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Health & Fitness

Plastic Surgery Talk

Updated 5 days ago

Health & Fitness
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Discussions on Plastic Surgery, Skin Care and Aging

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Discussions on Plastic Surgery, Skin Care and Aging

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Great info

By Musikiscool - Jun 29 2019
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Love the info. The audio quality is a little off but love the info

iTunes Ratings

5 Ratings
Average Ratings
5
0
0
0
0

Great info

By Musikiscool - Jun 29 2019
Read more
Love the info. The audio quality is a little off but love the info
Cover image of Plastic Surgery Talk

Plastic Surgery Talk

Latest release on Sep 17, 2019

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Discussions on Plastic Surgery, Skin Care and Aging

Rank #1: PST 014: Breast Augmentation

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The purpose of the Breast Augmentation is to add volume to the breasts. Today’s podcast will be about the intricacies of Breast Augmentation: the procedure, types of implants and candidates. Topics covered: What is breast augmentation Silicone vs Saline Breast Implants Using fat to augment your breast Are you the right candidate? Read the full […]

The post PST 014: Breast Augmentation appeared first on SpaMedica.

Jun 19 2018

31mins

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Rank #2: PST 043: Post-op Breast Augmentation

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Jun 21 2019

18mins

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Rank #3: PST 023: Tummy Tuck

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Join us for this episode of Plastic Surgery Talk as Dr. Mulholland talks about the tummy tuck procedure and what you need to know about it.

The post PST 023: Tummy Tuck appeared first on SpaMedica.

Aug 30 2018

24mins

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Rank #4: PST 044: All About Liposuction

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Read the podcast transcript...

Welcome to Plastic Surgery Talk with Dr. Steven Mulholland, brought to you by Spa Medica.

Hello, and welcome. Dr. Steven Mulholland here in Toronto, Canada on Plastic Surgery Talk. Welcome to our weekly podcast series. If you enjoy these podcasts, you find them entertaining, engaging, informational, please share, subscribe and comment.

Today’s podcast is on a very popular topic: liposuction. Liposuction is the number one surgical procedure, cosmetic surgical procedure performed in North America. Last year alone there was over one million liposuctions in North America. In fact it’s so common between men and women that now forms about 5% of all elective surgery is removing fat and contouring figures. So it’s very, very common.

Now, there has been a real evolution and a renaissance in liposuction from the crude, traumatic liposuction you saw back in the days of nip and tuck and Christian Troy, and it’s become a much more refined and sophisticated way to tighten skin and contour shape. So in this podcast today we’re going to analyze what are the new forms of liposuction? How are they performed? Who’s a good candidate and is it right for you?

So how do I know if lipo is the right choice for me? Well, first of all, the best liposuction candidates are those patients that have tried virtually everything on their own. They’ve tried diet and exercise, they’ve worked out, they’re fit, they’ve got a reasonable diet. They may have even tried non-surgical techniques, non-surgical liposuction techniques like Core Sculpting, SculpSure, BodyFX, Vanquish, Ultra Shape, [X-Less 00:01:53], Venus Freeze. These are a number of different non-surgical techniques that purport to kill small amounts of fat.

Once you’ve tried all those things, diet, exercise, technology and you still have annoying, excess, localized fat collections, you are probably then, if you’re medically well, a good candidate for liposuction. What are those annoying collections? They come often with cute, annoying names like the saddle bag for fat on the outer thigh, the trochanter saddle bag. The inner thigh, the bat wing or the arms, the abdomen or the pot, the love handles, the bra line, the double chin, the inner thigh and the inner knees. These are the most common liposuction areas on men and women. Guess for men also, the 50 year old [gynacomasture 00:02:41] male boobies.

So you’re a good candidate if you’ve got localized excess collections of subcutaneous fat, if you’re … tried diet and exercise, got to the best possible weight and fitness you can get at, you may have tried even non-surgical lipo techniques, and you want to do some localized contouring to make a difference in your measurements in centimeters. It’s not about weight. We’re not making difference in pounds. We’re making difference in shape, figure and form. Centimeters. Then you may, if you’re medically well and realistic, be a good candidate for liposuction.

