Friday Figure Fix: Back to back

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

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

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?

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

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

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?

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.