inherent to surgery apply: bleeding, infection, scarring, need for revision, etc. Some of these standard surgical risks do merit a deeper discussion in the case of breast implants.

Bleeding. We'll include hematomas and seromas in this part of the discussion. But first, some bleeding is expected; we are talking about putting surgical steel to the skin and parts beneath, right? Surgeons, and especially plastic surgeons, have a love/hate relationship with bleeding. On the one hand, bleeding is good - it reassures you that the tissue you're working with is alive; on the other hand, bleeding is bad - blood belongs on the inside, not where you're working...

Anyhow, when we're dealing with breast implant surgery, the rate of bleeding complications is fairly low; we're generally working in an easily identifiable layer where a lot of pesky blood vessels are not typically encountered. So hematomas (collections of fresh or clotted blood) and seromas (collections of clear fluid created by the body) do happen after breast augmentations, but rarely. A few surgeons place drains (tubes to help evacuate fluid from the body) to prevent hematomas and seromas from developing after breast augmentations, but most (including us at Duet) usually don't.

Infection. A lot of times in surgery, wound infections can be dealt with in a fairly straightforward matter; throw some antibiotics at the problem, and things get better. In plastic surgery when we're dealing with implants, we take any hint of infection much more seriously. Because if those implants become infected, surgery often needs to be performed urgently to remove them. If that happens, the body has to be allowed to heal - for several weeks to months - before you can put implants in again.

Asymmetry. Most women are not perfectly matched to begin with. One breast is often larger than the other, and sometimes the alignment of the nipples/areola can be off. Although plastic surgeons do their best to achieve symmetry, if you started out uneven you might still see some of that after a simple breast augmentation surgery. Sometimes the difference seems more exaggerated, because the size of the implants.

Scarring. Again, all surgery causes scarring. As we discussed a few weeks ago, there are ways to disguise the incisional scars necessary to place the implants in the right place. Rarely, those scars can become unsightly, itchy, or even painful. Some of that is caused by surgical technique, but a lot of it depends on your genetics and personal history (some folks, unfortunately, are just prone to scar worse than others).

Capsular contracture. This is a particular kind of scarring specific to implants. Whenever something foreign is placed in the human body, the body reacts by forming a capsule, or scar, around the non-self matter. It's sort of like oysters creating a pearl around an irritating grain of sand.

Sometimes the body overreacts to the foreign body, however, and capsular contracture can develop. The scar capsule that naturally forms around the breast implant is usually soft, pliable, and unnoticed by the patient. When it becomes a problem, that capsule becomes hard, contracted, distorted, and in the worst case, painful. This requires additional surgery to remove the capsule and sometimes even the implant.

Need for revision/replacement. Unfortunately, breast implants are not lifetime devices. On average, a woman who gets breast augmentation can expect to have some sort of surgery every 10 years. Surgery may be needed to remove scar capsule, as mentioned above, or replace the implant, which can leak, rupture, or deflate. This is not to say that surgery should be scheduled regularly, like a yearly physical or oil change. I've seen some women need their implants replaced within a few months, and others (who had the very first implants, in the 1960s) who have never had a problem.

But once you have breast implants, you do need to be vigilant about your breasts - self exams, mammograms, and just an awareness of what normal looks and feels like for your breasts. If you have saline-filled implants, it's relatively easy to know if the implant is leaking (you'll notice that one boob is smaller than the other, because the leaking saline is simply absorbed by your body). It's a little tougher to tell with the silicone-gel filled implants, since the cohesive gel doesn't run, so regular screening MRIs to look for leaks and ruptures are necessary.

And of course, while the vast majority of patients are very happy with the results of their breast augmentation surgery, a few women wish they had gone bigger, smaller, or not at all. Revisional surgery - to upsize, downsize, or remove the implants - can be performed.

More questions? Feel free to email me - AngelineLimMD [at] DuetPlasticSurgery [dot] com.

If only...

2010-06-30T13:26:00.000-07:00

Photo by Juergen Teller for NYMag

... everyone was as awesome as Dame Helen Mirren.

We've talked a little bit before on this blog about appreciating all sorts and shapes of bodies. I developed a little bit of a girl crush on Helen Mirren a few months ago, when these pictures of her surfaced on the interwebs. She looked totally great in her swimsuit and knew it. You have to admire that kind of attitude, and besides, she is a pretty good actor.

I bring this up because saucy girl that she is, Dame Mirren is oh so glorious in new photos. Plastic surgery or not, I can only hope to look so good when I crawl into my 60s...

Why, hello there. What are you wearing?

2010-06-27T11:38:00.001-07:00

Photo courtesy of jfelias

It's a hot day in Silicon Valley today - right now it's sunny, cloudless, and the weatherman is predicting a high in the 80's. In the Midwest, where my parents still live, they're sweltering in the 90s with high humidity. Just thinking about the heat makes you want to wear as few clothes as possible, right?

So before you jump into the pool, run off to the beach, or even hop into the car for a nice drive with the A/C blasting, remember this: The sun is our skin's enemy.

Want to look good now and later? Protect yourself from the sun (that means no tanning booths either - there is no such thing as a "safe" tan). You'll save yourself from premature aging, wrinkles, and skin cancer; all things plastic surgery can help take care of, but wouldn't you rather not?

Simple stuff: wear as much clothing as you can bear (long sleeves, pants - I know, it's hot in the middle of summer), a wide-brimmed hat, avoid the sun when you can, and slather on the sunscreen regularly. You can even go the extra mile and imitate some of the fair-skinned ladies I've seen in the Bay Area - a full face-covering visor and arm length gloves or "warmers".

Some light summer reading to inspire you:

UVA Reform: It's Not PDQ. The lengths that some folks will go to obtain the best sun protection.

SPF inflation in the sunscreen aisle. An explanation of what's really out there in SPF.

Clothing with UV protection built in. A different kind of style for summer.

"Natural" sunscreen: Better for you? Good question, answered by the LA Times.

Avoid getting burned by sunscreen purchases. Just putting it on isn't enough; you have to put on enough and reapply regularly.

Friday Figure Fix: Making them bigger, part 2

2010-06-25T08:05:00.001-07:00

So the quest continues, to make the mysteries of boob jobs and breast augmentation a bit less mysterious for all. We've addressed a few common questions (Saline vs silicone? Round vs anatomic?) and started in on the technicalities of this surgery - time now to wrap up Breast Aug 101.

Last week's Friday Figure Fix focused on the types of incisions available for placing breast implants. Now, let's delve a layer or two deeper and investigate where exactly those implants go.

It's fairly self-explanatory, right? Breast implants go in the area of the breast. But where, exactly? As plastic surgeons, we like to place implants in a well-protected area - more layers of defense against the outside world and a little padding to help camouflage the man-made construct. The luxury of extra coverage is not always available (like in breast reconstruction for breast cancer survivors, which is another topic entirely in itself), so we like to take advantage of that good tissue in breast augmentation surgery.

In the academic journals, some plastic surgeons like to split hairs when they describe the location/technique for breast implants (you'll occasionally run across terms like "subfascial" or "dual-plane"), but when discussing the future home for your breast implants, it pretty much boils down to two locations, as seen in my illustration above.

1. Submuscular (or subpectoral). Here we're talking about placing the breast implant underneath the chest muscle - the pectoralis major, specifically. Why do that? Again, the muscle provides another hearty layer of protection between the implant and all the bugs that roam about the outside world. Some people believe that the extra muscle layer helps blunt the slope of the breast, to give a "more natural" and "less implant-y" look.

There have also been some studies that show a decreased incidence of capsular contracture (hard and sometimes painful scarring around the implant) when breast implants are placed beneath the muscle. There is also speculation that breast function (e.g. sensation, breast feeding potential) is disturbed less with this technique, since there is less surgical manipulation of the breast tissue.

2. Subglandular. If you have enough breast tissue or subcutaneous fat to disguise the implant, subglandular placement (putting the breast implant underneath the breast - which is the gland we're talking about) is an option. Some folks prefer this placement because it looks "more natural" (Isn't that what we said about technique #1? Go figure.). Recovery time tends to be a little quicker, since you're not really messing with the muscle - much less soreness and crampy muscle pain.

So that's pretty much the ins and outs of the technical aspects of breast augmentation - all the key decision points you should hit in the consultation with your plastic surgeon. But wait, you say - all we did so far was gloss over the rosy bits of boob jobs - let's be realistic here - can't things go wrong?

Glad you asked. We'll discuss what can go wrong with breast implants/boob jobs/breast augmentation on the next installation of the Friday Figure Fix!

Plastic surgery bits and pieces: roundup

2010-06-21T14:41:00.000-07:00

Some items that have come across my desk recently:

Optimism not linked to higher surgery satisfaction. Whatever happened to the power of positive thinking? Although this facial plastic surgeon's study didn't find any connection, anecdotally, looking at all the patients I've had the privilege of taking care of throughout my career, the ones with good attitudes seemed to bounce back more quickly and do better after their operations.

Forget Botox. Floss your teeth. Well, I wouldn't throw out the Botox just yet, but I have to agree that dental hygiene is pretty important. Not just for your health, but yes, for your looks. All those folks on shows like Extreme Makeover? Some of the dental restorations were absolutely transformative - I was impressed by what a difference a beautiful smile made. I think the lesson here is to take care of yourself; otherwise, all the plastic surgery in the world won't matter.

Joan Rivers talks about plastic surgery... I have to admit, I was a big fan of her catty comments on the red carpet. It's also refreshing to hear a celebrity talk openly about plastic surgery, whether you personally appreciate the results or not.

Cougar cosmetic surgery on the rise... Perhaps a tabloid is not exactly a reference you'd include in the footnotes for your highbrow academic medical paper, but this little bit is interesting, nonetheless. Best part of the piece? The photo/caption: that's no physician performing a cosmetic procedure; that's the anesthesiologist intubating the patient. Nice work, guys.

How the other half heals. Not everything in my world is about plastic surgery - I'm always fascinated by the stories and thoughts of other physicians (right now, I'm working on finishing Atul Gawande's latest book, The Checklist Manifesto), and Teri Reynolds' piece is exceptionally articulate and thoughtful, if you get a chance to pick up this month's issue of Harper's.

Friday Figure Fix: Making them bigger, part 1

2010-06-18T13:17:00.001-07:00

Photo courtesy of preciouskhyatt, flickr.com

Last week we answered a couple frequently wondered questions regarding boob jobs, or more clinically speaking, breast augmentation. Now let's tackle some more technical aspects of what it takes to make smaller breasts bigger.

Breast augmentation, is of course, surgery. This may seem self-explanatory, but I really can't emphasize this point enough. You shouldn't be able to walk into a doctor's office for the first time and on the same day walk out with bigger boobs. Cosmetic surgery though it is, breast augmentation still requires a careful history-taking and physical examination by a skilled surgeon long before anything goes up a cup size or two.

Questions (like these) should be asked and answered. Another key point is the placement of the incision or scar. There are several options these days, as you can see in my illustration below.

1. Transaxillary. This is the "armpit scar" - a small incision is made in one of the creases of the armpit, and a tunnel is made to the breast area to allow for placement of the implant. Sometimes a small video camera is used to help see the creation of the pocket where the implant will live; sometimes not.

Some patients and surgeons like this approach because it does not leave any scars on the breast. Instead, you have your scar in a fairly inconspicuous location (hopefully, no one's looking that closely in your armpits).

The downside of the transaxillary technique is that it is a remote approach to the breast; some surgeons feel that fine control over placement of the implant is not as precise. Also, if you need a revision for any reason after a transaxillary breast augmentation, it is very difficult to use the same incision - which means that you might end up with a scar on your breast anyway.

2. Periareolar. A lot of folks commonly refer to this incision as the one that "goes around the nipple", which isn't quite accurate. The incision is made skirting the underside of the areola, the pigmented area around the nipple. Many patients prefer this scar, because they think that it will be well hidden in that area of color change. Many surgeons prefer this approach because it offers direct access to the breast for the implant placement.

Personally, I'm not a big fan of the periareolar incision. I think that the scar is often more obvious when placed around the areola - it often heals to become either lighter or darker than the surrounding breast skin or the areola. Also, the border of the areola is very indistinct if you look at it closely. It's neither a straight line or perfect circle; our incisions are either lines or arcs, which makes it easy to spot from across the room.

One more downside to the periareolar incision: because you're cutting through breast tissue so close to the nipple, you run a slightly higher risk of interfering with sensation and breastfeeding potential.

3. Inframammary. This incision is hidden beneath the breast, just above the bra-line. Patients like it because a well-placed scar ensures that no one sees evidence of their surgery, unless they're peering underneath their breasts with a flashlight and magnifying glass. Surgeons like it because it offers great access to the space where the implants go.

Personally, the inframammary approach is my favorite, for the abovementioned reasons.

4. Transumbilical. This technique was developed and championed more recently, as plastic surgeons attempted to find a "more perfect" approach for breast augmentation. You may have seen it on those reality TV shows or marketed as the "TUBA" technique. The incision is placed in the belly button, which is a great place to hide scars. Unfortunately, you face similar limitations as the transaxillary technique and are tunneling implants quite a distance; this approach never lived up to expectations, and I don't know of any respected plastic surgeons who routinely perform breast augmentations this way.

Next week, we'll take a closer look at where those implants actually go. More questions? Email them to me at AngelineLimMD [at] DuetPlasticSurgery [dot] com.

Kind of a big deal...

2010-06-08T13:33:00.000-07:00

Remember this? I was reminded of the whole "Math class is tough" Barbie debacle when I saw this piece by the New York Times' science columnist today, which revisits the hoopla over women in science spurred by comments from then-president of Harvard, Larry Summers.

I won't pretend to understand all of the obstacles and hardships endured by women who have fought their way to the top of academic math and science, but as a woman in surgery - and a female plastic surgeon, nonetheless - I can sympathize.

Let's face it, medicine used to be a boys' club. Growing up, my pediatrician was a lovely older man, and when the time came to choose a gynecologist, there were only men to choose from in my hometown.

But again, medicine used to be a boys' club. Now over half of all medical students are women, and the majority of pediatricians and OB/GYNs practicing today are women. In my surgical intern class at Stanford, six out of twenty-three of us were female, which was fairly impressive to me at that time.

The specialty of surgery, however, remains male-dominated. Why? Is it because men are better surgeons? I would have to disagree with that. Men tend to have bigger egos and greater hunger for power? As much as some may want to believe women are the fairer sex, no to that thought too.

Want to hear my personal theory (and that's all I claim for it - pure opinion, based only on my own experience and reality, no studies, no evidence to back it up)?

Surgery is tough. Any stubborn human being can put his or her head down, put the blinders on, and the nose to the grindstone for five, six, seven (or more) grueling years of residency. But women, as tough as we need to and can be, have an additional biological burden to bear; like it or not, our prime years are spent in surgical scrubs, sleeping in questionably clean beds in dingy call rooms, running around the hospital ward trying to answer to a dozen different bosses, staying on our clog-clad feet for marathon operations. A lot of women (and frankly, men, too) decide that this isn't worth it or that this life (temporary as it may be, if you can optimistically call five years temporary) isn't fair to their families.

I never thought about those harsh social and reproductive realities as a medical student trying to decide what kind of doctor to become. I liked surgery; I loved plastic surgery; and that was that. Maybe my naivete helped me endure. Being on the far side of those years, I can look back without regrets now.

Those years are exactly what make me unique; there aren't that many female plastic surgeons out there (kudos to Stanford for being at the forefront of training women in plastic surgery; perhaps a subject to explore in another post sometime).

And that is what makes my work relationship with Dr. Weintraub so special. Where else in the Peninsula/South Bay/San Jose area can you find a team of female plastic surgeons working together? That's right: Duet Plastic Surgery. We're kind of a big deal.

Friday Figure Fix: Sometimes bigger is better

2010-06-04T16:37:00.001-07:00

In contrast to some of the previous topics handled here in the Friday Figure Fix, breasts (or as some might say more casually, boobs, bewbs, boobies, and my personal favorite, "the girls") elicit a stunning variety of feelings and opinions.

For example, if you have a tummy issue, I can pretty much guess that you have a little more tummy than you would like and you want it gone. Whereas with breasts, it could really be anything: too small, too big, too uneven, too droopy, a combination of any of these, or too much like a girl's (for my guy friends out there, you are not forgotten here at this plastic surgery blog!).

So let's tackle one breast-related Figure Fix at a time; we'll start with "too small".

Now before anyone out there gets too huffy, yes, breasts are beautiful (we discussed that last time), and yes, size is relative. But let's just imagine that you are a smart, well-adjusted woman who has always felt that she's a bit on the small side for her own figure or a smart, well-adjusted woman who used to be a little bigger (weight loss, pregnancy/nursing, etc) and misses them. You've tried it all: the rolled up sock or wad of tissues in the bra, the "chicken cutlet" gel inserts, the push-up/wonder/water/miracle bras. You've had a friend or two who had "her boobs done" and now you want to know the facts about breast augmentation as they pertain to you.

Lucky you, this blog has the answers to your questions coming right up.

Basics first...

Can anyone have breast augmentation?

Not exactly. Like I hinted at above, you have to be savvy enough to understand what you're undertaking when you sign the consent form for surgery. You also have to be of age to consent (sorry, all you hopeful 16-year-olds out there, you're just going to have to wait). And, at least for me, you have to be a reasonable person with reasonable expectations.

Of course, if you look around hard enough, you'll find someone who's willing to be a bit more lax in their regard and restrictions. But is that what you really want in your surgeon, someone who prefers the fuzzy side of ethical?

Is a "boob job" real surgery?

