April 25th, 2016
By: Jeffrey Nelson
There are several reasons patients desire ear lobe surgery. Occasionally patients just have larger then normal dangling ear lobes that they wish to have reduced in size. For some they have an ear lobe that has torn from the long term weight of heavy ear rings; others a trauma like a child pulling an ear ring caused the tear. Since gages have become much more common, some people wish to have the gage hole removed as they seek out new employment options. The armed services, many fire departments or police departments require gage holes be closed before enlisting or starting training for public service jobs.
The up side of all these reasons for ear lobe surgery is that except in young children the surgery is easily performed under local anesthesia in the office with numbing injections. The ear lobe is a very easy structure to numb up with simple injections from a tiny needle, and can stay numb for 4 to 6 hours. This always proves to be a much smaller deal then the patients think as they chat with the doctor or just relax for a few minutes while they get a new ear lobe.
Once nice and comfortable ear lobes that have tears or most gage hole repairs have a pie wedge of the torn edges or sides of the gage holes excised and the front and back of the ear lobes sewn back together so it looks like an ear lobe before any piercings. A small tape dressing is applied and a week or so later the sutures are removed. Contact sports and swimming should be avoided for a few weeks to be sure no damage happens shortly after the procedure.
Patients having ear lobe reductions may have slightly different designs to the location of the incisions depending on the natural shape and size of the ear lobe, but the procedure and recovery is very similar to the other repairs. Ear lobe repairs is a very commonly performed procedure in Dr. Nelson’s office. If you have any questions don’t hesitate to contact us for an evaluation.
October 15th, 2015
By: Jeffrey Nelson
First and foremost the best individual to determine if it’s better to do Kybella or neck liposuction is the plastic surgeon who routinely does liposuction and injectables. The plastic surgeon has seen the anatomy from the inside and outside and knows what results can be obtained with each procedural option.
Kybella is the newest non-invasive option to get rid of the fat pad under your chin. While Kybella is a great product to have available to offer our patients it’s important that we cover the differences and similarities between Kybella and a simple localized neck liposuction. Kybella is “Deoxycholic acid” which is a chemical term that means it’s actually something made by your liver and found in your bile. Your body naturally uses Deoxycholic acid to help dissolve fats in your body. The term acid seems scary to some people, but remember our body makes this same acid and stores it in our gall bladders to use when we eat food. The purified form of Deoxycholic acid ” is what Kybella is”, and it can be injected into submental fat under our chin to dissolve away fat in a controlled way. Normally about 20 separate small injection sites are mapped out under your chin for the Kybella. Mild fat deposits would require two separate sets of injections usually six weeks apart, more fat deposits require three or four separate sets of injections. Large fat pads would need more injections to have the patient feel they really got the result they were after. Kybella does have to be placed in a very specific local area under your chin about 2/3rd’s the size of your palm. If injected outside the safe zone Kybella may injure nerves or tissues we don’t want Kybella near.
So Kybella is an excellent product that is well researched with relatively straight forward indications; so why even consider neck liposuction? This is where the plastic surgeon really can guide you toward the best choice for you. Almost all patients in my practice interested in neck liposuction are done in the office with numbing medicine using small specialized liposuction equipment made for the face and neck. This is a very low impact non stressful procedure that takes between 45 minutes to and hour and patients love the result. Neck liposuction in the office is much less expensive than doing three or four separate Kybella injection sets each 6 weeks apart. Also liposuction allows us to treat a much broader area than Kybella since we don’t have to worry about the chemical getting into places we don’t want it. Neck liposuction can go more laterally in the neck and lower in the neck, and can safely be done in the jowl area where Kybella is not to be placed. The other upside of the neck liposuction is you do the one treatment and you’re done an once some swelling or mild bruising goes down you can see lots of improvement. Kybella will take many more months to get to your goal. People shouldn’t think of neck liposuction as some big deal procedure, it is not. Neck liposuction is surprisingly minimally invasive as a procedure. So neck liposuction is less expensive than multiple Kybella treatments, is relatively non-invasive, and can get you from point “A” to point “B” quicker than Kybella, that does not mean Kybella isn’t awesome. If the patient has milder fat deposits and especially if they only need two sets of Kybella injections then Kybella would definitely be a great way to go. The key here is to see a plastic surgeon about this so they can guide you in the best direction for they can do the minimal surgery or the injections and can help you decide which works best for you, rather then someone who might only do injections so can’t even appropriately address surgical options. We’re delighted to have Kybella on the scene as a new option and we hope this helps explain why different patients may choose different options.