So what is this modern approach to liposuction? What has the evolution been in the last 10 years? Well, it’s been the addition of energy to the fat just prior to the lipoaspiration or the removal. So one of the problems with lipo. You have a little pot or a double chin or an arm, and the fat has tented the skin and the skin is tight. You remove the fat, and the skin is orphaned of that fat support and it goes bleurgh and your skin just droops. So loose, saggy skin is the big enemy of lipocontouring of liposuction sometimes. So the big advance over the past 10 years has been initially the advent of internal ultrasound, which gently liquefies the fat and creates less bruising and less swelling and viable fat cells, but not a lot of tightening.

After Vaser in the mid part of the last millennium, 2005 and 6, we had internal laser, which is internal laser heat. The heat allowed a tightening, a degree of tightening of the skin up to 17, one seven, percent area contraction by doing laser lipolysis or smart lipo followed by suction contouring. So we heat the fat, get the skin tighter, and then remove the fat we want to give you optimal contour, and rely on the heat at the time of the laser to give contraction and shape.

The most modern advance over the past 10 years has been the transition from laser to radiofrequency and the internal probes of RF. The bipolar technique tightening the outside and the inside part of the skin is called BodyTite. BodyTite made by InMode mix a number of applicators. BodyTite for large body areas, NeckTite, FaceTite, AcuTite, LidTite. All different site, bi-polar radio frequency probes that coagulate and liquefy and heat the fat and tighten the skin simultaneous. The advance of BodyTite applicators has meant that we, as surgeons, can get up to 35% area contraction. Tremendous shrinkage without the need necessarily for tummy ticks or arm lifts or thigh lifts. Excisional surgery.

So BodyTite has become the king of the industry in terms of soft tissue tightening. Then at the end of that coagulation, which takes about 10 minutes per zone, we have to end up removing the fat like we always have. So liposculpting or lipocontouring happens after the BodyTite heating. I liken it with patients to having a raw hamburger patty sitting on the grill. It’s going to shrink right in front of your eyes over 10 minutes, significantly. Up to 25%. Same things happens with your subcutaneous tissue and your fat. It shrinks after we apply the heat, and the heat itself is applied in a very safe and monitored way so that the risk of a thermal injury or a burn is essentially minimized to next to zero.

So BodyTite has become the most advanced version of lipocoagulation and tightening. We do have Vaser still if you want to preserve fat cells and use that for fat grafting. Laser can still have its advantages in small areas, tiny areas where there’s less fat and less skin to tighten.

How to know which device? Vaser, smart lipo, BodyTite? Well, if you want basic aspiration removal of fat with the tightest possible contoured skin on the tummy, on the arm, on the double chin, on the chest, on the inner thigh, on the bra line, after you remove the fat, make sure you use BodyTite because it contracts and tightens the best. When might you use Vaser? Well, Vaser and I have all three devices.

Vaser can be used when you want to preserve the fat. So let’s say you want to take a little bit of fat before you remove it. Don’t damage it with a hot laser or a hot BodyTite, but you want to save that fat, spin it down and reinject it for better coaugmentation like the Brazilian butt lift or fat grafting to the [inaudible 00:06:59] of the face. Then you use a low energy, gentle system like Vaser to cause a discohesion or separation of the fat cells, remove the fat cells, purify them, spin them down, wash them, whatever preparation techniques the doctor uses, and then reinject them. That’s where Vaser’s big niche is.

Laser, not as powerful nor as fast not as effective as BodyTite, but good for tiny little areas like small like areas of the inner thigh or the upper arm. So if you still have a laser system, you can still use them on small areas. BodyTite can be used on all areas where you use contraction. They have small applicators and large applicators. It just destroys the fat, so it’s not good for transplantation. So that gives you a sense of BodyTite, NeckTite, FaceTite, LidTite, when to use the BodyTite family. Vaser for fat grafting. Laser, if you still have one and you have small zones, it can provide a reasonable amount of contraction and tightening.