Uh, yeah. By "real surgery", you mean it involves a knife and blood? Yes. There's no magic in making boobs bigger. There will be some pain and soreness afterward. Sorry.

Who should I see to have this surgery done?

If it were me, I would look for a couple key qualifications: 1) a surgeon, 2) a plastic and reconstructive surgeon.

Generally speaking (and there are always exceptions), plastic surgeons who have completed 5-7 years of specialized surgical training are well qualified to perform breast augmentation (versus other doctors or medical professionals, who may not even be surgeons but claim competence after completing a weekend-type course).

See also answer to question #1, last sentence of second paragraph.

What exactly are these implants that are going to be stuffed into my chest?

All breast implants approved for use in the United States today are made of the same silicone shell; the major difference that's discussed is what fills those shells. They can be filled with saline (salt water solution, similar to the balance of fluid already in your body) or silicone gel (a squishier non-native substance, whose appearance helped earn the nickname, the "gummy bear"implant).

Photos courtesy of allergan.com

One's saline-filled, the other's silicone-gel filled. Can you tell the difference? Yeah, not so much by looking at a picture - but feeling the implants gives you the obvious answer. The saline-filled one is pretty similar to a water balloon, whereas the silicone-gel filled one is like one of those stress reliever balls you squeeze in your fist. Some say the silicone-gel filled implant mimics the consistency of the human breast more closely.

There are also other, more minor differences in implants. The shape of the implant can be round or what is termed "anatomic".

As you can see in my lovely illustration, the implants when viewed flat on from above look fairly similar in shape (round, or close to round). When the implants are placed on a flat surface and viewed from the side, you can see more of a difference. But when you hold up the implants as if in the position they will assume in an upright woman, the difference between the round and "anatomic" implants are fairly negligible - both resemble the natural breast pretty closely, due to gravity.

The implant shell can also feel different on the outside, which may or may not affect how the body heals around the implant. Some surgeons will only use smooth-surfaced implants, while others swear by "textured" implants.

The plastic surgical literature doesn't really have much evidence to say that one is "better" than the other, not in hard numbers from clinical trials. So deciding "smooth vs textured" is generally up to the surgeon and you.

Is this stuff guaranteed?

Well, yes and no. Within a certain time frame, most implant manufacturers will replace implants at no cost if their labs determine that the cause of the implant "failure" is if there was something inherently faulty with the implant itself. Depending on the situation, your surgeon may also waive his/her fee. But that might still leave you responsible for any additional OR and anesthesia fees.

Generally speaking, though, if you wish you had gone bigger (or smaller) after the fact, you might be stuck with paying for the entire surgery all over again.

Other questions? Stay tuned for further Friday Figure Fix installments, or email me at angelinelimmd [at] duetplasticsurgery [dot] com.

Just for men: the latest in faking it

2010-05-29T12:24:00.000-07:00

From the Sculptees website

Sometimes this blog can seem overly female-centric; but come on, I'm a female plastic surgeon. This blog is about plastic surgery, and the vast majority of plastic surgery patients are women.

But guys, this post is for you. We first heard about these innovative man-garments a little while back, but the NY Times Style section is hitting it up again.

Enjoy your Memorial Day weekend without fear!

Friday Figure Fix: Boobs, boobs, boobs!

2010-05-28T10:14:00.001-07:00

Photo courtesy of m_bartosch

Momentous day here:

Finally, a long-promised Friday Figure Fix post! And you thought I was just stringing you along.
According to Google, this is my 100th post. Amazing.

So, as you can tell from the title of this entry, there's nothing subtle about the subject matter. Everyone loves boobs, right?

Forgive my cavalier attitude, but as a female plastic surgeon who takes the matter very seriously and personally, sometimes you need to lighten things up a bit.

In previous Friday Figure Fix posts, we've covered just about every other major body part and "flaw", and now with Memorial Day Weekend fast on our heels, we can almost call it summer. You already know how to deal with the other anxiety-inducing bits unveiled by bikini season, now we have to face "the girls".

Breasts are remarkable appendages. We're mammals, so we've all got them, both men and women. In women, of course, the parts tend to be a little better developed - mammary glands, which serve an incredible function - producing milk for little ones. And of course, there is the aesthetic and sexual function of breasts.

Some women feel that their breasts are too small for their frame; others find that they are burdened by overly large breasts - headaches, neck and back pain, shoulder grooving from bra straps, skin irritation and rashes. And nearly every woman has been frustrated by the impossibility of finding a proper fitting bra.

Some women (and men, too) are born without a breast; others are forced by the diagnosis of cancer to have one or both removed.

Over a lifetime, breasts undergo quite a few changes; there is the joy of puberty, cyclical variations with menstruation, ups and downs with weight oscillations, growth during pregnancy, explosive engorgement with nursing, the stretch marks, droopiness, and deflation following child rearing, and the inevitable pull of gravity with aging.

Regardless of what you were born with, there is beauty within. Even after a lifetime of changes, many women are wholly appreciative of what they have; they have their fans as well.

But many women miss what they had before - or what they never had; besides, this is a plastic surgery blog, so we're going to discuss what to do with those boobs in the next few Friday Figure Fix posts.

Friday...

2010-05-21T17:47:00.000-07:00

And you loyal followers thought maybe, just maybe, there would be another installment today... No such luck in the MPL world. It's not over yet, though, I promise. I have more facts, thoughts, and wild opinions to share with all of you, don't you worry...

A My Plastics Life Public Service Announcement

2010-05-19T12:50:00.001-07:00

When I saw this article in the NY Times yesterday, it made me think of the presentation I give for the HealthTrust of Santa Clara to eager high school students about what I do as a plastic surgeon.

Sure, my life in plastic surgery is all about boobs and Botox - or some would think... I use the class period to reveal a little bit more about the wide, wonderful world of plastic and reconstructive surgery. The NY Times article talks a bit about the spills that professional cyclists endure, and part of my presentation describes dealing with the medical consequences of those accidents. In a few words: lots of stitches, metal plates and screws.

So the one thing I beg the students to remember from my talk? If you ride a bicycle, you need to wear a helmet. I can save your face, but first, the helmet has to save your life.

One student complained, But I had a friend who was wearing a helmet when he got into an accident, and the stupid thing cracked!

Exactly. Better the helmet than your head.

A day (or two, or three, or four) without the internet

2010-05-11T12:08:00.000-07:00

Wow. Four and a half days involuntarily deprived of internet access makes you a discombobulated technological cripple. No email, no Google, no news, no way to print out directions to Mother's Day brunch, and most horrifyingly of all, no blogging...

Lucky for us, today AT+T figured out that our woes were the result of a malfunction at the central office and they "just needed to turn the switch on". That took four-plus days to figure out?

Despite our Luddite-like hiatus, the world of plastic surgery still managed to spin on its axis. And although I sometimes fear that my continued posting on this subject puts this blog dangerously close to transforming into a hateful plastic surgical rant, I have to believe that it's all about information and education. So enjoy, more frightening news, this time from our neighbors and colleagues on the east coast.

Friday, but not a Figure Fix exactly: Your moment of zen

2010-05-07T14:57:00.000-07:00

A California poppy on top of Windy Hill

Sorry guys, you're going to have to be patient with me about this Friday Figure Fix thing. The column is slowly cooking in my head, and it will emerge fully formed at some point.

In the meantime, I was reading a new book called Drive, by Daniel Pink. It's interesting, a pop-business-culture examination of what motivates people. He opens one of the middle chapters with a snippet of poetry I've never come across before, but really enjoyed:

You need not see what someone is doing
to know if it is his vocation,

you have only to watch his eyes:
a cook mixing a sauce, a surgeon

making a primary incision,
a clerk completing a bill of lading,

wear the same rapt expression, forgetting
themselves in a function.

How beautiful it is,
that eye-on-the-object look.

- W.H. Auden

I love discovering beautiful things in unexpected places.

As plain as...

2010-05-05T09:01:00.000-07:00

Photo courtesy of djcodrin

The latest issue of Elle landed in my mailbox a few weeks ago; buried deep in the back of the magazine, under the "BEAUTY: PSYCHOLOGY" section were a pair of articles about rhinoplasty.

The first one, titled "Pieces of You", discusses the author's regret later in adulthood regarding her surgery; she felt she had lost a vital connection to her father, whose proud nose she had inherited and chose to alter as a teenager.

The second article, "Mother, Mirror", takes a different point of view; this author tells how she came to terms with the unique shape of her nose, despite everyone else's unsolicited opinions and advice.

Plastic surgery, clearly, isn't for everyone. The CNN article briefly delves into some of the limitations of age; it raises the question of whether or not rhinoplasty (or any cosmetic surgery, for that matter) is an appropriate "graduation gift" for a teenager.

Even beyond the age issue, I think the decision to change the shape of your nose is one of the most difficult, for both the patient and the surgeon. The nose is such a key architectural element of your face, and it often carries a lot of cultural weight. Much of your nose's shape and structure is related to race and heredity. Some people want to keep some of those ethnic or familial nuances when they have their rhinoplasty; others are committed to eliminate all traces in order to obtain their concept of the ideal nose.

There is no right or wrong; it's a very personal decision and one that you have to live with for the rest of your life. It's as plain as the nose on your face.

Hold on - lush lashes for anyone?

2010-05-02T09:41:00.000-07:00

Photo courtesy of djcodrin

The New York Times Style section has another interesting piece today, this time focusing on the explosive popularity of Latisse. For those of you who have somehow missed the Allergan-funded media extravaganza featuring Brooke Shields, Latisse is a medication that increases the length and thickness of eyelashes. As the article points out, Latisse is a prescription-only drug, but consumers and apparently physicians are finding ways around that stipulation.

As with a lot of medical discoveries, Latisse's usefulness for the "lash-challenged" was somewhat serendipitous. The drug, bimatoprost, was originally used and marketed by Allergan as a glaucoma medication; eye doctors noticed that their patients were growing longer, lusher lashes on the treated eye. Allergan moved to capitalize on that discovery, which now grosses them over $70 million a year.

The thing is, because Latisse is so "easy" and the perception is that it's "just" a cosmetic enhancement, it seems that not everyone is exercising the proper amount of caution with its dispensation and use. As with any prescription medication, not everyone is a suitable candidate, and there are benefits, risks, and known side effects with the use of Latisse.

Just as with all the other non-invasive cosmetic procedures, like Botox/Dysport and dermal fillers like Juvederm and Restylane, a qualified and experienced physician should do a full history and physical before determining if you are right for the procedure/medication.

This is what Dr. Weintraub and I do at Duet; call us conservative, but you are not just our client, you are our patient. We want you to look good and feel good, and I think that a little good old-fashioned doctoring helps achieve that. Even with something as "simple" and fabulous as Latisse.

Friday, but not a Figure Fix post...

2010-04-30T18:30:00.000-07:00

My apologies, dearest readers, but there is a lot going on behind the scenes at My Plastics Life right now. So in lieu of another insightful, thought-provoking Friday Figure Fix (I promise, one will be forthcoming), here's a roundup of all things vaguely plastic surgery-related I have been catching up on from the past week:

Yes, another article decrying the downturn in plastic surgery (but not all hope is lost!).
Somehow, I don't think the U.S. government is going to be following Brazil's innovative lead here. But can you imagine?
I'm all about looking good at any age, but this is slightly horrifying. Don't girls know how naturally beautiful they are?
A good thing? Or TMI? I admit, I refuse to join Facebook, for a variety of reasons.
It's a two way street: absolutely.
Summer's coming, finally. Are you stocked up on sunscreen and wide brimmed hats?

Not quitting my day job

2010-04-20T18:19:00.000-07:00

Screenshot from www.retroland.com. Not the title-winning shot, clearly.

It's definitely my inner geek crying out, but I sought out and loved the documentary, The King of Kong, which traces one pretty regular man's quest to be the best in one of the most famous games of arcadeland. There's something so fascinating about humans and their obsessions - and how scarily good people can get at something when they devote hours upon hours of their lives.

So a little cheer for this plastic surgeon, who saw the movie, and thought, I can do that. And did.

The best part? He's gotten two referrals out of the media attention following his claim on the championship.

Me? I admit I'm more of a pinball kind of girl, and I'm nowhere near approaching 10,000 hours of play. Something to shoot for, I guess. In the meantime, back to the grind at good ol' Duet...

Nothing says "thinking of you" like...

2010-04-19T09:26:00.001-07:00

... your old breast implants. Thanks, Sharon and Ozzy, for sharing.

Friday Figure Fix: Mental break

2010-04-16T10:34:00.001-07:00

Okay, I need a little more time to create something fabulous for the Friday Figure Fix column. Give me a week, and in the meantime, enjoy this beautiful view of the Bay Area from an overlook at the Montebello Open Space Preserve. I love living here!

Friday Figure Fix: No miracles here

2010-04-09T08:31:00.001-07:00

In what seems like an endless series of "caveat emptor" posts over here at My Plastics Life, now a new tidbit of information on what's really going on out there, this time from the FDA.

We've talked so many times before about how there is nothing magical about how to fix your figure, and something seems too good to be true, it probably is. In the world of medicine - and more specifically, plastic surgery - quick fixes can lead to disappointing, and sometimes even dangerous, results.

In this case, the latest culprit is "Lipodissolve". Who needs surgery when you can get fast results with injections that simply melt the fat away? Life, unfortunately, is not that easy , and it seems that a lot of patients were harmed for believing these practitioners' touts.

Caveat emptor, part three

2010-04-08T11:07:00.000-07:00

Photo courtesy of Graeme Weatherston

Seriously, how many times can we talk about this?

In today's Style section of the New York Times, there is a very interesting article discussing a very disturbing trend in cosmetic surgery: the awake breast augmentation. As the article points out, most of the practitioners of this procedure aren't plastic surgeons (or even surgeons) and aren't performing the surgery in an accredited facility.

The supposed benefits to doing a major surgery while the patient is awake? It's cheaper, for one (you don't have to pay for the anesthesiologist); and the practitioners claim that it allows the patient to have "of the moment" input into their bust size.

Maybe I'm a very conservative plastic surgeon, but those reasons seem pretty weak. I like having an anesthesiologist with me during surgery. Breast augmentation is a serious and delicate operation. Since I trained for years to learn all the details of how to perform surgery, I like to focus on what I'm good at and leave the anesthesiology part to the guys and gals who spent their years learning all the ins and outs of anesthesia. Makes sense, not just for my comfort, but especially for my patient's comfort.

As for the patient input claim? I'm definitely a patient advocate in this matter - I do my utmost to communicate openly and often with my patients about what their hopes and expectations are in terms of breast size, shape, and feel - and this should be done well before the operation. By the time the surgery starts, we're all on the same page, and my patients trust me to use my surgical skill and judgment to deliver the look they want. I personally think it's problematic if you don't have that sense of trust before going under the knife and you have to rely on last minute input from your "awake" patient who is actually fairly altered from the narcotics and barbiturates given for the procedure. If you can't drive a car or sign a legal document while on those kinds of meds, you certainly can't give an informed opinion on how big you want your boobs to be.

But that's just what this cranky female plastic surgeon thinks (although, from the comments in the article, it's what other well-known and respected plastic surgeons are saying too...).

I guess we shouldn't be surprised...

2010-04-07T09:16:00.000-07:00

It pains me a little to be returning to this subject, because I don't want to seem like I'm enthusiastic or even the least bit encouraging. But yes, Heidi Montag seems to be dragging out her latest stint in the plastic surgery gossip headlines - this time talking about "back scoop" surgery (at least this is mildly relevant to recent posts on this blog).

I feel slightly bad for her - and perhaps shame on her surgeon for this - how can you have a surgery without really knowing what it's about?

Caveat emptor, again

2010-04-03T07:20:00.000-07:00

Finally, a little research to back up what I've been on my soapbox about for so long.

So there you go, ladies and gentlemen. The fine scientists at Loma Linda have established that yes, there are an awful lot of folks out there practicing "cosmetic surgery" with no surgical background. Depending on your savvy and comfort level, maybe that's okay for some of the less invasive procedures like Botox and dermal fillers, but you probably want to do a little extra research on the physician you choose for your liposuction...

Friday Figure Fix: Back to back, part two

2010-04-02T08:54:00.001-07:00

86F at the Artists' Palette in Death Valley in March. A bit warmer than Palo Alto these days.

Now that cold, dreary weather has crept back on us in the Bay Area, it seems a bit wrong to be talking about how plastic surgery can help get you ready for swimsuit season, does it not? Oh well. The real spring will be arriving soon, with bright and sunny days that seamlessly meld into the sweltering, minimally-clad days of summer. Right?

And so we trudge onward, divesting the deepest secrets to a sexy back, courtesy of your favorite female plastic surgeon... Last week we talked about the main trouble areas associated with the oft-neglected but all-important back. Today, let's talk about fixes.

For overall definition and touch ups, liposuction remains a great solution. We've talked about lipo before, and the same theories apply to its use on the back. You should be close to your ideal weight to get the best results, and if you do have just a few nagging problem areas, liposuction can help trim down some of the fat collections so that your back looks smoother and more in proportion with the rest of your figure.

If we're looking more at rolls of skin and fat (like the ones that hang over the bra, or prevent you from finding a well-fitting bra/swimsuit), we might be veering more into the world of surgical excision. Sort of like a mini-tummy tuck, but on your back, the procedure entails removing that overhang of excess skin and fat. The trade-off for the cunningly named "back roll excision", of course, is a scar. Depending on where the targeted roll is, sometimes that scar can be very well hidden in the area that a bra would cover.