June 9th, 2015
By: Jeffrey Nelson
The Kythera company is creating a buzz with their new product Kybella. Kybella is an injectable agent made of Deoxycholic acid that can break down fat deposits under the chin. Kybella currently is only approved by the FDA for use in the submental region to shrink down fat deposits there. Kybella’s nitch will be as a non-surgical option to decrease the fullness patients have under the chin. Kybella will require numerous injections into the fatty deposits (10 to 20 injections) under the chin and most patients will need several treatments separated by a month or so to get adequate results. Patients with much larger thicker fat deposits will need more injections obviously.
Deoxycholic acid is a natural product made by bacteria when the metabolize cholic acid a type of bile acid. Our livers make bile acids to help us break down and absorb fats we eat in food. We naturally produce cholic acid and bacteria in our digestive systems modify cholic acid to Deoxycholic acid. Deoxycholic acid and other bile acids emulsify fats and break them down. Our own fat cells have fats in the cell membranes so injections of Kybella (Deoxycholic acid) will break down and destroy the fat cells and our body’s natural mechanisms will remove the damaged fat cells and fat released by those cells. This is how Kybella shrinks down the area of fats where it is injected. It is important to make sure the Kybella isn’t injected into non fatty tissues for it can injure nerves, vessels, or glands if injected into or next to those important structures. Kybella is a new kid on the block and will be a great addition to the other options we have to help shrink and tighten the area under the neck so people can improve those double chins.
February 12th, 2015
By: Jeffrey Nelson
It’s amazing how often patients suggest… “If I exercise more my loose skin will get tighter right?” Boy don’t we all wish it was as simple as that. Unfortunately it doesn’t work that way. Without getting to scientific about it all let’s discuss skin changes with weight, child birth, sun damage, and other aspects of mother nature.
Exercise is a great thing, most of us could use more of it and it’s great in assisting weight control, muscle tone, maintaining bone density, and keeping our heart strong and our blood pressure down. Exercise cannot tone your skin your skin however. Good muscle tone will show nicely “under the skin” but the skin itself doesn’t change as much as we’d like with fitness alone; some just not much.
In fact, if your fitness means being outside swimming, hiking, biking, running, gardening, playing tennis, or golfing the fact is the Arizona sun may be aging your skin significantly while you’re getting more fit everywhere else.
Don’t get me wrong; I’m an Arizona boy and I love my time outdoors in the sun. It is why we all choose to live here. Just make sure you are vigilant with quality sunblock, consistent with hydration and try to do the outdoor activity when the sun isn’t beating you down with noontime intensity. Quality sunscreen contains ingredients that are physical blockers i.e.; titanium dioxide and or zinc oxide.
Moderate exercise does improve blood flow to tissues balances our blood sugar lowers our blood pressure and can smooth out our hormone/endocrine physiology. Some of these physiologic parameters are good for the skin physiology, but again watch the sun damage. A significant component of skin aging is genetically driven and exercise can’t compensate for your genes. Excessive exercise is not necessarily good for you either. Remember your parent’s adage “everything in moderation.” Excessive exercise can lead to low grade inflammation in the body, the joints, the organ systems and that’s not a good thing. So be smart and be consistent with steady moderate exercise and in the long run you’ll be better for it.
Unfortunately if there is stretching of the skin from pregnancy, weight changes, whatever the cause you may need the tricks of our trade with surgery, lasers, truSculpt or other skin tightening procedures to accomplish your goal. Don’t stop exercising; jsu don’t think you can exercise your “skin” back to youth.