What is the cost difference between non-energy based liposuction and energy based? Energy-based liposuction means applying energy. Vaser, which is ultrasound, laser, which is smart lipo, or RF radio frequency, that’s BodyTite. Those are the three energy-based devices that are used to get advantages of contraction or fat graft preservation.

What’s the difference in price between that and your basic old school lipo? If you’re young and healthy, you have super tight skin, you don’t need the fancy, newer technology. That’s if you’re older, weight loss, weight gain, few kids, have loose skin. You really need to do the modern BodyTite approach to lipo. The difference is usually around $2000 a case when you apply energy. So whatever the base line price of a lipo in your city is. It could be 4000 per zone, 3000 per zone, 6000 per zone. Generally you’ll find the BodyTite practices charge a premium of about $2000 to ensure that 35% area contraction, like a scarless tummy tuck or arm lift of neck list, and usually it’s worth it for that extra 2000 because you get massive amounts more … 35% area contraction for the upsell and the technology and the procedure.

Basically physicians will offer you those if they have them in their practice. A busy liposuction surgeon is going to have to have some type of BodyTite procedure in the modern era. If they hope to contour older women, larger women, women with weight loss, weight gain or multiple kids, you need a BodyTite in your practice.

What’s the difference between non-surgical lipo techniques and surgical liposuction techniques? Well, the non-surgical lipo techniques are led BodyTite technologies where you don’t have to go to an OR. There’s nothing going under your skin. There’s nothing invasive. It’s done as an outpatient, and it can be done in medical spa type non-invasive for dermatologic environments. The number one non-surgical lipo technique or body sculpting technique, which is reduction of localized fat areas or without surgery, the number one technique in North America is called Cool Sculpting.

Cool Sculpting is suction coupled and non-suction coupled cooling or hypothermia, that if you expose that fat to minus five degrees for about 45 to 60 minutes, you’re going to get a small amount of fat that will die. So if you want a really … the best contour of your love handle or those localized areas, don’t do Cool Sculpting or non-surgical because you’re only going to get about a centimeter to two centimeters reduction. But if you have eight centimeters of fat, you’re going to still be frustrated. That’s why liposuction, modern liposuction is still your best bet.

However Cool Sculpting, if you’ve got a modest amount of fat expectation and reduction, kills fat permanently, consistently, one to two centimeters of pinchable fat. Cool Sculpting can be a very viable option. It’s less expensive than lipo. There’s no recovery. There are some side effects, but they’re reasonable and they’re tolerable, and so it’s very popular.

The next most popular after Cool Sculpting is a technique called SculpSure. SculpSure is non-surgical, non-invasive. Again like Cool Sculpting it does … as an outpatient in a medical spa. It’s the application of laser heat on the outside of the skin. Doesn’t go inside, just like Cool Sculpting. That’s called SculpSure. That again is non-invasive. You can kill one to two centimeters. It’s less expensive than Cool Sculpting, but it doesn’t give you the definitive contour which is still the domain of liposuction.

There’s some other technologies that kill fat, like BodyFX, which uses electroporation and RF to kill fat. electroporation damages the cell membrane. You can get a good two, three centimeters of reduction. It takes three or four treatments over six weeks, whereas Cool Sculpting or SculpSure is two treatments. One at the beginning, one at the end of six weeks. BodyFX, again. Cool Sculpting, SculpSure.

True Sculpt is using non-suction coupled radio frequency with skin cooling to kill fat. We have the Vanquish, which is placing the extra fat of the thighs or the tummy under a microwave technology which will oscillate the fat molecules using a hypothermia technique, but with microwaves, not a laser, will kill fat. That’s a permanent reduction technology. Then we have some ancillary techniques that are not as commonly used, but those are the big four or five. Cool Sculpting, SculpSure, BodyFX, Vanquish …

PART 1 OF 3 ENDS [00:12:04]

… CoolSculpting, SculpSure, BodyFX, Vanquish, truSculpt, proven fat killers. Multiple treatments, non-invasive, two centimeters of pinchable fat reduction. If you select your patients well, if you want two centimeters with no risk, those are your best bets.