The global pursuit of beauty

2010-04-01T13:42:00.000-07:00

I thought this piece in the New York Times' photography, video, and visual journalism blog was especially well-done, with stunning and thought-provoking photos. It reminds us that the pursuit of beauty is so wide-ranging, not just in geography and population, but also in what individual segments of society deem acceptable and not. Where do you draw the line between medical necessity/maintenance of health and hygiene/adaptation to social and cultural norms/preening/cosmetic surgery/obsession/psychiatric disorder? It's more difficult than it seems.

Friday Figure Fix: Back to back

2010-03-26T11:40:00.001-07:00

And we're back... so let's talk about backs, perhaps one of the more neglected body parts because it's not something that you necessarily stare at every day, but everyone else sees it an awful lot.

The back really deserves more attention than it gets in the cosmetic world. After all, we are fast approaching halter/tube top/bikini season, and if you want to look good, look good all around, right?

Medically and surgically speaking, the back is both relatively plain (not much to interact with on that side, really) and surprisingly fascinating. The skin is thickest on the back, and the fat that lies beneath the skin has a different quality from elsewhere on the body - it's a bit thicker, denser, and stringier.

If anyone ever has a complaint about the appearance of their back, it's usually related to excess weight that results in undesirable rolls (which have actually been scientifically documented and classified by one of Dr. Weintraub's mentors in New York, Dr. Berish Strauch). Everything that can get a bit thick on the front side often continues around to the back.

So ladies, I'm sorry to inform you, but that extra stuff under your arms that makes it difficult to get a good bra to fit? That's not breast; that's a roll of skin and fat that hangs laterally and continues along the bra line of the back.

Same story with the dreaded "muffin top" - the paunchy bits that hang over your jeans in front and above your hips - that stuff goes all the way back, too.

These "back rolls" are especially dramatic in our massive weight loss patients, where the skin envelope that was once filled with fat now just lie empty, with folds and flaps of unelastic skin layering the back. It's not just a cosmetic issue in these cases; often times these flaps and folds harbor rashes and infections.

Sometimes, however, patients looking for an aesthetic fix for their backs don't have such dramatic problems. Frequently, it's just a matter of having a little extra, unwanted thickness here or there.

I'll be back next week to talk about some cosmetic surgical solutions.

Perspective: thinking about training

2010-03-19T19:20:00.000-07:00

Wildflowers at Long Ridge OSP, heralding the long-awaited arrival of spring in the Bay Area

Today, the New York Times website posted an opinion piece that scurries around the belabored topic of resident physicians, work hours during training, and sleep deprivation. If you scroll through the hundreds of comments, you can see that it's still quite a touchy subject for many.

Including me. Although my plastic surgical residency now seems like a lifetime ago (there's nothing like rediscovering the pleasures of a "normal" life), it really wasn't. I'm not sure what the popular conception of the training required for plastic surgery is, but I assure you, it's not a bunch of folks sitting around sipping lattes, taking occasional breaks to inject Botox or do a quick boob job.

I started residency when talk of the mythical 80-hour work week was swirling about; but that's all it was, the stuff of dreams and fantasy, especially to a bunch of overworked, underslept surgical interns and residents who thought it was more of a cruel joke. One hundred- or 120-hour work weeks were not uncommon. I was routinely on call every other night or every third night - these became thirty, thirty-six hour stints in the hospital - do the math, and you realize you've hit 80 hours before mid-week.

I remember one of my general surgery chief residents dispensing advice to the newbies. Doug told us the three things key to surviving internship. When you finally make it home, eat first, then shower. If you go to sleep first, that just means you will go back to work hungry and stinky. And always put the car in park when you come to a red light.

Was it miserable? Well, yes - you're tired, you're hungry, you're working hard, you're not working hard enough, you're on your feet, you're getting yelled at - you're in survival mode. But there's a degree of martyrdom that colors your thoughts (it's 9 am, the time when normal people are just trickling in to work, and I've been at it for 5 hours already, and so many more to go), your spirits are lifted by the joy of actually helping people, and your awesome colleagues in the trenches with you are funny, encouraging, and ultimately save you.

And by the time I finished my training, the 80-hour work week was in full force. Did that mean that when the clock hit 80, the scalpel was removed from my hand and I was sent home? Perhaps for some of the newer trainees, yes, something like that. But some weeks I worked a more humane 60 hour week, and others clocked closer to 100 - but I had already learned to stop counting at 80.

A lot of my peers had the same mathematical dysfunction. Maybe we were the last of the old school, maybe we were already inured to the pain of the endless workday as it quietly merged into night. As surgeons, you just can't quit mid-case. As physicians, you just can't leave your patients. As professionals, you have pride; you want to follow through, you want to make sure that your patients get the best care possible, you want to see what happens.

It's hard to say what is right for the future of medical training, having been on both sides of the work hour debate. And as wonderful and impossibly precious as time and life seem now, outside of residency, I still get to experience medical training, but from another perspective - as the ever-waiting spouse.

My husband is still in the thick of his surgical training. Somehow he too has developed the inability to count beyond 80. It's tough to watch someone you love endure this. Maybe in some ways a resident's life is a little better these days; most months I do get to see my husband every day, if sometimes only for an hour as he shovels some food in and gets his exhausted body ready for another woefully inadequate amount of sleep.

But that's what we tolerate, because we aspire to be the greatest surgeons we can become and because we love what we do.

Friday Figure Fix: Loving lipo, part two

2010-03-12T08:55:00.000-08:00

I got so carried away with mythbusting and truthtelling the past two weeks that I neglected to cover the basics about liposuction! You'll forgive me, of course, as I use my awesome Adobe Illustrator diagrams to show you the magic behind the lipo curtain...

So now that we're all on the same page about what is true about lipo and what is just nasty rumor, what exactly are you getting when you sign up for liposuction?

Liposuction is pretty much what the word says - sucking fat. Over most of the body, we have two layers of fat - one is relatively thin and superficial (right beneath the skin), and the other is just below it and more substantial in thickness. When plastic surgeons perform liposuction, we're generally aiming for the deeper layer, for a variety of reasons.

Small incisions are made in the skin, usually well under half an inch. This allows for insertion of the liposuction instrument. By using a metal cannula (a tube of varying diameters) attached to a suction machine, we plastic surgeons remove fat in a planned and controlled fashion. If you've ever watched any of those shows on the Discovery Channel that show liposuction being done, you may have noticed that it can seem like a very brutish procedure.

But if not for the care and strategy behind the technique (and for us plastic surgeons, there definitely is a lot of thought behind the muscle and sweat), the operation could go very badly. How badly? Best case scenario (of bad cases): a little irregularity or lumpiness. Worst case scenario: the metal cannula ends up in the wrong space (like lung or bowel), causing significant organ damage. There is also a lot of physiology behind good liposuction technique; fluids are a critical component of this operation, and they need to be balanced precisely to ensure a safe, successful surgery. Good reasons to choose your surgeon carefully!

When done carefully and correctly, the cannula removes tunnels of fat, creating a swiss cheese-like appearance in the fat that remains, which collapses and heals to give you a slimmer, flatter contour.

Liposuction can be performed under a local anesthetic, with or without some sedation, or under a full general anesthetic, depending on the volume of fat to be removed. It is so important to find a well-trained, experienced plastic surgeon (and an anesthesiologist comfortable taking care of liposuction patients), because as you all surely remember: liposuction is still surgery.

Like I've implied, liposuction is not a terribly sexy procedure, especially during the recovery. Because of the fluid shifts, patients are quite swollen and need to wear compression garments around the clock. Immediately postop, you do get a glimpse of what your new shape will be, and many patients are thrilled by how they look a few days later after the swelling has peaked. But stubborn extra fluid tends to obscure a lot of the fine contouring, and the dramatic final results won't be apparent for up to six months to a year after surgery, once all that swelling has finally resolved.

But if you continue to take care of yourself (a healthy diet and exercise regimen that help you maintain a stable weight), the results will be worthwhile and lasting.

Um, the sky is falling?

2010-03-09T09:22:00.000-08:00

Yesterday's rainbow, stretching out over the South Bay.

There seem to be an awful lot of Chicken Littles running about these days, squawking about the demise of plastic surgery. I saw a few articles (here and here), drawing from statistics released from the ASAPS, pointing to the ongoing downward trend in elective cosmetic surgery.

Let's face it - last year was a terrible year for everyone, even us plastic surgeons in the Bay Area. But I disagree that this spells the end of plastic surgery; I still think that there is a lot of interest in cosmetic procedures (hence the noted uptick in less invasive - and cheaper - interventions like Botox and fillers) combined with increasingly pent-up demand. We're just all waiting for the economy to turn.

Are you listening, Washington? Make it happen!

Breast cancer awareness: how YOU can help

2010-03-08T06:23:00.000-08:00

Photo courtesy of Peter Bruce

Now, I'm not one for shameless plugs, but this is a special exception, and I think you'll understand why.

The "b for a cure" project is something I became involved with based on the sheer charm and conviction of its founder, Peter Bruce, a professional photographer who lives in San Francisco with his lovely wife, two daughters, and giant (but friendly) dog. He began this project to raise awareness for breast cancer, a cause near and dear to any woman's heart, especially this plastic surgeon's.

As a female plastic surgeon, I have been involved in the journeys of so many women diagnosed with breast cancer, from the initial cancer operation to the reconstructive breast surgery to the post-treatment recovery period. Breast cancer is somehow simultaneously heartbreaking and inspirational, and it remains a cause in need of our continued support.

Peter's project allows ordinary (and extraordinary - you know who you are) women to express that solidarity - whether by helping to garner attention for the project, purchasing the book (expected to be released later in 2010), or even becoming a model (emphasizing the idea that all breasts are beautiful) - I encourage you to visit his website to learn more.

Friday Figure Fix: Loving lipo

2010-03-05T08:21:00.000-08:00

So last week we did a little debunking of liposuction myths that refuse to die. Which I know was all old news to you, my dear readers, because you are a smart and appropriately skeptical bunch. But for those of us who are new to the wonderful world of plastic surgery, let's discuss what lipo can actually do for you.

1. Lipo is great for contouring.

If you're reasonably close to your ideal body weight and are stuck staring at stubborn problem areas that absolutely won't budge, no matter how carefully you watch your diet or rigorously train, liposuction is a fabulous technique.

A lot of us women are blessed with womanly figures, but sometimes the proportion can be a bit off, often in the areas of those child-bearing hips and cursed saddlebags. Liposuction can help reduce some of those bulges, so that your overall proportions seem more reasonable:

With lipo, which is a little like sculpting a block of marble (except your plastic surgeon is removing bits of fat, not chunks of stone, with an aesthetic eye), you still retain your womanly curves, but in a refined manner.

And, of course, lipo is not just for women. Plenty of men are looking for a discreet little touch up for their love handles and whatnot.

2. Lipo is versatile.

Where there is fat, there is possibility... Common areas treatable by liposuction include the area under the chin/neck, arms, breasts, back, belly, hips, thighs, and sometimes even around the knees and ankles. Pretty much anywhere.

3. Lipo is that great final touch.

A lot of times in our practice, Dr. Weintraub and I combine liposuction with another procedure - most frequently the tummy tuck. It just allows us to really smooth out the contour of the trunk and waist, so that there are smooth transitions between the chest and the newly tightened belly. This concept of using lipo to supplement another surgical procedure works well; a touch of lipo with a facelift, arm lift, thigh lift is fairly commonly done - with great results.

Nip/Tuck no more?

2010-03-02T17:51:00.000-08:00

I must admit, I haven't watched any episodes of Nip/Tuck recently (the bizarre plot twists got beyond my personal tolerance level sometime after Season Two, and my husband and I discovered the freedom that comes with living a cable-free life), but I am somewhat sad to hear that the series is coming to an end this year.

Like I've mentioned in this blog before, I admired the show for bringing the surgical special effects to a whole new level of realism (although no nurse has - or ever will - tie my mask on for me). And, of course, the rocky, drama-filled partnership of Dr. Christian Troy and Dr. Sean McNamara will always remind me how lucky I am to have a wonderful, functional relationship with my partner at Duet Plastic Surgery, Dr. Jennifer Weintraub.

Friday Figure Fix: Learning about lipo

2010-02-26T08:36:00.001-08:00

You'll forgive me the facetious bit culled from the wire earlier this week. Sometimes stories like that are just too good to pass up in this line of work.

So let's get down to business, and talk about liposuction (or, lipo for short). As a real, live female plastic surgeon, I'd like to clear up a few misconceptions about this very popular procedure.

1. Lipo will help me melt the pounds away.

Sorry, nope - lipo is not a substitute for weight loss.

There are a lot of surgical procedures out there these days that are designed to help overweight or obese patients lose weight. Liposuction is NOT one of them. If you've been downing the Double-Doubles with fries and a shake regularly, thinking that a little plastic surgery can take care of that one day, you are incorrect.

Liposuction is a fabulous tool in the plastic surgical armamentarium, but it is designed for body contouring in a person who is at, or pretty close to, their ideal weight. Why is that? For one, the results are much better and much more appreciated. More importantly, it's safer for the patient. Speaking of safety...

2. Lipo isn't really surgery.

True liposuction absolutely, positively is real surgery. Every day, there is always some gimmicky new product appearing that promises "lipo" but with no scars, no surgery, no pain, no downtime (you know what they say about things that sound too good to be true...); sometimes they use flashy words like "laser" or phrases like "melt the fat away". These gimmicks are NOT liposuction.

Real liposuction is a tried and true method of body contouring that has been utilized by plastic surgeons for decades. It involves making a small incision in the skin (= surgery), inserting a long metal tube into the fatty layer beneath the skin (= surgery), and sucking out the fat in an informed and controlled manner (= surgery). There may or may not be additional technology involved (e.g. power-assisted lipo and ultrasound-assisted lipo). The surgery may be performed while the patient is awake (but anesthetized so that they are comfortable) or asleep. The procedure may be done in an office setting or in the operating room. This brings us to our next debunkable lipo myth...

3. Anyone can do lipo.

Well, sure. But really?

If I were looking for someone to do a surgical procedure on me, I would check first to make sure they have a valid medical license. You would be surprised.

Then I would check to see what kind of training they have had - they may be an M.D., but did they do their residency in pathology, or do they have a surgical background (because of what we learned in #2)?

And finally, call it a personal bias, but I would also want a plastic surgeon to do my liposuction. Why? Because our years of training include everything you've ever wanted to know about liposuction - how to do it, how to do it well, what complications can occur and how to take care of them. Your plastic surgeon is not just some bearer of a certificate from a weekend course. Our extensive training has taught us to deal with the entire body - "the skin and all its contents" as some like to say; we understand how everything in the body relates to each other, which is important when it's your health and your body.

So right, anyone can do lipo. But why would you want them to?

Who needs lipo?

2010-02-23T16:55:00.000-08:00

Not this lady - apparently putting off her diet plan and having a little more to love saved her life.

Friday Figure Fix: Special "Extreme Makeover" Edition

2010-02-19T15:02:00.000-08:00

Heidi Montag's cover story, from People, January 15, 2010

Let's take a slight diversion from the usual Friday Figure Fix posts and address a topic that has been on the minds of many folks out there. Being a plastic surgeon always stimulates a lot of interesting small talk, and after this story took over the gossip headlines a few weeks ago, the ensuing conversations about this dramatic figure fix were no exception.

Most of the folks who brought up Ms. Montag's transformation were frankly a bit horrified, and were curious if that's an example of what most plastic surgeons - specifically, me - do.

As a disclaimer, I have never met nor taken care of Ms. Montag, so all the information that I have regarding her surgeries is the same as what you've got - from People, Us Weekly, and the vast Interwebs. It seems like she had 10 separate procedures under one anesthetic on one day, performed by one plastic surgeon, uneventfully.

Honestly, as a medical professional, I can't judge this particular case, since I don't know the patient, surgeon, or specific circumstances.

But in general? I do judge - that's part of my responsibility as a plastic surgeon. Even if it's a "cosmetic" procedure - or rather, especially if it is - I need to make sure that my patient needs whatever surgery they initially came to see me for. Sometimes what someone wants isn't what they need; sometimes, for a variety of reasons, they don't need anything. As much as I love operating, I have to be honest with myself and my patient - there should be no moral dilemma there at all.

Beyond determining whether a patient needs a particular surgical procedure and which procedures are appropriate, a plastic surgeon also needs to use judgment as to what is safe, in terms of number of procedures performed and the combination of surgeries. It's more than a simple matter of safety under general anesthesia or during the recovery period for the patient; it's also a matter of surgeon fatigue during the operation. Believe me, no one wants a tired, cranky surgeon.

Luckily for me, I have a fantastic partner in Dr. Weintraub at Duet. Having a second pair of highly skilled hands to help is wonderful, for both our patients and for us. But that doesn't mean that we're wild advocates of the "extreme makeover" philosophy; to the contrary, I think it makes us both a little more circumspect when we're discussing figure fixes, which makes and keeps our patients happy.

Friday Figure Fix: Taming the tummy, part two

2010-02-12T08:49:00.000-08:00

As Jim, the incredibly well-trained instructor for my figure-drawing class, explained one day, everyone has a little convexity to the lower part of their abdomen. Armed with a piece of chalk at the chalkboard, he deftly illustrated that a little curve to the belly is how the human body comes naturally; with a straight, or even concave, line below the belly button, the drawn figure looks odd.

This is how the human form is meant to look, he insisted, pointing with his stub of chalk to the curvy line he had drawn, which in his magical hands looked perfectly like a belly. This just isn't right, no matter what they tell you, Jim said of the flat abdomen he drew beside it.

There's no arguing with Jim, especially when he's pretty much spot on (an old plastic surgery mantra: there are no straight lines on the human body), but that doesn't mean that we can't aspire to be sleeker versions of ourselves.