January 2nd, 2015
By: Jeffrey Nelson
If breasts are narrow at the bottom and protruding out like snoopy’s nose they are what is classified as Tuberous breasts. This type of breast shape is reported in 5% of patients but the exact incidence isn’t known. Tubular breast deformity can occur in men and women. Originally classified in three grades of severity a few typical characteristics are present. First like the name states the breast has elongated tubular appearance. Most often this is due to a shortage and tightness to the tissues only the lower half of the breast. This is why tubular breasts are also called “constricted” breast for the tighter lower portion of the breast narrows to the base of the breast. This constriction tends to make for a higher inframammary crease which is where the breast joins the chest wall. Typically the distance from the nipple to the inframammary crease (IMC) is shorter than normal. Also, this constriction of breast tissue leaves a wider than normal spacing between the two breasts. The patients Areola and nipple may look like its being pushed out from the breast and frequently it may a bit large relative to the rest of the breast. Patients with constricted breast deformities may have a lower chance to breast feed than the general population, but this has not been formally studied.
So what can be done to assist the patient in managing the tubular breast? Breast Augmentation with tissue scarring is the mainstay of addressing tubular breast deformity. Tissue “scarring” means the surgeon will make some cuts into the breast tissue to allow it to relax and stretch quicker with the breast augmentation. How much “scarring” depends on the tightness of the native breast.
As mentioned earlier tuberous/tubular breasts can have an enlarged areola that is pushing out from the breast. To create a better contour to the breast a “donut” mastopexy might be needed as well as the breast tissue scarring. A donut mastopexy or some variant means we remove a donut shape of the extra areola skin to make it an appropriate size. Also, releasing the breast from the overlying skin permits I to push the herniating breast/areola tissue back in so it doesn’t look like snoopy’s nose anymore. If the tubular deformity is mild it might be suggested to hold off on the mastopexy to see if after augmentation is even needed. Frequently a donut mastopexy can be done under local anesthesia down the road if needed.
Occasionally a patient might have a severe enough deformity that a tissue expander could be suggested. Tissue expanders allow the surgeon to stretch out your breast tissue over time by adding salt water (saline) solution into a type of breast implant expander made for this purpose. Tissue expanders are commonly used in breast cancer reconstruction. The need for the expander is rare for tuberous breast issues. There are expandable implants that can serve as your expander and a final implant. However in my opinion, in the very rare patient that an expander is utilized the end result is better & the expander is changed out for a more standard implant after the expansion process is finished. We hope this sheds some light on tuberous/tubular breast deformity. Feel free to contact us at 520-575-8400 for an appointment for a personal assessment.
August 19th, 2014
By: Jeffrey Nelson
First let’s define what Capsular Contracture (C.C.) is vs. simply a capsule around a breast implant. Anyone who gets a breast implant will form a capsule of natural tissue around that implant. A capsule is your body laying down a thin layer of collagen and cells around the object. Any medical device placed in the body will get this capsule made around it. Pacemakers have capsules, joint replacements have some capsule, and internal insulin pumps have capsules. The formation of thin scar tissue around the scar around the implanted object is pretty normal. So every patient with an implant has a capsule, but most patients don’t have a “Capsular Contracture”(C.C.). The contracture part of the equation is the piece we wish to avoid. Contracture means the capsule is getting stiffer, thicker or hard enough to distort the breast. Years ago Dr. Baker gave a simple grading scale on how to access how firm a capsular contracture (C.C.) was. Baker’s Class goes form I to IV. A Baker’s class I means a soft normal feeling breast without evidence of C.C. A class II looks normal, but on palpitation the surgeon or patient can tell the breast is firmer than normal. Class III typically has more hardening and perhaps some visual distortion of the breast. Baker’s class IV has even more hardening, distortion and possibly even pain in the breast or pain with palpitation. This classification scheme is not very detailed or scientific, but it is a standard way to follow and grade the degree of C.C. a patient has.
So what causes capsular contracture? Why do some people get it and some people don’t. Also why does it happen to one breast and not the other? The reality is we don’t have definitive proof of one single cause, there appears to be several potential culprits leading to capsular contracture. The underlying process that leads to C.C. is anything that increases inflammatory reactions in the breast space around the implant. The likely contributors can be extra blood around the implant at time of surgery, any extra foreign body like surgical glove powder, cellular debris, serum, or bacteria in the space that generate inflammation, but not infection.