If you want the best option and you want all fat gone in that localized area, liposuction. Then decide to add energy not if you need skin tightening, and the contour of coagulation, and contraction, BodyTite being your best option.

The two big fears of liposuction are, “Will I have excess skin,” or, “Will I have indentations or irregularities?” Excess skin, that’s when we make the wrong assessment and we take the fat. What’s left behind is loosey goosey, wiggly jiggly skin. How do we minimize that? Well we add the right energy device to get good soft tissue contraction. BodyTite with radiofrequency energy. Smartlipo with laser energy. These can provide internal contraction to compensate for the risk of loose skin.

Now if the skin is too loose you’re not going to have enough compensation, 35% isn’t enough. You need to know which patients are going to benefit from BodyTite or Smartlipo, lipo coagulation, and aspiration, and skin removal. Like a skin pinch tummy tuck, or a mini arm lift, or a mini behind the ear neck lift in addition to liposuction. We have three options when it comes to the risk of loose skin after lipo.

Have excellent skin, have the right technique, get good contraction, the skin tone should be fine. If you have compromised skin you may do the BodyTite lipo, get 35% [aeric 00:13:32] contraction and a modest, mini skin removal procedure, like a mini behind the ear neck lift, or a mini arm lift, or a mini C-section size tummy tuck, or inner thigh lift in combination with lipo. Some patients have such loose skin that the right physician, with the right experience, is going to be able to tell that patient, “No, you’re not a lipo candidate. You need a formal tummy tuck. You need a formal face or neck lift. You need a formal arm lift. You need a formal thigh lift. You can not get away with lip, even energy based lipo like BodyTite, alone. You need real surgery.”

How to avoid loose skin? Pick the right surgeon who has the right energy devices. Pick the surgeon that has experience. Pick a surgeon that’s going to be able to tell you whether you can get away with BodyTite lipo versus an excisional surgery like a tummy tuck.

The next most common feared side effect of liposuction is irregularity or indentations. Indentations are the lumpy bumpy appearance of the skin after lipo. You see that with some of the Instagram posts from some of the stars who have been caught in Mexico, or in southern California, or the beaches of Hawaii with indentations or irregularity. Most famously the Tara Reed tummy with multiple indentations or irregularities. Those are lipo contour defects from over aspiration. A zone of over sucking leads to an indentation.

Again, how do you minimize that? Well sometimes it happens even in the best of hands but you want to pick out a surgeon with a lot of experience. The more experienced a good body contouring surgeon is the less likely they’re going to leave you with very noticeable irregularities or asymmetries. There’s always some slight imperfections but they’re subtle. So pick the right surgeon. The surgeon with the right technology. Making sure you have access to BodyTite, Vaser, energy based devices that help him contour and contour symmetry.

Then post operative care. Most body contour liposuction surgeons are going to put you on suction coupled heating devices like BodyFX, Venus Freeze, the FORMA Plus, the tripolar, devices that bulk heat the skin and get tighter, smoother skin after the lipo. You usually start those treatments around six to eight weeks.

Indentation and irregularity, loose skin, the two most common side effects you want to watch out for. Most are mitigated by the selection of the right surgeon who picks the right procedures for you.

What are the contour indications to liposuction surgery. Number one contour indication, unrealistic expectations. Make sure your patient is realistic about the kind of outcomes they can get. Patients out there who have medical illnesses. If you have advanced cardiac disease, or hypertension, or uncontrolled diabetes, or breathing problems, COPD, emphysema, asthma, you’re not a good candidate for even a minimal invasive treatment like liposuction. You’ll need to consider non-surgical lipo techniques.

If you have really excess loose skin and you need an incisional procedure, not a candidate for liposuction. If you have a pacemaker or have a bladder of the heart, you’re not a candidate for any kind of energy device and you might not be a candidate for liposuction. If you have a lesion, a sore, an undiagnosed non-healing wound in the area of the treatment you want to make sure that’s not a skin cancer, you’re not a candidate for liposuction. If you’re pregnant. If you are pregnant you are not a candidate for any surgical procedure, liposuction being one of them. You need to wait till you’ve had your baby, and your skin has retracted, and you’ve recovered from … Pregnancy has subsided, which takes about a year, six months post-breastfeeding. Then you could consider liposuction to some problematic post-baby areas in a mommy makeover.