Last Friday, we investigated the most common reasons why bellies go bad, why women get poochy after pregnancy, and why some of us just didn't win in the genetic skin lotto.

Today, let's delve into the world of abdominoplasty, or tummy tuck, the plastic surgeon's answer to the problem of "the flat belly".

The simplest scenario would be this, the patient of every plastic surgeon's dreams: a thin, healthy, young(ish) woman who had finished bearing her children and upon exam had no muscle separation (that pesky diastasis I mentioned last week), only a little extra skin on the lower part of her belly. Our straightforward case would be represented by the left side of the drawing below, where there is just the slightest "pooch" of extra skin and fat below the belly button:

This simple scenario would be addressed by a relatively simple procedure, the so-called "mini-tummy tuck". Since there is no weakness of the abdominal muscle/wall, the excess skin can be trimmed, leaving the patient with a small scar low on the belly (represented by the pink line on the right side of the drawing). This type of incision would be similar to a c-section scar, easily concealed by underwear or a bikini bottom.

Since the surgery time is relatively short (about one to one and a half hours) and no muscle work is done, patients can go home after a mini-abdominoplasty and enjoy a relatively quick recovery (around a week).

However, most of us aren't that lucky (that is, we're not exactly thin, young, and have remarkably intact abdominal walls), so the "flat belly solution" is more complicated. What this entails is a full-out abdominoplasty.

We know we have a muscle issue (that six-pack just isn't doing it anymore), where the abdominal muscles have become lax and separated, as I've illustrated (below, left):

As plastic surgeons, a huge part of our training and practice mission is to restore anatomy and function. So a major component of the abdominoplasty is the muscle plication (above, middle), where the abdominal muscles are realigned and tightened, resulting in a "corset"-like effect. The extra skin (often from above the belly button to just above the pubic bone) is removed.

The result (above, right): a waist that's slightly cinched in, a flatter, tighter belly, a slight lift of the pubic mound (yes, gravity affects everything), and scars hidden in the shadows of the umbilicus and low across the belly, from hip to hip (again, represented by the pink lines). The circumferential belly button scar usually fades pretty imperceptibly, and anyone wearing a reasonable set of underpants won't be showing off the lower abdominal scar. A small (but wonderful) bonus for moms who undergo tummy tucks is the removal of those impossible stretch marks where the skin is excised.

The full abdominoplasty takes a little longer (two to two and a half hours) and is also performed under general anesthesia. If patients are healthy and have reliable help around, they can go home after the operation; if not, they spend at least one night in a medical recovery center or hospital. Recuperation after this surgery is a bit longer as well (the muscle tightening is pretty painful - imagine doing ten thousand crunches, but worse), anywhere from two to six weeks.

One step beyond the tummy tuck I describe above is the circumferential abdominoplasty. Now this is a procedure most commonly done for patients with massive weight loss. After losing so much weight, not only is the skin of their bellies stretched out and hanging, but it continues like this all the way around the hips, flanks, and back. The circumferential abdominoplasty (also, belt lipectomy) addresses this by continuing the skin excision all the way around as well; the end result is an improved contour, in exchange for a scar that rings the waist like a belt.

Tummy tucks are often done in conjunction with liposuction, to smooth out the contours of the upper abdomen and flanks; but lipo is a whole topic on its own, which we will tackle on another Friday.

Breaking news from Britain: Man-boobs on the decline

2010-02-06T10:04:00.000-08:00

Apparently, male breast reduction procedures have skyrocketed in popularity at our plastic surgery colleagues' offices across the Atlantic. (A gentle word of warning: the graphic that accompanies the above-linked BBC article is rather in-your-face.)

Gynecomastia - the official medical term for what everyone's taken to calling "man-boobs" (or even "moobs" for short - ugh) - is not a new problem, and certainly something that we plastic surgeons are familiar with, even here in the high-powered, relatively crunchy San Francisco Bay Area.

Rarely, men who notice their breasts are growing (men do have a smidge of breast tissue) discover an underlying medical problem, like a hormone imbalance (due to medications, prescription or slightly less than legal - classically, marijuana is a known culprit) or even breast cancer.

More often than not, gynecomastia is due to excess fatty tissue and is treated with surgery, either liposuction, surgical reduction/excision, or a combination of both.

For those men who aren't quite ready for surgery, though, there's always this option.

Friday Figure Fix: Taming the tummy

2010-02-05T08:29:00.000-08:00

Perhaps the most common request Dr. Weintraub and I get at our plastic surgery office in Palo Alto is the "tummy tuck" or abdominoplasty.

Typically, the requestor is a woman (which doesn't surprise us, and as female plastic surgeons, we totally feel it ourselves and sympathize wholly). There are basically two camps of patients: folks who have lost a bit of weight (either through diet and exercise or with medical/surgical assistance - like lap-bands or gastric bypass) and moms who are done having babies.

People who come to us at Duet for a tummy tuck consultation aren't conceding defeat to fat. Believe me, these patients are in great shape, highly motivated, with super-active careers. They may still be hanging on to that pesky extra five or ten pounds, but they are not fat. They have come to our office because they finally realize that no matter how many crunches or how healthy their diets, the little (or big) pooch that hangs beneath their belly button is not going away.

Exhibit A:

This is what prevents us from wearing the size of skinny jeans we truly are. This is what morphs into the dreaded "muffin top". This is where the bulk of those ugly stretch marks live. But why?

Like the saggy upper arms and brachioplasty discussed last week, it's mostly a skin problem. Those blessed with youth and good genes can get rely on our skin's inherent elasticity; the rest of us suffer with skin that doesn't go back to the way it was before the pregnancy or weight gain. The severity is exaggerated in many of our gastric-bypass patients, who have lost weight so quickly that their skin couldn't keep up, resulting in unflattering sharpei-like folds.

Luckily (hmmph?) for us women, we can blame one more culprit for the loss of our figures: pregnancy. As the uterus expands to accommodate the growing bundle of joy, the belly stretches out as well - not just the skin, but everything underneath as well:

Top to bottom, outside in: the skin of your belly stretches (epidermis and dermis; when the latter tears, we get stretch marks), as do the underlying fat and abdominal wall. Unfortunately, that abdominal wall (the six-pack of rectus muscles plus the enveloping fascia) doesn't have a lot of resiliency, resulting in this problem:

See how the belly goes from softly rounded in the relaxed photo on the left to sort of pointy in the photo on the right (taken while flexing in a sit-up)? That, ladies and gentlemen, is the abdominal diastasis.

Not quite a hernia (where your bowels are seeking to escape through an actual opening in the abdominal wall), but close - your abdominal contents bulge at an area of weakness. This particular area of weakness associated with pregnancy is the space created by your six-pack muscles moving farther apart to accommodate the growing fetus.

Exhibit B:

Don't get me wrong. This is great for the baby, but once mom's ready to move on, the fascia is too stretched out, the muscles don't return to their original position, and mom gets a poochy, flabby waist that contributes to the thick appearance of the belly.

So we've got a skin problem, a muscle/abdominal wall problem, and maybe a teeny little fat problem. What's a girl (or guy) to do?

Stay tuned for next week's Friday Figure Fix: all about abdominoplasty.

Friday Figure Fix: Up in arms, part two

2010-01-29T08:01:00.000-08:00

Last week, I left you hanging with thoughts of flappy, flabby arms and promises of resolution in the future.

The real challenge for plastic surgeons is dealing with those arms that aren't blessed with the fortune of having fantastic skin resiliency and "flab" due mostly to a small amount of fat. In my Palo Alto plastic surgery practice, that translates to a good 95% of patients out there with this complaint, unfortunately for everyone.

Like I've said in this blog before, plastic surgery is not magic. We don't yet have anything in our plastic surgical armamentarium that makes extra skin disappear without scars. What we do have is surgery, which always leaves scars.

A lot of what makes scars heal nicely (dare I say, invisibly?) is mostly dependent on you and your genetics. A few external, controllable factors come into play: smoking and sun exposure (avoid both if you want to heal well and nicely). Lastly, as plastic surgeons, we do have a few tricks and techniques up our sleeves to make those scars look as good as possible, but again, we're not magicians.

So imagine your arm looks like this:

What you've got there is mostly extra, sagging skin on the underside of your arm; a little bit of fat, too. A brachioplasty removes that extra skin and fat - in a similar fashion to many of the other body contouring procedures we plastic surgeons do (like tummy tucks and thigh lifts) - so that the normal contour of the arm is restored (there's that triceps!):

But like I've mentioned previously, it's not magic. In exchange for getting rid of that stubborn flab, you end up with a long scar along the underside of your upper arm, sort of like a seam on a shirt:

A well placed scar won't be very visible if your arms are at your side. However, not everyone is willing to make that trade off, especially if your goal is to show off in a tiny tank top or bitsy bikini.

The surgery is usually performed under general anesthesia (that means going to sleep with a breathing tube down your throat), takes anywhere from one and a half to three hours, and if the brachioplasty is the only procedure being done, patients can go home afterward with compression garments that need to be worn for several weeks. Routine postoperative follow up and care is done in the office.

Unsightly scarring is always a risk, as well as asymmetry, change in sensation or nerve damage.

Brachioplasty is certainly not a perfect solution for the problem of flabby arms (when our nation's hardworking scientists discover magic, I'll be the first to let you know). But if it's the constant flapping that is the bane of your existence or the nightmare of finding clothes that actually fit, brachioplasty can help change your life.

Next week: maybe we'll tackle the topic of tummy tucks.

Friday Figure Fix: Up in arms

2010-01-22T08:03:00.001-08:00

Photo from iStockphoto

Welcome to the inaugural edition of the Friday Figure Fix! Today's topic: batwings, flag wavers, hi-helen's, or simply, flabby arms.

Now that it's the new year, everyone's an optimist about warmer weather coming soon. And warmer weather means we can dust off the tank tops, spaghetti straps, and sundresses that have been languishing in our closets all winter (all of us in the Bay Area could use a little airing out, after hiding out from this deluge all week). And cute tops = bare arms = uh-oh?

It's a near-universal problem for us ladies (more so than men) - we get to a certain age, and suddenly all the definition we may have had in our triceps has disappeared, leaving us with a little looser arm than we'd like. Sometimes there is a perfectly good explanation for the new-onset flabbiness hanging from our humeri - a lack of devotion at the gym, massive weight loss... but often it's a problem that seems to have materialized overnight.

Flabby arms - what's there to do? The first thing to try is the simplest, although not always the easiest: make sure your weight is where it ought to be, and get back to the gym for some arm-toning workouts. For inspiration, look at what amazing things Madonna has done with her arms - no batwing problems there.

Oftentimes, though, all the triceps curls in the world won't do the trick. And that's when you talk to your friendly female plastic surgeon. Hello!

Arms are a tricky thing for plastic surgeons and their patients, especially if the goal is to wear those cute tank tops. If you're lucky, the flab waving is a moderate bit of fat buried beneath good, resilient skin. An illustrative cross section of what I'm talking about, from the inside (muscle) - out (epidermis):

If this is the case, liposuction can be a great solution. A small (1/2 inch) incision, which usually heals to become fairly unnoticeable, allows some of that thick subcutaneous fat layer to be removed, leaving a more proportioned arm.

Liposuction is not magic, however; it is still surgery, and it requires the proper patient, good health, strict postoperative compliance, and patience. Although the procedure itself may be relatively short (often an hour to ninety minutes) and can be done as an outpatient, the care after the surgery is critical. Compressive garments need to be worn on the arms around the clock to ensure optimum results.

Bottom line: after liposuction alone, it'll be at least 4-6 more weeks before you can shed those rather unfashionable garments and replace them with those cute tank tops.

So that's Option One - liposuction for the lucky patient whose flabby arms are the "right" type (again, it's not the solution for everyone). Next Friday, I'll discuss some of the other plastic surgery options for addressing that extra skin hanging off the upper arm; we're talking serious, we're talking brachioplasty.

The cookie that could end my career?

2010-01-20T11:10:00.000-08:00

You have to love the indomitable human spirit. Such innovative genius, such creativity, such. . . suckerdom?

One of the more curiously interesting parts of my job involves keeping up to date on all the latest trends - truth, hype, or flat-out falsehoods. The quest for shapelier breasts never ends, and since the tired-and-true method of breast augmentation is, well, surgery, there is always a flashy new product promising the impossible.

I'll have to check out my local Marukai Market to see if they're stocking these Japanese treats, cunningly named "F-Cup Cookie" - available in two flavors (soy milk, and pralines and chocolate, for those of you who are wondering). According to a post in the LA Weekly Food Blog, the cookies contain an herbal root called Pueraria mirifica whose plant estrogens are supposed to do all sorts of things for you, including a boost to your breast size.

Normally I'd say that although eating a cookie like this won't increase your bust, it probably won't hurt. But as Emma Courtland, the LA Weekly blogger eloquently states at the end of her piece: This post is not an endorsement of plastic surgery. Also, F Cup Cookie may cause "loose bowels if taken in excess."

I think my plastic surgical career may be safe after all.

The Friday Figure Fix

2010-01-15T07:49:00.001-08:00

Photo from iStockphoto

A new idea here at the My Plastics Life blog - a little bit inspired by the onslaught of Jan/Feb 2010 editions of "girly" mags like Glamour and Elle, the ones that proclaim "New Year! New You!" and "Five Minutes a Day to a Better Body!!!" - you know you've seen those articles, all timed to pounce on universal post-holiday regrets.

Some of the inspiration comes from a drawing class I'm taking in figure representation (yes, all plastic surgeons are secretly tortured artists), and of course, all of those folks I've met who bashfully or boldly ask what a female plastic surgeon like myself can do for their post-holiday bods.

So I'll try to devote some of 2010's upcoming Fridays to posts about some of the most common "fixes" that plastic surgeons offer for those looking to improve their figures.

And it's not just about that little five-pound holiday indiscretion. We're talking about people who have lost significant amounts of weight with medical or surgical assistance or just plain old sweat and tears, and are now stuck with stubborn flaps and rolls of skin disguising their new healthy selves. We're also talking about moms who have seen their bodies undergo the most amazing changes to accommodate a beautiful new being, but once that little human is introduced to the world, their bodies don't exactly snap back to the previous model.

So stay tuned - the Friday Figure Fix will be a fresh and exciting way to learn a little more about this part of the world of plastic surgery!

DUET: Plastic Surgeons to the Stars!

2010-01-13T15:21:00.000-08:00

Well, not really. Celebrities like Britney Spears and Lindsay Lohan had been contacting us through our website incessantly (come on, girls - enough is enough!). It was mildly entertaining at first as we seemed to cycle through the A list and down through the B list, I must admit.

Thankfully, a few master keystrokes from our web guru took care of that little spam problem.

But 2010 is still young; we'll see what the rest of the year brings.

Farewell, 2009!

2009-12-31T11:08:00.000-08:00

One of the stunning emerald-furred trees dotting the trails at the Long Ridge Open Space.

It's funny how, the older I get, the faster time moves. Remember summers as a kid, when it seemed like the days were endless and vacation would never end? Now, it the year whooshes by straight-faced, without drama.

Well, there is always plenty of drama in the wondrous world of plastic surgery, right?

2009 was no exception - new techniques for breast enhancement, a competitor for Botox (welcome again, Dysport!), a resounding defeat for the cosmetic procedure tax. And small steps in my personal year of plastics - a little but big move for the office (all the way up the street to Palo Alto), a big anniversary for this partnership of two women trying to conquer the big bad boys' club of plastic surgery (couldn't do it without you, Dr. Weintraub!), and yes, another year of semi-devotion to this blog.

Thank you for putting up with my wordiness in 2009. I promise more exciting revelations as the days move swiftly in 2010. Happy new year!

Bo-tax goes down, and other news in the world of plastic surgery

2009-12-23T08:21:00.000-08:00

Good news, the Bo-tax got defeated. It seemed like the entire "community" of cosmetic proceduralists temporarily put their differences aside and organized together to make it happen. Apparently even the NOW rallied against this crazy idea, since it unfairly targeted women.

In an interesting twist, the Senate decided to go after tanning salons instead - hefting a 10% use tax on consumers who aren't convinced by the "pale is beautiful" trend or the fact that UV exposure correlates to skin cancer. Seriously, does anyone tan anymore? I thought that unnatural bronzed look went out sometime in the late 80's/early 90's.

And finally, I caught this article through the online version of the San Francisco Chronicle. It doesn't tell you anything new, dear readers, but I must admit to a base fascination with plastic surgery horror stories with the tiniest little modicum of sadness and regret that I can't help everyone see the light about finding themselves a good (female!) plastic surgeon.

Another reason to celebrate being a woman: more wrinkles?

2009-12-17T16:48:00.000-08:00

Personally, I thought the actual reference article in this piece discussing how women have the great luck of being prone to more and deeper wrinkles than men was just fine.

But come on, Amanda Gardner, HealthDay Reporter for BusinessWeek, get it straight. When you lead off your article with "Dermatologists have discovered yet another gender inequity. . ." and proceed to quote the senior author, who is identified as a plastic surgeon in said article, it becomes clear that someone didn't do their homework.

For the last time, dermatologists are NOT the same as plastic surgeons.

Okay, I'll put the soapbox away again. Thanks for listening.

To be young and beautiful

2009-12-15T12:51:00.000-08:00

A lookout sullied by low lying clouds two weeks ago at Fremont Older Preserve, part of the Open Space lands of the Peninsula.

This morning I had the wonderful opportunity to speak to Tracey Gunn's honors anatomy and physiology class at Santa Clara High School. I've been working with the HealthTrust of Santa Clara; part of their mission is to get high school students interested in careers in the health sciences.