As surgeons have become more aware and sophisticated with our performance of breast augmentation the occurrence of C.C. has decreased over the years. First you want your surgeon to be very meticulous about the dissection decreasing the risk of extra blood or serum getting in the space around the implant. If there is extra blood the body has to generate more inflammation to clear it just like absorbing a bruise over time. More inflammation can lead to more capsular reaction and then contracture. Also extra blood or serum can act like culture medium if there are bacteria in the space around the implant. For the last 25 years better studies have been done looking at bacteria as a reason people might get a capsular contracture. Bacteria do live normally on our skin, there are bacteria in the air around us and even the most sterile environment can have a few bacteria hanging around. While a true implant infection is extremely rare in breast augmentation the chance of some bacteria getting on the implant is real. This risk of bacteria getting on an implant is one reason we prefer not to use incision around the areola as much as we used to. Breast tissue and glands have bacteria in them naturally, and there is the hypothetical chance of periareolar incisions causing more chance of bacteria coming in contact with implant. This is not a proven hard scientific fact, but it does make sense.
The position and surface style of an implant also changes the capsular contracture risks. Smooth implants above the muscle (subglandular placement) in most studies have a higher C.C. rate than if the implant was placed under the pectoral muscle (submuscular placement). However a textured (rough surface) implant placed above the muscle doesn’t have as much C.C. risk as the smooth implant. The belief is the textured surface can break up the alignment of scar tissue so it can’t organize in one direction to pull on the surface of the implant. The understanding of this is not precisely understood for both smooth and textured implants under the muscle have fairly low capsular contracture rates. Its implants placed above the muscle that seems to make a bigger difference here. Studies will be going on for many years before we have a better and more complete understanding of capsular contracture and how to prevent it. For now a key way I keep capsular contracture as low as possible is to not open an implant until right before it goes into the patient. The moment we open an implant it is immersed in antibiotic solution to make it hard for a bacteria to even land on the implant. My surgical gloves are changed to new gloves and washed with antibacterial solution. No one but me ever touches the implant to decrease chance of contamination. I irrigate the space for the implant with antibiotic solution also. These and other sterility maneuvers have been documented to have lower C.C. rates with breast augmentation.
Capsular Contracture will continue to be an area of active research and as of yet we don’t have all the answers, but we keep getting the incidence lower and lower so C.C. are much lower than several decades ago. If you wish greater details on this topic give us a call and set up an appointment to fill in any gaps in your understanding of this component of breast surgery.
July 30th, 2014
By: Jeffrey Nelson
There are many choice for facial fillers to correct fine lines, deeper wrinkles or to add real volume to the face. Juve’derm Voluma XC is the new kid on the block as a true volume filler for the midface and cheeks. The FDA approved Voluma XC for midface filling in early 2014, which makes it a fairly new product. Voluma is still a hyaluronic acid product like Juve’derm Ultra plus XC , Restylane-L, Perylane, or Belotero to name a few. Each new product even if made of Hyaluronic acid (H.A.), like many established products, still has to go through FDA guidelines to get approved so expect to see many different spin offs of hyaluronic acid over the next few years to fit specific needs for types of filling. Hyaluronic acid (H.A.) is a fancy chemical name for something your skin is naturally made of. Hyaluronic acid (H.A.) is a form of gel (think of jello) that our collagen and cells, blood vessels and nerves travel through as part of our skin. Hyaluronic acid is also known as hyaluronan. Oddly enough, back when I was a youthful general surgery resident much of my research related to collagen and hyaluronan. Little did I realize that many years later I’d be using these hyaluronan products all the time for cosmetic improvement for my patients.