What is the safest methodology of performing liposuction in the modern world? Well generally safety will involve avoiding a general anesthetic with intubation, and ventilation, and paralysis, and pretty serious medications, if possible. Well trained liposuction surgeons should now be able to offer you non-general anesthesia lipo, where it’s done under a twilight sedation, usually oral, subcutaneous, light IV sedation. Then I use a lot of laughing gas or nitrous oxide, so we use the laughing gas or a nitrous oxide while we put the localized anesthesia, the local freezing. Once your fat is frozen and there’s no feeling you don’t feel the liposuction procedure being done so you don’t need any kind of heavy anesthesia, just that light twilight sedation.

The anesthetic technique has evolved from everyone getting general anesthesia 10 years ago to out-patient, ambulatory, local anesthetic liposuction cases. Where we can then add the right local anesthesia with laughing gas, and some intravenous, and oral sedation. Then using gentle techniques. Techniques that heat the fat, liquefy, coagulate so the fat comes out easily and induce a nice contraction. That’s usually BodyTite or other technologies like Smartlipo or Vaser. It’s a combination of technology and technique that leads to the safest possible lipo contouring results.

Then, of course, don’t take too much. You don’t want to take over five liters of combined aspirate. Make sure you replenish the fluids, through the IV, that you’re taking out through lipo. Adequate fluid resuscitation. Making sure the patient’s well volumized. Thinning the blood by using some specialized blood thinners like Lovenox or Heparin minimizes the risk of a DBT. These are all the elements that you bring to a very safe liposuction procedure. Many of which the patient doesn’t even know what’s happening, in order to keep it as safe as it has become.

What to look for in a liposuction surgeon, a liposuction facility, that keeps it as safe as, and efficacious, and quality as possible. Well first and foremost you want to make sure that the surgeon is a surgeon. Many physicians in North America perform liposuction and they’re not always surgically trained. Now there’s some very good liposuction surgeons that are not surgeons, that are family doctors or internists that have garnered a tremendous amount of experience, but if they’re not surgeons they should belong to a surgical society like The American Academy of Cosmetic Surgery. They should have done hundreds of cases, have a lot of experience, and a good reputation with good online testimonials, but make sure you have a surgeon. A board certified plastic surgeon or a cosmetic surgeon who may not be a board certified plastic surgeon but belongs to a surgical society and liposuction’s a big focus of their business.

Number two, make sure your surgeon’s done lots of cases. Make sure they’ve got hundreds of cases under their belt. They can show you lots of before and afters. They have lots of testimonials. Then go outside their practice online to rating sites where the surgeon can’t control the messaging, to see that there’s lots of liposuction patients that sing the praises of the quality and the experience of the facility you’re exploring.

Make sure they have a high quality certified liposuction OR that is certified because many states require certification for liposuction over a certain amount, under local anesthesia, under an IV sedation or general anesthesia. A certified OR by a regulatory body, a state medical board, or a national OR certification like AAAASF, or some certification body. Make sure that the physician keeps a log of complications. Ask them what complications they’ve had with liposuction that they kept for their state medical records and how they manage those complications.

You want to make sure that the operating facility has all the resuscitation, the 911 equipment and a 911 protocol that would be needed if there was an adverse event like a cardiac arrhythmia in your case. What’s the 911 protocol and transfer to a tertiary hospital protocol in place for that physician? Does the physician have hospital privileges or did have hospital privileges in a hospital for liposuction because that means they’ve been vetted by a regulatory body, like a medical board, that assesses their qualifications and vets their skillset being able to perform liposuction safely.

These are the things I would look for. Look up the state medical board records or the college records. See if the patient’s been disciplined for liposuction or any surgical procedure. Make sure there’s no medical legal actions by looking up medical legal malpractice suits in your state or province.