I've done a handful of these little talks now, and the caliber of these students never fails to impress me. They are all so bright and beautiful, curious and clever.

In these talks, I skim over the nuts and bolts of how to become a doctor - all the classes, applications, tests, etc. These students aren't dummies - they're all college-bound (and right now, waiting anxiously for the legendary fat envelopes) - when I ask them how old you have to be to become a physician, they're pretty accurate. Usually they guess around 30, although today someone blurted out "80!" which is sometimes how old you feel at the end of the day...

I also talk a little bit about what it means to me to be a plastic surgeon, how it's not all boobs and Botox, and most importantly, why I love what I do. In this part of the talk, it gets more graphic and interactive - I put up pictures of tough cases I've confronted in my surgical career and challenge the students to "be the plastic surgeon". Their response is always impressive, perhaps revealing a few aspiring surgeons in the crowd.

So thanks again to Ms. Gunn and her students for graciously hosting me this morning. It was fun, and hopefully we all left with something more to think about.

Happy surgeons = happy patients?

2009-11-23T16:15:00.000-08:00

Photo illustration courtesy of Veer

Perhaps you've seen this article circulating out there in the ether - it talks about how doctors who feel burnt out or depressed admit to making more medical errors.

Lucky for all of you Duet fans out there, Dr. Weintraub and I love what we do and are very happy doing it.

The Botax-man cometh

2009-11-19T18:09:00.000-08:00

We've all heard this one was coming. Plastic surgeons and their patients make a very easy target for politicians, right? But will it really go through?

Everyone points out the disappointment of New Jersey, which levied a 6% tax on cosmetic procedures in 2004. Some speculate that the tax has actually cost the state $3.39 for every $1 collected.

So maybe the question is not, will the "botax" be passed by the Senate, but if it does, what will it actually do?

I can do what with my frequent flier miles?

2009-11-14T08:21:00.000-08:00

Photo from Veer

Harrumph. Maybe I'm just getting old and grumpy already, but it seems like this is another one of those really terrible ideas.

Caveat emptor

2009-11-05T14:26:00.000-08:00

We've talked about this before, but it's still frightening.

Running the numbers

2009-11-02T08:01:00.000-08:00

Have you ever read the Harper's Index? You've probably seen some permutation of it, usually a pithy or surprising factoid phrase, followed by a defining number. I've been a big fan of Harper's ever since high school, when my history teacher would hurl the facts and numbers at us in his amazingly deadpan voice (thanks, Mr. Brown!).

I was reading this month's Index, and it happened to have a couple professionally relevant tidbits, which I found so interesting, as the Index items always are.

Estimated length of human nose removed by U.S. plastic surgeons each year, in feet: 5,469

Factor by which this exceeds the length of George Washington's nose on Mount Rushmore: 260

Discussing the do-over

2009-10-30T08:37:00.000-07:00

The New York Times' Thursday Styles had another great piece about plastic surgery, this time discussing the challenge of revisional, or secondary, surgery.

These types of surgeries can give any plastic surgeon pause, to be sure, and this article proffers some choice quotes from some of the luminaries of the American plastic surgical world.

Magic with muffins

2009-10-29T10:58:00.000-07:00

Illustration from MSNBC.com

This photo was just too good not to share... It accompanies an article on the MSNBC website discussing the conjunction of so many women's dreams and the miracles of modern day science: moving the fat from your hips to give you a bigger bust.

It's a great idea, and not a new one, as the piece discusses. Plastic surgeons have been doing this sort of thing - fat grafting - for decades. Unfortunately, not all of the transferred fat stays where you put it; fat cells are fairly finicky creatures, and reports of 50% volume loss over time aren't unusual. Plus, there is the added risk of confounding cancer detection when fat cells (which often calcify) are moved to the breast (where calcifications are warning signs on mammograms).

The twists that the article reveals are two: MRIs these days are better at sussing out true malignancies from benign calcifications; and you can apparently keep transplanted fat cells happier with giant suction cups on your breast.

Anyone remember seeing ads for the Brava device in the back pages of Glamour or Cosmo? It was basically two giant suction cups, one for each breast, that promised to increase your size by a cup or two. The catch? Other than two giant suction cups - you had to wear the vacuum assisted bra all the time.

So despite decent results, the Brava device never took off - women just couldn't commit to the bulk of the machine. Reenter Dr. Khouri, the inventor of Brava, who has found a new application for the unloved device. A recently published small study of his reveals that using Brava gives patients longer lasting, more predictable breast augmentation with fat grafting.

Dr. Khouri's disclosures and all, you still have to examine these results with an eyebrow raised. I'll be curious to see how the patients do in other plastic surgeons' hands, and whether or not women will be ready to commit to giant suction cups on their breasts this time around.

The verdict is in...

2009-10-23T13:18:00.000-07:00

... well, sort of. As you know, Botox finally got some competition earlier this year in the form of Dysport. Same drug, essentially, but with a couple tweaks to give it some sort of market advantage over the industry standard (can you really be the industry standard, if you're the only game in town?).

Dr. Weintraub and I were intrigued by Dysport, as were many of our patients. Who wouldn't be - with promises of quicker onset, longer duration of action, and cheaper? Although we've seen the scientific studies and heard the testimonials, we've been trying to reserve our professional judgment until we used it ourselves.

This is purely anecdoctal "evidence", but I will share with you the reactions of two patients with you, which have been pretty representative of our overall experience.

One woman in her mid-thirties, who was a "botulinum toxin virgin", tried Dysport to correct her glabellar folds and a few crinkles beside her eyes. She reported back to us, saying that the medication seemed to kick in that very night. The morning after the injection, she called the Duet office, absolutely ecstatic over the results: "I look like I have the face of an 18-year old again!"

The other story is perhaps a little more telling. This woman in her early forties is a long-time patient of ours who got Botox regularly. She was willing to try Dysport, and she too was thrilled with the outcome. Being very familiar with the action of Botox, she liked how Dysport seemed to work slightly faster but was really enthralled by how this injection was equally effective, but had a "softer look and feel."

And the verdict? It's still a little early to tell whether or not the longevity claims will pan out, and by no means is this a scientifically unassailable conclusion, but our patients seem to really like using Dysport and having the choice between products. I'll keep you posted.

Scientists say...

2009-10-18T09:35:00.000-07:00

This article in Thursday's New York Times Style section got me thinking for a while.

The section's Skin Deep column always runs pieces that I find interesting - both professionally and personally.

This latest column discusses the trend of skin care companies pushing over-the-counter creams, lotions, and potions that work with the body's day and night cycles. That is fascinating enough - what woman doesn't have a random assortment of bottles and jars, some for daytime, some for nighttime, some for work, some for going out, some for really special occasions?

But the part that caught my curiosity was the discussion of what being a "cosmeceutical" really means. Companies want us to believe that there are hard data and stern scientists behind their claims of "47% improvement in radiance in just 7 days" when we buy their products; but if there were any real, objective proof, they would require regulation by the FDA, which is clearly something they're not interested in getting mixed up in for their drugstore brands.

It makes sense, right? How effective can these over-the-counter promotions be at "reducing the appearance of fine lines and wrinkles" or "tightening loose skin without surgery"? Otherwise the FDA would be regulating whatever "special active ingredient" as the latest, greatest drug...

Should seem obvious to a medical school-educated person with loads of practical experience in dealing with the FDA's fine print and convolutions. I guess it was just the hopeful consumer in me that was lulled into suspending disbelief by the pretty pictures and fancy words of cosmeceutical ads. Yeah, I bought it. A lot of it. But, now, both eyes are open - I'm on to you companies now.

Can it be? A plastic surgery app for your iPhone?

2009-10-15T07:40:00.000-07:00

For all you iPhone addicts out there...
http://www.reuters.com/article/pressRelease/idUS103166+14-Oct-2009+PRN20091014

I'll have to rely on you hip folks out there to let me know how it is. Unfortunately, I am personally still in the dark ages of cell phones, with my old-fashioned flip phone without a text or data plan (the horrors!).

Settled in

2009-10-08T14:29:00.001-07:00

It's been a week since the big move for Duet to Palo Alto. Dr. Weintraub and I have settled in fine. This office complex is actually quite familiar to us; it's the same site as the Stanford Chief Residents' Cosmetic Clinic.

Our signs will be going up soon, but in the meantime our patients seem to be finding us in our new location okay.

Goodbye, Mountain View... Hello, Palo Alto!

2009-09-30T10:00:00.000-07:00

The old Mountain View office, RIP 2008-2009.

Well, it's moving day for the Duet ladies. We're not going far, just up the Peninsula a little way.

Nearly everything else is staying the same - our phone number, our website - Dr. Weintraub and I are just relocating the physical space of our unique little plastic surgery practice to a rather convenient location in the heart of Silicon Valley, Palo Alto.

New office hours, though, and new neighbors. Although I'll certainly miss our old neighborhood in Mountain View, I'm definitely looking forward to showing everyone our lovely new office.

Forget Tupperware parties

2009-09-23T10:54:00.000-07:00

Image courtesy of Allergan

Speaking of breast augmentation, Dr. Weintraub and I met with our local Allergan rep at the Duet office a little while ago. The rep showed us an interesting package the company just started promoting a few months ago.

At the risk of sounding like a corporate shill, I'll go on, but only because I genuinely think it's a neat idea.

Called their "pre-consultation kit", anyone interested in breast augmentation can send away for this package, which includes information about augmentation (both a booklet and a DVD), a bra, and best yet - "sample implants" to try out in said bra.

It's pretty brilliant because it allows women to toy around with "implants" in the privacy of their own homes. You can imagine inviting a couple girl friends over, opening a bottle of wine, and cracking up over the grown-up attempts at "we must, we must, we must increase our bust". . .

The "implants" in the kit aren't real surgical implants, of course - they're plastic, filled with mineral oil - which give just a general approximation of size and feel.

At the office, at our consultations and pre-op visits, we do a similar process with a range of real surgical implant samples. We often get asked by women (and sometimes, the men who accompany them) if they can take a few home for a sort of "test drive". The problem was, the silicone gel-filled samples are so irresistible to squeeze, that a lot of the samples never made it back to the office.

The kit from Allergan helps solve that problem - and provides a closer idea of what breast implants might look like in a bra and clothes than the old stand-bys, rolled up socks or sandwich baggies filled with rice.

Perhaps the most redeeming feature of this offer is the handful of rebates. You do have to purchase the kit, and pay for shipping; but if you really are interested, you do get a rebate on your future implant purchase, which evens out the expense.

And even if you're not actually interested in breast augmentation, the kit includes rebates that can be used for Botox and Juvederm, which are worth more than the cost of the kit. . .

My secret Sunday addiction

2009-09-20T10:03:00.000-07:00

I remember first seeing this photo a few weeks ago on Postsecret. Visiting the site has become a nicely anticipated part of my weekend, sort of like the soul-satisfying thud of the Sunday Times, ready to be perused and lingered over with a steaming cup of coffee.

That postcard, that image, that secret have stuck with me, for some very obvious reasons.

But it makes me wonder again about what a charged topic breast augmentation truly is. As a plastic surgeon, for whom it literally becomes an everyday kind of thing, if you're not careful, you can quickly become inured to the whole idea: Woman wants larger, fuller breasts. Woman gets implants. Woman is thrilled.

It is, however, so much more complicated than that. As the confessor in the postcard implies, there is so much emotion and judgment and conflict and mystique wrapped up in breasts and the concept of augmenting them. And not just for the women who are thinking about it, the women who are planning to have it, and the women who have already done it; but also for their partners, friends, family, coworkers, and acquaintances.

In the end, it is a very personal decision. And it should be.

Keeping cool

2009-09-18T19:41:00.000-07:00

I am in a calm, happy cool place, not worked up by maddening articles about Botox, not sweating in a very indelicate manner in this latest Bay Area heat wave.

I am back at Lassen National Park, overlooking one of the lovely Sifford Lakes which you see above, where the air between 7000 and 8000 feet was cool and clean and crisp last week.

Sigh.

Botox-To-Go. Really?

2009-09-18T19:01:00.000-07:00

It's a little bit funny - I was just chatting with a patient this afternoon about how crazy it is that there are folks out there who will let anyone touch their faces. And we weren't talking about your monthly facial or whatnot; we were talking about injecting Botox.

As my patient put it, gesticulating wildly about her face, "There is an awful lot of stuff I like going on here!" We agreed - we wouldn't let just anyone even begin to approach our precious faces with a needle and neurotoxin in their hands.

Which is why I was amazed by this news article, which landed in my inbox this afternoon. A piece in the online version of the Tampa Tribune, it describes taking cosmetic enterprise to a whole new level, almost like Botox-To-Go. A company envisioning bustling storefronts in busy shopping malls is set to capitalize on shoppers who happen to wander by and decide to pop in for a little Botox on a whim. One location is already doing business, "tucked between a Chico's and, yes, a LensCrafters."

If that doesn't make you squeamish, maybe this will do it: "Licensed technicians" will be performing your medical procedure.

Seriously? Will they do my mani/pedi when they're done injecting my Botox?

It is absolutely serious. Botox Cosmetic (and its counterpart, Dysport) is a neurotoxin, a FDA regulated medication, and despite so many attempts to downplay it, injection is a medical procedure that is not suitable for everyone who walks through the door.

No offense to the many talented nail technicians out there, but I definitely want someone who knows what they're doing if they're putting a needle to my face. I want someone with solid medical training, like a nurse or a doctor. And when push comes to shove, I want someone who is intimately familiar with every intricacy of facial anatomy and what Botox can do to it - like a surgeon who has been inside the face and understands what's going on.

And so does my patient.

Last days in China: Changde to Changsha to Shanghai to Home

2009-09-01T15:32:00.001-07:00

Alex, in the borrowed team office, with the local charge nurses.

Friday was the team's last day in Changde. A few people had already left earlier in the week, so our numbers were sadly dwindling as our memorable trip to China was quickly drawing to a close.

After morning rounds on the handful of our remaining patients, we took one last opportunity to thank the local staff for their kindness, patience, and fantastic care.

Alex and me, flanking the very capable Dr. Fu - the local doc who helped make things happen on the first floor ward.

Back at the hotel, a pensive-looking Johnny, displaying the framed and signed scrub shirt for our translator/guide/friend, Pan.

The giant custom frame was extraordinarily cheap, by U.S. standards - I think we paid less than twenty bucks, for a very nice job that would have fleeced us for hundreds of dollars here.

If you can zoom in on the scrub top, there are a lot of very sweet messages and meaningful sketches. Quite a few of us managed to scrawl our Chinese names beside our American ones, myself included.

On this, the last day of the trip, after I had been "signing my name" repeatedly with all the grace of a struggling kindergartner, a couple native speakers pointed out that I was writing my name wrong... Part of the character for my given name was backwards! Apparently, I've been doing this for the last twenty years... And there it is, on the shirt, behind glass, preserved for Pan and posterity.

Well, now I know.

Saying our goodbyes in the hotel lobby. Here's Faith, soaking it up like a regal princess.

Almost unbearably cute, Alfred and Rosa. Newlyweds (I think six months still qualifies). Rosa - who is a periodontist in Hong Kong - joined us for the second week of the trip.

The scene as we tried to board the bus. There were a lot of tearful goodbyes, and promises were made to see each other again at next year's trip. All of our translators were so sweet, kind, and helpful - not to mention quite good at helping us understand and communicate throughout our stay. I am sure each of them will go on to achieve great things.

And so another bus spirited us away, this time a nearly three hour journey to the city of Changsha, where most of us would fly to Shanghai, spend one night, then find our ways home.

This bus ride was a bit more subdued, from a combination of exhaustion and contemplation.

And the flight from Changsha to Shanghai, on China Eastern, was much less memorable than our first flight to Changde. In a good way.

But there was still more Pan to enjoy! Here he is, captured as he tries to figure out a logic puzzle.

The Shanghai crew finally settled in at the hotel late, around 9 pm, but we were determined to see at least a glimpse of the city - which was nearly an hour's taxi ride from the hotel. Ever patient, Pan - who was in Shanghai for some very important interviews - convinced this restaurant to stay open to serve us.

One last feast, in Shanghai.

Left photo: center bowl, fish soup laced with Sichuan peppercorns. Clockwise, starting at 12, barbecued rabbit, deep fried whitefish, braised fungus, a dried rice and syrupy tropical fruit amalgam, spicy pork, another spicy dish, mashed potatoes!, and roast duck.

Right photo: my favorite dish of the night, silky tofu with the slightest touch of spice, in broth.

I had about 6 hours in Shanghai proper. But we made the most of it, before heading back to the airport and finally returning home.

Thank you to everyone who's been following this sordid tale.

This cleft trip to China was such a rewarding experience - not just seeing a tiny slice of this giant nation firsthand as an amazed tourist, but being able to give back a little something of myself too. Thanks to everyone behind the scenes (Jackie, Judy, all the foundations who helped us get to Changde) and the generous locals who helped us all the time, every day. It was a privilege to be part of the American team; every single one of whom rallied to make it happen for the children.

In China, day twelve

2009-08-31T13:40:00.000-07:00

Thursday was the last day of operating for the team in Changde. With only two cases for the entire day's schedule, I had the day to myself, after checking in on the patients in the morning.

One of our translators, a very smart and spunky girl named Zhong, wanted us to try lamb noodles - and she knew just the place, a very short walk from the hospital.

Breakfast was never so good. The meat was sliced thin, cooked perfectly tender without any of that gaminess that often plagues lamb cooked in the States. The soup was spicy, of course, but not mind-numbingly so.

Quite a few members of the team raved about a beautiful lake they had been to during the week, easily accessible by hopping on the bus just outside the hotel for 1RMB and riding it to the end of the line. It sounded like "New Year Lake", with pagodas and weeping willows and boats.