So if hyaluronan is a regular part of our skin why are there so many product options. Of course one reason is pure competition by different medical product companies for parts of the market. Competition to make better products is always a good thing. More important for you the patient is to realize that each product is slightly different to fit different purposes. Voluma, to keep the concept simple, is a thicker denser form of hyaluronan than the other Juve’derm products so it can last up to 2 years, but is also designed to be placed deeper into the tissues to create a true volumizing of the face. Voluma is not meant to be used close to the surface under an individual wrinkle like Restylane or Juve’derm might. The differing densities of the hyaluronic acid products lets one be better for a real fine line and one be better for a deeper groove, and Voluma to be better for cheek augmentation as an example. There are other products like Voluma, Radiesse as an example, that can similarly be used for cheek augmentation. Both are great products, both work well, but any given patient might want one or the other for various reason, or any surgeon may prefer using one or the other. At my office I use both routinely and like both products a great deal. For the purpose of this blog we’ll focus on the H.A. product however.
Hyaluronic acid is a hydrophilic molecule. This means H.A. wants to attract water so depending on the density of the H.A. in the gel it pulls water toward it and holds on to water while the body slowly breaks down the product over a long period of time. This hydrophilic effect is what creates some of the extra volume creation by the product. It’s all pretty cool when you really think about it. We are using a natural occurring molecule that our skin looses with aging and we put it back in specific places and with specific products to get the youthful plumpness back into the skin; pretty awesome really. By changing the cross linking of the hyaluronan and the density of the product we get different degrees of water absorption (like a sponge holding water) and different rates of breakdown of the product. That’s why Juve’derm or Restylane might be great for lip lines, the Voluma would be a bit stiffer and denser and might not feel as smooth in that location. Voluma XC is an excellent midface filler and it’s great to have another option for patients. The XC designation just relates to the product having a little lidocaine anesthetic mixed in with it so the injections are less painful and the area injected gets a little numb quickly so it doesn’t feel achy after the injection. Most injectables we use in our office already has lidocaine in the product or we add it to the product prior to injection. Another nice touch is to use a topical anesthetic before injection that also makes it a more pleasant experience than a straight injection without topical anesthesia. The price of Voluma XC varies greatly from one office to another so it’s often wise to check with a given office what they are charging so you don’t pay a great deal more than you need to. Of course, balance this against the experience of the injector and office.
June 3rd, 2014
By: Jeffrey Nelson
So may Aesthetic options so little time (and of course money). Plastic Surgery has many terrific options to keep us looking healthy vital and refreshed. Some of these are completely noninvasive and can take years off your appearance for very little cost. One such option is Intense Pulse Light or what we call “IPL” therapy. While patients sometimes think of IPL as a type of laser; it’s not a laser but does use light energy to improve the appearance of your skin. True lasers use one specific wave length of energy to do its job. Intense Pulse Light uses a narrow range of wave lengths from the light spectrum for specific purposes.
My IPL system has multiple special energy delivery heads that serve different purposes. Each head or hand piece has a band of wave lengths that are a part of the light spectrum. The device has a red, green, yellow & purple hand piece to deliver different methods of laser or light source to the skin. One head is good for brownish pigment of the skin another for reddish tones another for hair removal as examples. If you have heard the term photofacials; IPL is that type of treatment. What has been shown is that patients who do perhaps five photofacials each year over five or more years have skin that is much brighter, healthier and younger appearing after those five years than it was before they were ever treated. Not only do the color tones improve but the texture, fine lines, wrinkles and general appearance of the skin is improved.
IPL treatments have a nominal cost to our patients and there is no downtime. Photofacials or IPL treatments are great first steps in keeping your skin looking refreshed when blended with quality skin care. Come see us for a skin care consult and start turning back the clock.