Then, at the end of the day during your interview, make sure there’s a confident sense that this physician and their team is going to offer you comprehensive care post-op followup, to minimize the risks of complications, which can happen to any procedure and with any physician. Make sure you setup all the odds in your favor by having the best physician and the best facility.

Okay. The liposuction is done. You’re on the table. You’re going to get a great result but in that canister, in the aspiration canister or canisters, you got a number of CCs of your fat. Sometimes one, or two, or three, or four milk bags, which are liters and liters of your fat. What can you do with this fat? Do you throw it all away? Most of the time yes. We just dispose of it through a certified biological waste company. However, in certain circumstances patients can re-deploy that fat. They can re-inject that fat and make it work somewhere else for you. Steal it from Peter and use if for Paul.

Where are the three most common areas we inject fat, where there’s needs for fat? The number one area is the breast and the buttock, so body areas. Fat grafting the buttock is called the Brazilian butt lift or BBL. When done in the subcutaneous fat, not in the deep muscle, it can be very safe. It can add a nice, modest, round muscular look to a bum. Give a bit of a bum lift by using fat you’re going to throw out anyway. Steal from your hips and put in your butt. Number one area.

Number two area is the breast. The upper pole of the breast. After weight lose, weight gain, multiple breastfeeding, multiple children, age, you get a pfft or deflation of the fullness of that upper pole. Fat grafting to the breast is never going to replace a cohesive gel gummy bear breast implant. That’s still your best option for breast fullness but you can get a nice half cup improvement, little fullness in that upper pole, by fat grafting to the breast. Fat grafting to the breast, number two.

The number three area for fat is the face. Facial fat grafting. Marionette lines, smile lines, under the eye, across the cheeks, along the jawline, lips and nose. These are the areas that I commonly will fat graft. That’s another area where you can re-deploy fat that’s destined for the garbage that given you a nice contour on your body for enhancement or …

PART 2 OF 3 ENDS [00:24:04]

Nice contour on your body for enhancement and rejuvenation in your face. Lastly and less commonly would be fat grafting to previous liposuction defects. So areas we’ve got indentations and concavities we can use release and fat grafting techniques to smooth in your post liposuction irregularities.

Consideration of use of fat, redeployment, ecologically sound, environmentally friendly, and aesthetically pleasing. You’ve probably read about liposuction, scars, or ports. Where do we go? Where did they go? Where do we put them? How do we hide them? Women have gotten very sophisticated now. They know what little lipo marks look like, those little three millimeter scars that are in the open tummy or in the bra line or the flanks are a no-no nowadays. We want to hide those little three millimeter, four millimeter lipo port insertion areas. The access ports in creases where possible, between the gluteal fold, out the top of the gluteal fold, under the bum crease, in the groin crease, in the belly button, under the chin point, under the breast fold, areas where people typically are not going to see a mark in the open area of your skin.

So gone should be the days of obvious liposuction marks. Through judicious use of creases and longer probes and cannulas, we can always keep those incisions hidden so you can keep them guessing, “Did she or didn’t she? Is that all hard work and personal trainer and diet and exercise commitment, or that plus a little help with lipo?”

What about numbness after liposuction? Because you read a lot about the numbness that can occur in everybody after lipo get some numbness. Because undermining that fat and traumatizing the fat damages those little sensory nerves and you can get numb skin. Fortunately, unlike a scar or a tummy tuck or a general surgery tummy scar or breast augmentation lifts scar, these scars often stay numb forever. With liposuction, the skin that is numb usually comes back within 6 to 12 months, there’s a natural return.

Now, what can you do as an adjunctive technique to improve your liposuction result that’s nonsurgical? Most good liposuction surgeons will have after care treatments starting at around the 10th to the 12th week if you’re not too tender to, number one, tighten your skin using noninvasive bulking technologies such as Forma Plus, Venus Freeze, Exelis. These are the big three that are used to heat your skin to 42 degrees and get you even more tightening than BodyTite skin will give you. So you get maybe 35% under the BodyTite, another 10% from your noninvasive technologies. So series of treatments once a week or once a month for about four to six treatments after your liposuction to get tighter skin.