With my bad Mandarin and the help of an assortment of English-speaking locals (everyone, it seemed, had a friend they could dial up on their cellphones), Heidi and I eventually made it to Liuye Lake.

The AC on the bus was lovely, and we were treated to a motley parade of sights through the windows. Changde is a medium sized city, but even within city limits, there is still a surprising amount of rural character.

Even though it was a hot summer day, the breezes off the lake kept it bearable. Apparently Liuye Lake is another famous area in Changde, developed as a resort complete with a five-star hotel.

We were surprised by how few children there were at the lake's grounds. The ones we did see, though, were definitely having a great time.

Heidi and I had heard that you could take a boat out to an island in the middle of the lake. These ones clearly weren't going anywhere.

We eventually figured out how to purchase a ticket for a boat ride, provided by this politely curious gentleman.

Passing some of the other boats. With all the haze, it was a little hard to see to the distant shore. The internets tells me that there are several beautiful mountain peaks hiding back there.

We eventually "docked" at a rough stone pier, where our boatman gestured we could get off. Heidi and I looked at each other, and as we climbed a rustic path away from the boat, hoped that he would still be there when we returned.

The island was small, and we were immediately accosted by a family, who appeared to be the caretakers of the island and its small temple. A man offered us the most giant stick of incense I've ever seen, as thick as a baseball bat but longer; we politely declined. He eventually gave up.

Wandering around, we found this grove of trees, perfectly spaced for hammocks. A woman was taking advantage of the quiet setting, peacefully reading a book.

I don't know why I love chickens so much.

Our friendly boat man was indeed waiting for us, and he ferried us back to shore, taking a leisurely course past a large pagoda where men were fishing.

Heidi and I bravely tried out a tandem bike. I must say we were pretty successful - riding to the pagoda and back. Although we did get dusted by a mom with her young daughter.

In China, day eleven

2009-08-29T11:43:00.000-07:00

The mission was nearing its end; today was my last day of operating. For me, it was a full day of working hard to piece together both revisions and a "fresh" cleft lip.

This gentleman was 20 years old, and he just wanted whatever could be done to make his lip look a little better. His initial bilateral cleft lip repair was done some time ago and looked fairly good - just a few minor adjustments needed.

He seemed pleased by the results - realignment of his upper lip border, and a tiny little flap of tissue tucked to give him a little more fullness where a notch had existed before.

This six year old girl had also had a bilateral cleft lip repair done previously. She had extremely wide "train-track" scars, and as you might be able to tell in the photo above, she had some bulkiness on either side of her upper lip.

The orbicularis is a muscle that circles the lip and allows us to do things like pucker and whistle. In children with cleft lips, that muscle is discontinuous and misaligned. If at surgery, the muscle edges aren't approximated well, things can look a bit off.

After surgery. Her wide scars have been excised, and the muscle aligned properly.

My last patient of the mission was perhaps the most remarkable of the trip. You can see the little 7 year old guy in the photo above (courtesy of my new friend, William Zhao), sandwiched merrily between his parents. In Tibet.

This incredible story (and the photos shared above and below) was told to me by William, whose kindness and dedication will become evident shortly.

Word of the Chinese Agape mission in Changde had somehow made it to this little boy's family. With a lot of help and planning (and William, who lives in an entirely different city in China far from Tibet, was instrumental as guide, translator, and friend), the little boy and his father made the fourteen day trek - mostly on foot, but also via donkey, bus, and train - from their village in the mountains of Tibet to our hospital in Changde.

The brave little fellow, before surgery. I was only allowed to repair his bilateral cleft lip; despite the team's pleas, the hospital would not allow us to perform the repair of his palate as well.

Resting the next morning after surgery. When he was shown pictures after the repair, it took him a long while before he seemed to recognize himself.

With William and the patient's father at his bedside. His father was so happy. And I'm happy to report that everyone made the long journey home safely from the hospital.

Another day ends with dinner. This night, our graceful translator, Anita, organized an outing to a more "homestyle" restaurant that her family has enjoyed frequenting.

Just a few of the many dishes we enjoyed. Left: a bowl of cold fermented rice soup. Refreshing with effervescent rice grains, this dessert-like soup was about two steps away from becoming shochu. Right: flavorful fish soup. The girls were so sweet and insisted on finding the big chunks of meat to serve us.

In China, day ten

2009-08-28T11:32:00.001-07:00

Another day at First People's Hospital in Changde. Johnny and Alfred with one of the local nurses.

Steph, modeling the latest and greatest in gown couturewear. The attached muff is a brilliant idea - handy, convenient, stress-reducing for hawkeyed circulators breaking in new medical students... We should get these on all our paper gowns in the States. Who do I have to call?

All right - caution signs and blinking lights here, for all of you with weaker stomachs. Photos of a slightly more invasive surgical nature (two, to be exact) are next in the lineup.

One of my cases of the day: a big kid (17 years old) with an unrepaired cleft palate.

In a way, working on the older patients is easier in terms of cleft work. The structures are bigger and easier to see, and often their tissues are a little more generous when you're trying to get holes closed and covered up.

Unfortunately, if patients wait too long for surgery, you do lose a lot of the advantages of early repairs, like bony molding and speech development (which I mentioned briefly in an earlier post). There are always trade-offs in surgery.

Dinner that night: a barbecue and hot pot place. Off to the right of the photo, behind where everyone is congregating, is the open room where the grilling was done, over a charcoal brazier. Notice the hot red glow.

The young man who tended the fire was also the one who schlepped all of our food up to the second floor. Shirtless and sweaty, he seemed astounded that we would attempt to eat all of it.

Left: fresh lotus seeds, which you shell and eat. Right: butterflied chicken drumsticks, fresh from the coals. I had no idea you could butterfly a drumstick. It was tasty. Part of a seemingly endless parade of grilled foods - squid, lamb, peppers, potatoes.

"Uncle Johnny" and his women. The young translators all adored Johnny, as you can see in the photo. They also called him "opa", which Korean girls use to address an older brother. Some of the rest of us started calling him "opa" too.

In China, day nine

2009-08-27T14:08:00.000-07:00

Laundry day at the hospital. Actually, every day was laundry day - each morning you could see a different assortment of clothes hanging outside windows and on railings. With the degree of humidity in Changde, I'm surprised anything was able to dry...

In the secret elevator with Johnny and the daytime operator.

He had a stool and a pack of cigarettes, so he could wait patiently until summoned. But he wasn't this friendly to everyone. When called to a floor, the operator put on his stern face, eyeballed the waiting crowd, and refused and even kicked out anyone who didn't look like they belonged in the OR.

Another day, another tube. Paul, making his work seem effortless.

This little girl was six and a half years old. She had her bilateral cleft lip and palate repaired previously, but there were some minor touchups that could be performed.

Playing in her bed after surgery. A few minor revisions, to narrow the nostrils, redo the widened scars, and line up the pink of her upper lip a little better.

Charles, focusing. He is assisted here by Heidi, who is a fourth year medical student in Colorado, applying for residency in general surgery. She was incredibly smart, hardworking, and helpful; I'm trying to convince her to come to Stanford...

The famed shoe lockers, as demonstrated by Johnny.

In the bottom right hand corner of the photo, you can see a slightly askew cabinet - inside lie all those rubber slippers, arranged from smallest sizes at the bottom to largest (which, as some of the team found out, weren't all that large) at the top.

For dinner that night, most of the team went to a Western-style restaurant. The menu was vast - everything from steaks to salads to pasta to Korean rice pots to waffles.

I opted for the restaurant's special steak, which was in a word, interesting. You can see Carin's reaction in the photo above; she had ordered the same thing.

The steak was a little different from what we're used to in the States; it was thin, either extremely tenderized or cobbled together from lesser parts, and drowned in a black pepper sauce. The plate was garnished with part of a corn cob (also very different from what we get here: rather than supersweet kernels, Chinese corn is very chewy and starchy) and a fancy-cut hot dog.

The drink is fresh-squeezed Chinese pear juice, which was a refreshing change from the usual breakfast-time watermelon routine.

And let's just say that the pizza was pretty different, too.

In China, day eight

2009-08-26T16:30:00.001-07:00

Another hot and humid day in Changde. On our way in to the hospital, posing out front from left to right: Alex, me, Charles, Alfred.

Johnny, on rounds on the first floor.

Operating, with a helping hand from Stephanie and Alfred.

Finally, a chance to see the town in the daylight.

We were all warned about the traffic in China. Although there are crosswalks, those painted lines on the street just demonstrate a convenient place to be run over. Pedestrians do not have the right of way on these streets.

We learned that when crossing, drivers of scooters will generally slow down when they see you, whereas drivers of cars and trucks will actually accelerate and aim for you.

Scary at first, by the second week in Changde, we were all darting through traffic like locals.

A foray to "RT Mart", which was explained to me as being bigger and better than the local WalMart (which was located in a central city plaza, flanked by the KFC and McDonald's).

I always think it's so interesting to see what is being sold in local markets. Here, baskets and baskets of dried seafood - little fishes, shrimps, and other shellfish.

And rice - bushels and bushels of all sorts of different varieties.

The scatterings of English phrases were always stunningly insightful, whether intentional or not.

It made me think about the popularity of getting Chinese character tattoos here in the States - which, when shown to a native reader, turned out to be jibberish, or even worse. Does the converse occur in China? Are there thousands of Chinese punks or hipsters with funny English phrases tattooed on their parts?

Dinner that night was another test of our spicy tolerance. Here, we sampled crawfish, crab, and frog bathed in chili peppers. Once we had picked out all the succulent pieces of meat, a waitress poured hot broth into the metal bowls, creating a spicy hot pot - perfect for cooking trays of sliced meat, fresh cut vegetables, spongy tofu, and slippery noodles.

So much work for such a tiny, delicious morsel of meat. Totally worth it.

In China, day eight

2009-08-25T12:43:00.000-07:00

And Saturday was our "day off". After checking in on our babies in the hospital first thing in the early morning, the team packed on to yet another bus.

Inexplicably, we took a quick detour to a bus depot first.

Two and a half hours on the bus. In a matter of minutes, leaving the crush of the city for more bucolic landscape.

I think our driver tried to pop in a DVD of some dubbed German martial arts B-movie, quickly rejected and replaced by a series of Chinese pop music videos that revealed an alarming amount of gyrating pre-pubescent flesh. Thankfully, that didn't last long either.

Most of us either dozed or became entranced by the scenes framed by the bus windows. As we traveled through Hunan Province, we got to see a little more of the "real" China. So much farmland, so many shades of lush green stepped into the earth, dotted with bent backs and water buffalo.

We stopped for a delicious lunch - loads and loads of banquet-worthy food.

Left photo, top to bottom: braised pumpkin, the ubiquitous green bean and eggplant, incredibly tasty five-layer pork.

So called five-layer pork, because the cut displays these gorgeous ribbons of thick fat alternating with a relative scarcity of soft-cooked meat, sitting on a bed of braised salty greens. It's a delicacy in Chinese cuisine. I must admit, I do love my food, but I usually carefully dissect away big chunks of fat. On this day, I gobbled up every bit of that unctuous pork. I don't think I've ever had any better.

Right photo, top to bottom: whole chicken stewed in broth, a different (!) kind of fatty pork, creamy eggs scrambled with Chinese chives, and a perfectly crispy green onion pancake. And that rustic wooden bucket filled with steamed rice.

The bus finally arrived at our destination, Zhangjiajie. A famous scenic area of Hunan, the scale reminded me a bit of someplace like Yosemite here at home. We had a single afternoon; we could barely scratch the surface of the park.

I'm here with Sarah, one of our sweet translators for the day trip, in front of the ticketing area for Zhangjiajie.

The start of the scenic nature walk. Bravely, we turned down the tram that took you past the whimsically named rock formations. Instead, we walked. And sweated.

Jen and Alex, helpfully pointing out the "Tourism Etiquette Rules for Chinese Citizens". The particular phrase they're highlighting: Don't go barebacked in public places. If the resolution on your screen is good enough, you can zoom in on the text; it's chock full of gems like that.

The other part of Zhangjiajie we did get to see was the cable car ride to the top of one of the mountain peaks.

In the cable car: Stef, Alex, and Faith. The look of terror on Faith's face is absolutely genuine. She had a terrible fear of heights, but our stalwart young translator from Nashville stuck it out and lived to tell about it.

The views from the top were absolutely worth it.

The way back down was a bit rougher on the spirit. Two hours of creeping towards the cable cars, trying to keep cool, and defending our personal space. Then back on the bus, homeward bound.

In China, day six

2009-08-24T15:33:00.000-07:00

Surprise - not a gratuitous food picture. Instead, the beautiful Steffanie doing her best to comfort a scared little patient.

Traveling from the first floor ward to the operating rooms involved a convoluted trek from one building to another. This is the sign that let us know we were on the right track. It seemed like admitting was on the right hand side of this picture (where the gleaming metal bars are, a disturbingly recurring jail theme here).

Once you got an elevator to the 11th floor, you were greeted by this familiar face. She assigned you a shoe locker and a clothes locker, and handed you a passel of green hospital scrubs, disposable cap and mask. As you can see by my spicy surgical cap, we did manage to bend the rules a bit...

First patient of the day for me, another incomplete cleft lip, a 14 month old boy.

Looking good after surgery.

After cleft surgeries, the parents (and the patients) had to learn how to drink very carefully, using a syringe to squirt liquids into the mouth. These precautions are taken to avoid disrupting any of the delicate work done on the lip and/or palate during surgery.

Pam, taking expert care of the babies, getting them ready for a good sleep.

Second patient of the day. If you look carefully at this 13 month old boy, you can see a tiny notch on the underside of his upper lip. Following that up towards his nose, it looks like maybe someone has already been here - a nice surgical scar, perhaps?

But according to his family, this baby had never had surgery before. What looks like a surgical scar on his lip is actually a microform cleft lip.

After surgery. He was a very peaceful fellow.

With my patient Changde scrub nurse, Tien. She was so excited to hear about how much Jen and I appreciated spicy food, that she brought some spicy dried pressed duck, a Changde-only delicacy, for us to try.

Charles, looking stellar as always. His scrub nurse's name was Mao-Mao, as in Mao Tse Tung.

Maybe it looks like hard work and long days, but some of us got a little extra help to push through the pain. Exhibit A: Charles getting a back massage in OR 2.

Exhibit B: Alex, receiving icy saline bags to help cool down his back.

Alfred can't believe it either.

The morning-friendly surgeons of the first week, left to right: Charles, Jeff, Alex, me, Johnny.

The babies were all brought up to the operating rooms in their own clothes; if you were older, you got to change into these special patient gowns. See what I mean about the jail-ish theme?

The local nurses were so smitten with their American counterparts, they gave them their own uniforms, complete with the cap. Lee Ann and Krista definitely owned the look.

In China, day five

2009-08-22T11:14:00.001-07:00

A new day, a new taste. Smack in the middle of the plate of old favorites, a tea egg. If you've never had one before (available at roadside stalls and 7-11's throughout Asia), they're pretty easy to make.

Hardboil some eggs, and crack the shells with the back of a spoon to make a beautiful cobwebby pattern. Mix up a concoction of soy sauce, loose leaf tea, star anise, black peppercorns, a touch of sugar, and a cinnamon stick. Simmer the hardboiled eggs for at least an hour; I like the flavor to really infuse the eggs, so I let it go longer. A perfect snack (I've even taken them hiking).

Morning rounds. This little guy was a total ham.

All right, surgical-type photos coming up. Notice has been given.

My first patient of the day. Another incomplete cleft lip, this one on a 22 month old boy.

Healing quickly after surgery. If you've been wondering why every lip has an oddly purple tinge to it, it's the Dermabond. Perfect dressing for lips in any country.

If you've been wondering why every baby has that Angelina Jolie look going for them, it's normal postoperative swelling. It usually peaks the first day or two after surgery, then comes down to a regular sized lip.

Warning: more graphic surgical photos upcoming...

Second case of the day: an isolated cleft palate on a darling 2 year old boy.

This cleft was a bit narrower than the previous day's cleft, and the palatal shelves came together nicely.

My little guy, after surgery. He was still working on getting his pep back up to his normal wildly spirited self.

With my patient, his mom, and a beatific Jen in the background.

Skulking about the OR with Abby, one of our more petite translators.

From left to right: Carin, Anita (elegant and graceful, another one of our very hospitable interpreters and city guides), me, and Azriel.

After another long day in the OR, we trotted off to have massages. Here I am with Johnny in front of the joint, being welcomed.

There were a good dozen or so of us weary boys and girls, and I was a little concerned that there may not be enough masseuses to go around. Silly me - this is China, land of 1.2 billion strong.

Not only were there enough masseuses, but we could each get one for the body and one for the feet, working simultaneously. And, we had the option of a male or female masseuse, and then another choice: regular-sighted or blind (the Chinese believe that the blind have a special skill for massage). Incredibly, all that attention - for over an hour - cost us the equivalent of around USD$20.

The girls, enjoying our post-massage tea and our post-massage hair. Left to right: Stef, me, Steph, and Pam.

I heard that in the boys' room, there was a little alarm over some of the neck manipulations being performed. Not to name names, but Charles asked if the masseuses had ever killed anyone. Apparently they just giggled in response...

And, the dinner of infamy.

Another excellent choice by our designated host, Pan. This restaurant was famous in Changde for its stinky tofu and pigs feet.

In the photo above, you can see folks lined up for some of that famous tofu to go. 1RMB for 3 delectable pieces, if I remember correctly (Alfred couldn't wait to be seated, and it was a very excellent decision).