May 27th, 2014
By: Jeffrey Nelson
Many of the breast reconstruction patients I see are interested in nipple sparing mastectomies. A nipple sparing mastectomy means the cancer surgeon has decided the patient can keep all their natural breast skin including the nipple areola. Certainly keeping your own nipple areola is a nice option; the problem is once the mastectomy removes most of the blood supply coming into the breast’s skin the nipple may not have enough blood to survive. This means as days go by the nipple may darken, dry up & the skin dies a slow death from lack of blood supply. This is what we call “ischemic skin necrosis.” Ischemic is a medical term that means not enough blood supply and oxygen to keep a tissue healthy. Necrosis means it progressed to the point that the tissue didn’t survive. So when someone has a heart attack the heart is “ischemic” with less blood, and if it’s bad enough it’s called a myocardial infection for part of the heart muscle died. So when a cardiologist does a heart catherization they can put in a stent or use the medications to open the vessel blockage affecting the heart. In plastic surgery we can’t do much to help skin with poor blood supply after it happens so there is a good surgical maneuver I can use on the front end. This classic procedure is called performing a delay to the nipple areola skin. Many years ago plastic surgeons realized that if you partially remove the blood supply to an area of the skin, that over the next few weeks the small blood vessels that are still intact open up and get heartier bringing home blood to the injured skin. If my patient is a good candidate for a nipple sparing mastectomy I will often suggest that I do a “delay” procedure several weeks or more prior to the mastectomy to greatly decrease the chance the patient will have any healing problems with the skin of the nipple areola. The delay procedure means I will make a small incision that allows me to separate the nipple areola from the breast underneath for an inch or two around the whole areola. This delay procedure removes the connections to little blood vessels coming up through the breast so that the small blood vessels in the skin get bigger and stronger so when the mastectomy is performed the nipple’s blood supply is already more robust. The delay procedure is a fairly minor operation and often can be performed with local (numbing injections) anesthesia in the office.
Not everyone is a good candidate for a delay procedure. Large pendulous breasts are poor candidates compared to smaller breasted patients. Also a candidate for nipple sparing mastectomy who has a large projecting nipple needs to consider a delay procedure for their nipple is more at risk for ischemia post mastectomy than a small flatter nipple. For information on skin and nipple sparing mastectomy look at that blog.
May 23rd, 2014
By: Jeffrey Nelson
Patients have great interest in skin sparing and nipple sparing mastectomies these days. Classical mastectomies used an incision across the central breast mound removing the nipple and areola as well as several inches of skin medial and lateral to the areola. This approach gives great access to reliably remove the breast tissue, but because of the amount of skin removed I’d have to replace that lost skin with skin from elsewhere. To replace the lost skin we might use tissue from the abdomen as in a TRAM flap or DIEP flap, or from the back with a Latissimus flap (learn about these flaps in other blogs). Another option was to stretch the local skin with a tissue expander placed under skin and chest muscle. The expander is a fancy balloon that we can slowly fill with salt water over time to stretch the skin out with time. Once the skin and muscle are stretched adequately we can go back and place a breast implant or the patient’s own tissue into that expanded space to make the form of the new breast. A skin sparing mastectomy removes as little extra skin as we can get away with, and a nipple sparing mastectomy keeps all the patient’s skin including the nipple and areola. It’s very important for my patient’s to realize that not everyone is a candidate for a skin sparing or nipple sparing mastectomy. Patient’s with large pendulous breasts have just too much skin to begin with to make a skin sparing type procedure logical. Mastectomies require removal of all the breast under the chest skin leaving thin long flaps of skin. If these skin flaps are fairly long there won’t be enough blood supply to keep the edges healthy. It’s easy to imagine how a very large breast would have much longer skin flaps than the smaller breasted patient so the blood supply entering the flaps don’t have as far to travel through the skin and back.
Patients also have to realize their cancer location or type may make a nipple sparing mastectomy not a good option. If a cancer is located right under the nipple areola your cancer surgeon will want to remove the nipple areola in that circumstance. As a plastic surgeon I always let the cancer surgeon first decide if the patient is even a possible candidate for skin or nipple sparing mastectomy. If the cancer doctor says it’s ok than I can advise the patient about whether it’s a good option relative to there anatomy and reconstructive desires. While keeping your own nipple seems like a great idea on the front end, if your skin or nipple dies due to lack of blood supply it can greatly slow down your recovery, be an emotional hurdle you didn’t need, or require another procedure. No one wants more operations, or extra hiccups in their recovery if they can be avoided. An option to make the blood supply more reliable to the nipple is a procedure called a “nipple areolar delay”. This is a simple procedure to cut just enough of the blood supply to the nipple areola weeks prior to the mastectomy so that the blood supply to the skin has improved and gotten stronger so the nipple skin is healthier at the time of the mastectomy. To learn more about the delay phenomenon and it’s use in nipple sparing mastectomies read my blog on Breast Reconstruction: Nipple Areolar delay.