Stinky tofu, you ask? Yes, it's exactly as it sounds - fermented tofu, with a very distinctive odor and surprisingly sublime taste. Kinder fans might try to trick you by translating it as "fragrant", but there's really no mistaking cho dofu for anything else. Catch a whiff of something vaguely resembling ammonia, rotten eggs, and maybe a bit of dog poo (sorry, but it's true) from a very crowded restaurant? You've found it.

Although to be honest, this restaurant's version wasn't half as stinky as some I've had elsewhere.

Left: the famed stinky tofu, deep fried and glorious.
Right: pigs feet (or trotters). The Chinese say that eating pigs feet makes women more beautiful; the science behind it might be all the collagen in the dish...

Charles and Jagoda, one of our lovely caretakers - who speaks five languages, and was working on making Chinese her sixth. Notice the Michael Jacksonesque style she's sporting; it was a key maneuver in manhandling the pigs feet, which were incredibly sticky to eat.

Fish head soup. Tasty, but watch out for bones...

Left to right: Jeff, Alfred, Heidi, Charles, Jagoda, Max, Joyce, Karra Lea.

Left to right: Paul, Jen, Alex, Stef, Pam, Johnny, Steph.

Fortunately, it never came down to this. Sorry, but if you don't know, you'll have to ask any of the folks in the pictures above for the full details...

In China, day four

2009-08-21T16:22:00.000-07:00

I've come to rely on my breakfast photos as daily bookmarks... More of the same this morning. Note the beverages in the top right corner: a super-watered down Tang-like beverage (perhaps the Chinese version of VitaminWater?), and something vaguely resembling warm milk (hopefully not melamine).

Morning rounds on the first floor. That's Jeff, on the left, one of the plastic surgeons on the team, who brought a little bit of Hawaii flavor to China. Azriel, one of our charming translators, on the right. In between them: one of those "I love you" balloons ruthlessly hawked outside the hospital. Someone must have fallen for it.

As you travel through China, you notice "the squat" is the favored position of the people. Anytime, anywhere. Old people, young ones. I guess it's in the genes.

All right, fair warning. A few surgical-themed photos coming up.

This is the cleft palate of a little girl, almost 3 years old. A little more ground to cover here, than the previous day's case.

This was a challenge, but everything came together - after deploying nearly every trick in the book.

My little patient in recovery.

Apparently at the First People's Hospital of Changde, there is no recovery room. The local anesthesiologists wake up the patients in their ORs, recover them on the operating room table, and transport them directly from the OR to their beds on the wards.

Admittedly, this wasn't what any of us Americans were used to, and following the Changde custom would slow down our surgical day's progress considerably. Besides, our team included some talented nurses who were itching to get to work.

We were able to commandeer an empty OR and transform it into our PACU. Hats off to our recovery nurses and all the caretakers for working their magic. You can see a little "MacGyvering" in action in the photo above: a plastic drinking cup works double duty as an oxygen blow-by.

The little girl, doing well the day after surgery.

At work in the OR. This photo reminds me a little of the spirit of Rembrandt's The Anatomy Lecture of Dr. Nicolaes Tulp.

Back on the patient ward, with a feisty little guy.

He was so hungry, he wasn't letting anything get in his way.

Success!

Speaking of hungry, our group couldn't be called slackers in the appetite department, either.

Our friend Pan took us to another restaurant for dinner, this one famous for their duck. Our translators and guides were so incredible and very proud of their wonderful city; we were taken only to "the best" and the "most famous" dining spots in town.

Prep work in the restaurant.

Mmm. Digging in to the hot duck dish. Left to right: Pan, Alex, Charles.

Top left: spicy duck in the hot pot. Right: mung bean "tofu" - very soft cubes with a mild, herby flavor.

Bottom left: bean thread noodles. Bottom right: braised cauliflower.

After dinner, we convinced our young local guides to take us to KTV.

For those of you unfamiliar with KTV, it's karaoke. But you haven't really experienced karaoke unless you've been to KTV in Asia. Private rooms, so you can privately embarrass yourself in front of all your friends. It's wild.

This particular place was called "Greek Myths" - you can sort of make out the opulent theme in the double-wide room we got. Gilt this and that, fake columns and ancient styled busts. Right, and the very serious karaoke machine - complete with two mikes, two projection screens, disco lights, and an eardrum-blasting sound system.

Bless his heart, Pan was not a big fan of KTV, as you can see in the photo above. But he did sing a tune or two as the night went on...

A few of our translators, belting out Chinese pop songs. With the mike on the left, Nancy; on the right, Carrie.

By the end of the evening, I was convinced that Alfred was not who he said he was. He was actually a Hong Kong pop star masquerading as a do-gooder oral/maxillofacial surgeon. Maggie was no slouch, either; she did a very impressive cover of this Jay Chou "classic":

And this gentleman, well, he tore it up. Not just singing, but a full dance routine, and such passion! You couldn't pry the mike out of his fingers.

In China, day three

2009-08-20T14:26:00.001-07:00

Have to start off the day with breakfast, right? I have to confess - every evening, housekeeping left two meal tickets on my nightstand for the following day's breakfast - even though I didn't have a roommate. On more than one occasion, both tickets were redeemed. What can I say? I like to eat.

Clockwise, from the bowl. Chewy glutinous rice flour balls filled with a sweet black sesame filling, cold seaweed salad and seasoned bean curd skin, pan-fried wide rice noodles, mildly spicy cabbage, cold cucumber pickles, a slightly sweet white flour bun, and another bun filled with a savory pork-chive center.

My first and only patient of the day - a very handsome 18 month old boy with a cleft palate. He was very attached to his shoes.

This trip was interesting in that there were a plethora of surgeons; depending on the day of the trip, anywhere between 5 and 7 very capable cleft lip and palate experts were available. Since we had three excellent anesthesiologists on the team (along with a surprising amount of local assistance - a number of Chinese anesthesiology residents and techs helped out), we were able to keep three rooms running pretty much all day. But with more surgeons than operating rooms, we tried to divvy up the workload fairly. I think everyone was pretty happy in the end.

A word of warning: the next few photos are a bit more surgical in nature. Not for the faint of heart - scroll down quickly, past the blood, guts, and gore (just kidding, but not really about the blood part...).

A fairly typical cleft palate. Imagine yourself looking up into the roof of a child's mouth. You can see the two pendant shaped things, hanging on either side of the middle gap; those are the uvula - that funny thing that you see in the back of your throat when you say "aah". So clearly, those are supposed to be one structure in the midline - along with all that other tissue above it, the soft and hard palates, extending forward (or up, in this photo) to the back of the teeth.

Now imagine yourself doing surgery to fix it. You're almost working upside down and backwards to fix some smallish structures in a small, deep, dark hole. You do have a little help, from this friendly looking medieval torture device called the Dingman retractor, whose metal attachments help keep the tongue and cheeks away from the area of interest.

And, if you're smart, you bring your own operating headlight - so that light actually goes where you're looking. And if not, you're at the mercy of the circulating nurse - especially if the light handles are not sterile, as was the case in Changde.

It all seemed to work out okay. You can see the giant hole in the middle has been closed, by bringing the tissues from the sides together. The gaps on the sides quickly fill in with tissue in the days after surgery. When the cleft palate is repaired, the babies are able to drink and eat without liquids or food regurgitating out of their noses.

The most important part of this operation, which you can't particularly appreciate in this photo, is bringing the muscle of the palate back together. A good muscle repair - in a child who hasn't started vocalizing yet - can eliminate many of the speech stigmata associated with clefts.

After palate surgery, the babies are usually a little miserable. But they're pretty thirsty and hungry, and the most amazing thing about the whole process is how they bounce back so quickly.

This guy seems a little suspicious of me now.

All is forgiven. Here I am, with the family.

The moms of the babies were so sweet. They happily assembled to pose for me, but only after a few of them fussed a bit in the mirror.

Lunchtime. I've eaten in a lot of hospitals over the years. Hands down, the grub we got in Changde was the best hospital food ever.

Clockwise, starting with the seaweed soup in the bowl. Slightly curried cauliflower, greenish strips of a crunchy vegetable no one could think of the English name of (I'm thinking it might have been kohlrabi?), softly cooked slips of wintermelon, beef and peppers, a mildly spicy white bean condiment, spicy pork and red peppers, and braised eggplant with green beans.

One of the most peculiar hospital customs that the medical team had to adjust to was the wardrobe ritual.

I know a lot of us who work in the OR become a little more particular about our garb as time goes on. Speaking for myself, I often hoard and launder my own sets of scrubs (as another surgical resident confessed to me once, "The hospital-washed scrubs are just not as soft!"), and my OR shoes of choice are clogs that I've broken in over the span of my entire career, which are incredibly comfortable while standing all day, now. You get attached.

We had all brought our own scrub tops and pants and shoes, but the lady standing guard at the front desk to the ORs stopped us soundly. We finally figured out that we were supposed to change into their green scrubs, wear their disposable hats, and change into these flip-flops.

The flip-flops, as you can see in the photo above, turned out to be non-negotiable. But we obnoxious Americans slowly pushed to have our way with the scrubs and caps.

Wearing slippers in the OR was, to say the least, a new experience. At least I had packed socks.

Johnny's grinning in the blue scrubs; he will join the ENT staff at Loma Linda later this year. Stephanie, one of our awesome scrubs from Utah, is assisting a surgeon, whom I believe to be Alex. Notice he's got the headlight on. Smart man.

Jen, on the left, flanked by some of the Changde hospital locals. He was consistently surrounded by a local anesthesiology crew, who were eager to pick up some American terminology and tips. I think they really appreciated his proficiency in Mandarin.

The back table setup. Rather than the usual sterile blue field, all the drapes were this unforgiving whitish cloth.

I tried to learn the Chinese names for my most frequently requested instruments: mie tze (pickups), dao (knife), jien dao (scissors). The most frequently seen reactions from my local scrub? Gentle laughter or confusion. How do you ask for "6-O fast absorbing gut, on a small needle driver please" in Mandarin? I often resorted to pointing and grabbing...

That thing in the back, which you would hope to be an air conditioner? It wasn't.

It turned out to be some sort of air purifier. The heat/humidity was pretty amazing in the ORs, especially after you put the thick, heavy cloth gown on. When we felt the sweat dripping more than usual, we'd ask the nurses to turn the A/C (which, thankfully, did exist) back on.

I'm sure we thought we were crazy; I started to notice the staff wearing additional layers under their scrubs by the end of the first week.

A typical scene in the ORs the first week. The guy with his mask down, hands to head? That's Pan, one of our incredibly kind, generous, and patient translators. That turned out to be a very common pose for him during our stay in Changde.

Dinner. We coerced Pan into taking us out to eat that night. He brought us to one of his favorite noodle restaurants, right by his old high school. In the center photo, you can make out two giant pots of noodles, sitting on burners (not Sterno, but some white waxy block wrapped in flammable plastic). The bowl on the left was the non-spicy option, a very tasty chicken broth with delicate, chewy noodles. The bowl on the left was the full-spice option, as you can see from the dangerously dark red oil floating on top.

Pan also ordered up a parade of small dishes for us to try. Some of them seen here: (left photo) crunchy seasoned wood ear fungus, (right photo) top plate of smoked ducks' necks, bottom plate of fried whole fish, possibly anchovies.

Some local color on the walk back to the hotel from the restaurant.

Everyone's ready to be the next Yao Ming.

One of the spots Changde is most famous for is the poetry wall along the river - I believe they have the world record for length. On the other side of the retaining wall lies the famed poetry wall - all these beautifully carved slabs of polished stone, inscribed with Chinese calligraphy retelling ancient poems of Changde's history.

And then there is the skating rink. So the river's not just about the poetry wall - at the riverwalk section very close to our hotel, there is a social area, where a lot of the young people of Changde seem to hang out. In the photo above, you can see the rather talented teenaged boys going all out on their roller skates.

There is also a rickety suspension bridge. I guess the local custom is for young lovebirds to inscribe their names or wishes on a padlock, and clamp it onto the bridge. Another local custom seems to be grabbing the side railings and jumping fiercely up and down, to scare the Americans.

Johnny and Carin, in the photo above, apparently unperturbed.

What a good looking group!

Alex, at the end of a long day, sums up many of our thoughts.

In China, day two

2009-08-19T07:41:00.000-07:00

In my excitement, I've jumped ahead of myself; I should give you a little more information about the trip itself.

Spearheaded by the generous folks at the Chinese Agape Foundation, the focus of this medical mission trip to Changde was purely cleft lips and palates. Additional support came from the Jackson Family Foundation, the CARIS Foundation, and SmileTrain.

I first heard about this trip through friends and colleagues at Stanford; they had been on a previous year's mission (to a different part of China). Having had such incredible cleft surgery experiences in Guatemala and Mexico, I jumped at the opportunity to join this year's trip to Changde. I recruited my friend Charles, another Stanford-trained plastic surgeon, and we joined a team of about 30 Americans hoping to do good things for the people of China.

Although I had traveled a bit in Asia before, I had never been to mainland China. The sheer mass of people here impressed me every day. This is the view from our home away from home, the fifth floor of the Jinyue International Hotel. You can see the density of housing structures, but always with a little bit of planned greenery interspersed here and there.

Breakfast: noodles, made to order. I'm not even going to show you the first plate of food I devoured that morning.

Our first official day of work in Changde. But before we could start, a very official opening ceremony, held on the basketball courts outside the hospital.

In the photo above, you can make out Max, our fabulous no-nonsense OR nurse, heading for her seat, while Alex, one of the other plastic surgeons, is escorted to his by a bevy of beautiful Chinese ladies in traditional cheongsams.

There were many speeches this morning. First, the Chinese officials, followed by an English translation. Then, the American foundation heads, followed by a Mandarin translation. The American portion of the audience roasted patiently in our seats in the oppressive heat and humidity. I don't know how Ron Brown managed to stay so dapper in his suit.

And the entire time in China, I never saw any of the locals ever break a sweat. Amazing.

The local nurses, looking so lovely in their old school uniforms.

Finally, off to work. This is the view from the entryway to the operating room suites, on the 12th floor of the hospital. That grayish haze? Every day in Changde, blanketing the city in a warm, wet, dirty embrace. I didn't see any sign of the sun until the second week there - but I definitely felt it.

My first patient. This little heartbreaker was a 6 month old boy with an incomplete cleft lip. Notice the logo on his shirt. We saw it everywhere, on everyone - men, women, and as you can see, even babies - apparently one of the most popular clothing brands in China, Kappa.

The hospital itself was pretty well equipped and run. Unlike the previous medical mission trips I had been on, where we were MacGyvering it in desperately rural parts of the country, this hospital in Changde was essentially like your typical community hospital here at home.

Of course, there were a lot of adjustments to be made, especially figuring out how things worked the first day, with a formidable language barrier. Western medicine and surgery are pretty universal, but every place has its own particular style and procedures. Learning how to scrub and prep to keep the Changde circulating nurses from losing their minds was like becoming a third year medical student all over again. Overall, the partial assimilation process was entertaining, with just the tiniest whiff of frustration on both sides. All you can do is laugh a little together.

The day after surgery. He wasn't letting anyone get between him and a meal.

This charmer was my second patient of the trip. Another 6 month old boy, this time with a complete unilateral cleft lip. He was a remarkably peaceful baby; I think he had learned to work his cleft to the max - he seemed to enjoy stuffing almost his entire hand into his mouth for comfort. So cute.

The next day, with mom, who was so happy to see her little boy's lip repaired.

My new friend, Alex, hard at work. He'll join the plastic surgery staff at USC in the fall.

My old friend, Charles, observing intently. He's currently on staff at Santa Clara Valley Medical Center, here in San Jose.

That was an awfully long stretch without a food photo. After dining at the "westernized food" section of the hospital, we finally caught on and joined the regular hospital staff for their meal service.

A little spicier, and oh so good. Clockwise, from the top left of the tray: braised pumpkin, spicy stir fried cabbage, chicken with peppers, a really tasty special Changde-style milled rice condiment (just hot enough), savory beans, and the requisite serving of watermelon.

Enjoying lunch in the doctors lounge: Charles, Jen (our unflappable anesthesiologist from Las Vegas), and Alfred (an oral maxillofacial surgeon from Hong Kong, one of the veterans on this trip).

The streets are dotted with little storefronts open late into the night, usually selling an assortment of fresh fruits and cool beverages. If you're tough, you can bargain with the shopkeeper to get the price down from 5RMB to 3 (saving yourself the equivalent of about 20 cents, but really, it's a matter of pride).

I was so excited to see my favorite tropical fruits - a lot of which aren't readily available fresh in the States. I had the pleasure of introducing longan, rambutan, and mangosteen to the crew. You can see Carin (the official trip photographer, a lovely girl slumming it at Harvard) learning how to pick a good mangosteen.

We opted out of the durian. Not hotel-friendly.

Nighttime at the hospital.

First day in China: San Francisco to Tokyo to Shanghai to Changde

2009-08-18T17:19:00.000-07:00

Somehow, I seem to have taken over 500 photos during the two weeks I was in China. Digital cameras: a blessing and a curse. Lucky for my gracious readers, I will spare you the dreck. Only good stuff on this blog.

Let's start at the beginning, which we'll call Day One (really, it was two days, July 31-August 1, but all that traveling fluidizes into one in my mind). Almost 20 hours total of flight time, not counting stopovers... Once a non-believer, I really appreciated my TED hose on this journey.

Above, you can see my carriage awaits.

The international arrivals gate at Shanghai-Pudong. It was a wild scene; I also received my first mosquito bite of the trip - on my right index finger.

After arriving in Shanghai (finally getting to the hotel, perhaps around midnight, with my woefully inadequate Mandarin), a quick night's sleep and off to the breakfast buffet! I started out strong, with not one - but two - breakfasts that first day. An embarassingly large proportion of my photos are of food; but as you'll see, my appetite could not keep up as the weeks wore on.

You know I'm a California girl when I'm taking pictures of this man lighting up cigarettes with his buddies at the breakfast table. While eating. The horror!

After breakfast, the team met for the first time in the hotel lobby, and it was time to get on a series of buses - one to take us from the hotel to the Pudong airport, and another to take us from Pudong to Hongqiao, where we would finally figure out how to get our boarding passes for the flight to Changde.

Krista, one of our incredible PACU nurses, is seen above, figuring out if she's got what it takes for a different kind of day job.

The amount of luggage we had collectively was staggering (to be fair, close to half of it was medical supplies to be donated to the people of China). The bus actually ran out of room underneath, and in a very Chinese kind of way, we stuffed the remaining bags in the front seats, in the aisles, on the steps - thoroughly blocking any entrance or egress.

And we survived the flight from Shanghai to Changde. The domestic Chinese flights are very interesting. I wouldn't personally recommend China Spring Airline, unless you're into group calisthenics in lieu of entertainment and random products being aggressively hawked on the broadcast system the entire duration of the flight (Mickey Mouse towels, anyone?).

We were finally claimed at the Changde Airport, a humble little spot that reminded me a bit of the old airport in my hometown in Ohio. Tiny, simple, intimate. Dodged the smokers to take a quick squat in the restroom, pocket pack of Kleenex in hand. Aaahhhh... welcome to the real Asia.

Some local boys gawking at the airplanes.

More food! First, we met Ron Brown, the director of the China Agape Foundation, who helped us settle in at our hotel - which would become our home in Changde for the next week and a half.

Then it was off to the hospital for a lovingly cooked meal. The hospital staff was extremely concerned about us Americans getting enough to eat. They prepared an entire feast of "westerner-friendly" dishes for dinner. Forks and spoons, nary a chopstick in sight that night. And then, inexplicably, there was the fishball soup.

You can see the unstoppable Stef, one of our great OR nurses, reaching for the ubiquitous watermelon. So refreshing!

We then had an official meeting at the hospital. In the picture above, you can see the backs of many people's heads. I believe they belong to, from left to right, Heidi (our awesome medical student), James (trip coordinator), Sophie (his girlfriend), Joyce (another RN extraordinaire), and Maggie (translator, who had actually been on trips with the China Agape group before).

At the meeting, many important people were introduced, including the local hospital officials. We also received our nametags. They got my last name right, and since I hadn't given anyone my Chinese name, they made a great attempt at transliterating "Angeline" into Chinese characters.

A funnier attempt was seen on my friend Charles' nametag. They managed to break down "Charles" into three syllables: "cha" + "li" + "sheen" = Charlie Sheen?

Some high expectations, already.

The eye clinic on the first floor of the hospital was commandeered for our use.

Gratuitous treatment, indeed.

By the time we got to tour the hospital and OR, it was rather late when we finally got to see the patients for the next day. The babies were asleep already (mostly).

The parents were excited to see us; the babies, less impressed.

All of the babies with cleft lips and palates were so sweet and wonderful.

Ready for a big day tomorrow.

First amendment, forever

2009-08-16T21:02:00.000-07:00

At least this time I have a valid excuse: the Chinese government.

Having fully intended to blog daily about my cleft lip and palate trip to Changde, China (and perhaps even Twitter a bit!), I was thwarted by the hamfisted policies of the Chinese government. No access to Blogger, or most any other blog service, Twitter, or even Facebook (although Myspace was oddly excluded from the forbidden list). Rumor was the government wanted interwebs silence regarding the Uighur conflict in the west...

So I'm back on good ol' free American soil, trying to organize hundreds of photos into some semblance of a narrative of my last two weeks in China. Stay tuned.

Just another day at the beach

2009-07-27T17:33:00.000-07:00

One of the things about my job that I never take for granted is the wonderful flexibility that Dr. Weintraub and I have built into Duet - not just in terms of schedules, but also the spirit of our "giving back" philosophy.

Volunteerism is such an important part of our identities, and it doesn't have to start or end with plastic surgery or medical mission trips. The fabulous thing is that there are so many different ways to contribute.

And we're lucky here in the Bay Area to have OneBrick, an organization with a mantra of "volunteering made easy", which does just that - they sift through the hard stuff and find a spectacular array of events that need able minds and bodies. I've participated in a few OneBrick events over the last two years and have enjoyed each and every one.

These photos are from this weekend's habitat restoration at Pacifica State Beach. It was another gorgeous day in Northern California, watching the fog get chased away by the late morning sun. And as any of the day's OneBrickers could tell you, wrestling the surprising firm grip that the invasive ice plants have on the sandy dunes becomes strangely hypnotic, addictive, and therapeutic...

Us vs. them

2009-07-25T10:46:00.000-07:00

I was reading through the New York Times Health section today, and I came across some provocative statistics buried deep in one of their articles. Originally sourced from the Center for Studying Health System Change, a report was published in August 2007 describing some of the changes in the landscape of physician demographics.

Interestingly, there has been a decline in the number of physicians taking on solo/small group practice - overall, about an 8% decline from 1997 to 2005. In 2005, only 32.5% of all physicians were in solo or two-person practices. The percentages get even smaller when you look at specific age groups; for physicians under the age of 40, only 24.8% are in one- or two-person practices.

I suppose it's not that surprising after all. Many of our classmates and colleagues congratulated Dr. Weintraub and me when we declared our intentions to hang up our shingle. They admitted that they were impressed by our bravery and courage (which is a funny thing to hear from other physicians and surgeons, all of whom are pretty unflappable and heroic folks); nearly all of our friends had opted to join an academic hospital-based practice or Kaiser-type entity, both great options here in the Bay Area. There is a lot to be said for the ease of mind that comes with a built-in patient base and referral system, guaranteed salary, and benefits.

But here at Duet, we are happy to continue to buck the trend - a two person private practice, plastic surgeons that work together as a team, two female plastic surgeons... Perhaps one of a kind, and certainly here to stay.

Already on the outs

2009-07-24T12:06:00.001-07:00

Alas, this article in the NY Times tells me that Twitter is the new Blogger... And just when I was getting used to blogging. That noise? Oh, that's just me sticking my head back in the sand.

Twitter, let me know when you do pictures.

Ready for my close up

2009-07-20T09:18:00.000-07:00

With all the medical-themed shows on TV these days, as a physician it's always fun to chat with "normal" people (i.e. those of us who don't spend their waking hours immersed in the medical field) and trade impressions. They always wonder, Is it really anything like what we see on TV? And I tell them, Yes, but a conditional yes.

Probably the first show to become a national phenomenon, at least in the time of Generation X, was ER (well, that era also brought Chicago Hope, if anyone out there is keeping track, and I'm not going so far back as those before-my-career-began classics MASH or Marcus Welby, MD).

ER was especially riveting to any person out there who devoted even half a brain cell to the consideration of the medical professions - from middle-schoolers to seasoned attending physicians. I know of medical students who formed regular Thursday night viewing parties - faces glued to the screen, sucked in by the drama, exchanging insiders' winks over the technical parlance, and of course, swooning over George Clooney and his Caesar-style haircut.

But then there was the problem of the Hollywoodization of medicine; accuracy was sacrificed for optimizing storylines, facts changed to move the plot along, visuals modified for viewer palatability - raising eyebrows and inducing groans from medical professionals across the nation. But I suppose that is part of the joy of watching television - it's a magical escape to a different world, and with a finite allotment of time, there isn't room for the slowness of reality or the dead weight of pesky fine details.

As the entertainment industry began to realize what an appetite the American public had for medical shows, they multiplied and mutated. Talk to anyone in the medical field, and we'll all admit to watching - and seeing a little truth in each of the shows.

ER definitely captured much of the drama of medicine. Scrubs highlights how much humor is a critical part of the workday and night. Grey's Anatomy brings out the soap opera plot twists that often surface in the hospital. House sometimes says the things some doctors wish they could say in real life.

And yes, I must admit that the plastic surgeon in me was totally engrossed by Nip/Tuck Season One, and maybe even Season Two, before the wild plot twists and turns lost me forever. But even Nip/Tuck has some professional commendation due: their depiction of surgery (at least the visually sensational parts where the scalpel slides through the skin) is perhaps the best out there.

Photo courtesy of NBC.com

Something for every season

2009-07-18T09:48:00.000-07:00

As all of us in the Bay Area struggle through another "unusually" hot and humid July week (is it fair to call it "unusual" when these bouts of weather seem to be a regular part of summer now?), I start to think a little about passing time - both the little and big things that happen every year, giving us a way to mark days gone by and to anticipate the enjoyment of fleeting pleasures.

In grade school we learn to name the four seasons, the delights of which are perhaps not fully appreciated here in the year-round pleasantness of the South Bay - speaking as a born and bred Midwesterner (not that I miss having to wake up a half hour earlier to scrape ice off my windshield).

And in plastic surgery, there are trends you notice as the years go by - a different kind of seasonality. Even at my office in Mountain View, I've noticed definite ebbs and flows of cosmetic patients as the seasons change.

Late fall and winter bring in patients interested in little tweaks and touch-ups, with special attention to the face and skin. In November and December at the office, Dr. Weintraub and I go through a lot of Botox and fillers, like Juvederm and Restylane. I think many folks like to do a little something for themselves in the winter, perhaps to look especially ravishing at all those holiday parties.

After the holiday season, it gets quieter. People seem to be recovering from all those parties - or trying to give their wallets some recovery time after the big flurry of buying gifts. Things pick up a little as you approach Valentine's Day - again, who doesn't want to look good for the holiday of love and romance?

Spring continues to stay busy, until mid-April: Tax Day. That ominous day tends to start a slowdown; everyone tends to get a bit more serious when they're thinking about what they owe the IRS.

And then you transition into summer - always a fun and exciting time. At Duet, we've had a rush of people interested in "tummy tucks" and breast augmentation. I think it's swimsuit season that makes everyone think a little more about plastic surgery and body procedures. We're seeing a lot of women, who are so happy to be talking to a pair of female plastic surgeons who truly understand what it's like to wear a bikini.

All of a sudden, it's fall, then winter, and the cycle begins anew.

It's a different perspective by a plastic surgeon's calendar - a neat and unique way to watch the days go by.

Traveling for a smile

2009-07-15T14:11:00.000-07:00

Some of my favorite moments in plastic surgery have been on medical mission trips. In previous posts, I've talked about the breadth and depth of plastic surgery, and I think that these trips have added sparkle to those dimensions. Most of the time, the focus is on repairing cleft lips and palates, but we always try to take on anything that comes our way.

Above is a scene from my 2007 trip to a tiny little town in Guatemala called Nuevo Progreso. A long flight to Guatemala City, followed by a long bus ride into the southwestern corner of Guatemala, up a narrow winding road to the Hospital de la Familia. The colorful crowd in the photo is an energetic yet serene assortment of patients and their families, waiting to be seen in the busy surgical clinics.

The photo above is from my 2007 trip to Guanajuato, Mexico. These little ones were enjoying a reception the staff throws for their honored patient-guests every year. The babies are always incredibly sweet and inevitably end up stealing your heart.

Partially sponsored by Smile Train, two intense days of cleft lip and palate surgeries were tempered by our gallant host, Dr. Abel de la Pena, who organized a fun international crew of surgeons.

A few satisfied customers in Mexico. It is such a privilege to be a plastic surgeon, and you never feel it more intensely than on these trips. For more photos, including some of Dr. Weintraub's trip, you can click here.

I am very excited to be going on another cleft trip soon, this time to China: two weeks at a hospital in Hunan province, with a team of almost forty American medical providers and about twenty more local Chinese staff. There were rumors of internet access, so I'll keep my fingers crossed on being able to blog from the trip.

Some of you might wonder, How is there time for me to spend two weeks in China? I would be tempted to respond, How is there not time?

I am very grateful to Dr. Weintraub and to our shared philosophy of giving back at Duet Plastic Surgery. We fiercely believe in the good that these mission trips achieve, and we have chosen to incorporate its spirit into our practice.

Why private practice?

2009-07-12T15:01:00.000-07:00

Another popular follow up question is, "Why private practice?"

There is a long answer to that question. Here's a somewhat condensed version:

Jennifer and I had been talking about the idea of "Duet Plastic Surgery" for years. We met when we were medical students, interviewing for plastic surgery residency positions. Luck (and frankly, a lot of hard work) brought us together at Stanford, and we developed an amazing friendship through the trials and travails of residency.

Our training created a hard edge that neither one of us liked, and we both were afraid that it would become permanent if we continued our careers in an institutional behemoth of a hospital. We were also dying for some modicum of freedom, which simply was not an option during surgical residency.

But those difficult days also brought us hope - I can't tell you the number of times female patients have sighed in relief when they saw a woman surgeon come through the door. We female plastic surgeons are still a rarity, even though the vast majority of plastic surgery patients are women.

We felt that there was a definite need - many women are curious about plastic surgery but are not comfortable discussing such private and personal matters with the stereotypical older male plastic surgeon. We embodied a different perspective - and aesthetic - as women; there is something to be said for truly understanding a woman's psyche and physical being, inside and out. We also strongly believe in finding flexibility and balance, not just in our work lives - by giving back through medical missions and volunteerism, but also in our personal lives.

And so, flying in the face of the conventional wisdom and advice offered by those very same older male plastic surgeons, Duet Plastic Surgery was born.

Why plastic surgery?

2009-07-07T12:03:00.000-07:00

I often get asked this question when people find out what I do.

A lot of impressions of plastic surgery have been formed thanks to the popular media: you know which TV shows, magazines, and websites I'm talking about. People can't imagine why anyone would choose such a vapid life of handing out gigantic breast implants and wild nose jobs, dealing with superficial, looks-obsessed people, and feeding into unhealthy "addictions." And it surprises me when people are surprised to find out that life at Duet Plastic Surgery isn't exactly like what goes on at Nip/Tuck (yes, we are plastic surgeons; yes, there are two of us; yes, we do see patients together; NO, that is where any similarities end). . .

Plastic surgery is an incredible field, and it is a privilege to be a part of it. Neither Dr. Weintraub nor I can imagine doing anything else.

There is such breadth and depth to plastic surgery, which challenges your technical skill and artistic creativity every day. One day in the operating room can offer a remarkable range of stories: a small child who fell off his bike and needs his nose set back in the right place; a young woman who has saved money from all her summers as a nanny so that she can have breast surgery; a mom of two active boys who has lost 40 pounds through sheer willpower and can't wait to fit into "regular" jeans again.

Every day we are inspired by our patients, from the present and the past. Vivid memories of taking care of the tiny Guatemalan baby whose mother shed tears upon seeing her cleft lip repaired, the heartbreakingly charming 6 year old who survived the house fire started by his family's Christmas tree, the stoic young man who needed his fingers reattached after a shop class accident, the ecstatic silver-maned lady whose only regret was that she didn't have her breast reduction sooner.

It is amazing to meet these patients, to get to know them as people, to participate in their lives for a sliver of a moment, but to carry their stories in your heart forever.

The new year begins, for some of us

2009-07-01T19:16:00.000-07:00

Every summer in any academic teaching hospital is punctuated with a little bang on July 1st. The traditional start date for nervous interns, tired residents, and anxious fellows, the first of July is when hordes of well-educated, hard-working physicians descend upon hospitals for a period of their lives marked by intense learning, teaching, and taking care of patients.

It's a very interesting time in the hospital: those last few weeks of June and the early part of July. Because interns, residents, and fellows turn over relatively quickly (due to the length of their programs, usually between 1 and 7 years), many of the hospital staff (who often sport pins rewarding decades of service on their scrub uniforms) turn a jaundiced eye toward the flurry of activity before the Independence Day holiday.

At the end of the "academic" hospital year, trainees feel good about their knowledge and skills; they've finally discovered their comfort zone and how to get into it quickly. They know their own duties and the expectations of their attendings ("attendings" = the veteran doctors who supervise, instruct, and mentor - all while doing their own jobs as physicians) so well by June 30th that it becomes a little disheartening to see the calendar tick over to July 1, because that means starting over.

But it's also exciting, to move on, to finish, to start something new. For some, that just means another year out of many checked off on the torturous route to the finish line. For others, it means a new life of freedom and (hopefully) a salary that lingers above the minimum wage for once.

Often, around this time of year, the media turn their attentions to this transition time in the hospitals. The pendulum of public opinion swings back and forth regarding trainees and patient care. There are some who would never think to have their care anywhere but a "name brand" Ivy League-type hospital; others look distrustfully at the thought of being "practiced upon".

Even the so-called experts disagree. Some think that community hospitals (where there are only attendings, no trainees) provide better care for patients, while others think that academic institutions are safer or more effective.

As someone who has been in both worlds, I would be hard-pressed to issue a sweeping opinion. I know so many excellent physicians - and they're not all in academic institutions or all in community hospitals. If it were a matter of making a medical decision for my loved one, I would want them to have the absolute best care, of course. But the "best" depends on so many variables: the patient, the problem, the specialists, the procedures, the location, the aftercare...

Honestly, I think that all else being equal, this is a situation to go with your gut. Seriously. Perhaps the most important thing for patients is to be able to trust their doctors - and you can't do that unless you feel comfortable with them, their staff, their hospital - academic or not.

My Plastics Life

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Rain, rain go away

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It's not just the ugly Americans

Plastic surgery bits and pieces: roundup

News bits and pieces in the plastic surgery world

Friday Figure Fix: Next installment, coming up

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Scientists say...

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