We can also deploy other technologies if you have a little extra fat on one hip or one side, not quite symmetrical, which is very common after lipo. We don’t want to leave indentations, but it’s not uncommon to have a little bit of fat asymmetry between one side and the other.

We can use our nonsurgical killing techniques such as Body Effects, Cool Sculpting, Sculpture, Vanquish, non-surgically, starting at 10, 11, 12 weeks to kill additional fat.

Last but not least, we’ve added other technologies to work on the next layer, skin, fat, and now muscle. So we can work on a six pack. Once you’ve done that abdominal lipo and you’ve revealed, and thin that fat layer on top of the rectus abdominis, we use something called the Emsculpt, which increases the muscle mass, increases the muscle definition and tone after a series of four to six treatments after lipo. So, Emsculpt, additional fat killing technology, and skin tightening technology, all noninvasive, can be performed on your lipo areas starting around 10 weeks after surgery to get an even better result than we’ve ever had before.

A lot of patients ask me, “Can I freeze my fat and use it next year if I take it out?” Unfortunately, no, you cannot store your fat. Although it’s possible to do it, you cannot store your fat to redeploy it later. That would require in every state in the United States, every province in Canada, to have a very expensive and complex transplant center, a center that uses fat and tissue banking and needs a tissue banking license to have these auto transplantation. So tissue banking is very regulated. No private plastic surgery office is going to have a tissue banking license in order to facilitate freezing your own fat. So you use it or you lose it. Use it when it’s fresh, reinject it, or we’ve got to throw it away.

Let’s say I have some loose skin and I want to combine my lipo, my BodyTite Lipo with a mini skin removal procedure. That’s done all the time. Rather than a great big long tummy tuck or extended tummy tuck incision from hip to hip, we can do shorter scars and BodyTite Liposuction with good contraction of the upper belly. We can do BodyTite in combination with little armpit lifts rather than a full brachioplasty, little anterior thigh groin crease lifts rather than a full thigh lift, or under the chin and neck with neck tight and a behind the ear limited neck lift scar. So the combination of Lipo contouring with energy based thermal devices such as BodyTite, NeckTite, FaceTite, AccuTite, and limited excision surgery is one of those hybrid procedures that’s found a good niche because it gives an even better result than BodyTite Lipo or energy based lipo without the big scars.

So let’s say you’re interested in Lipo. You find the right surgeon, great safe facility, good reputation. What are you looking to pay, usually? Most surgeons in North America will charge lipo by zone. And in general you pay anywhere from 2,500 to $3,000 for a zone in less expensive markets or cheaper practices, and upwards of 4,000, 5,000, 6,000, $7,000 for the first zone, and 4,000 or 5,000 for every zone thereafter. And those are the range in prices you see in North America.

Generally, the guys that are very busy, very experienced, own three or four image based technologies have a good market reputation, are going to charge a little more per zone than less experienced individuals with less notable reputations. You also pay a little more per zone if you’re bigger. So you have a tummy and you weigh, let’s see, a BMI of 34 and you have another patient with a BMI of 24 and a small amount of pinchable fat, that tummy is going to cost the smaller patient a little less than the bigger patient. So there’s large zone prices as well.

And then there’s sometimes quite often an upsell for energy based technology, like the addition of BodyTite or Vaser or Smart Lipo. These are usually upsells for the advantage of that tightening you get. One of the energy based devices that typically doesn’t cost you more is something called power assisted. Power assisted, or PAL, is a cannula with no energy, basically basic liposuction cannula, that’s motorized. So it goes back and forth about 1,000 times a second, and the surgeon’s arm is moving about one cycle per second and it removes fat much faster, speeding up the procedure, making it safer. And so, those are the prices you can see in North America in general.

And the last category is secondary lipo. These are patients who’ve had lipo before, they have irregularities, indentations, laxity problems. They usually are going to pay more for secondary lipo, upwards of sometimes 8,000 or 9,000 or 10,000 for the first zone, and it can easily cost them 14,000, 15,000, 16,000 for two or three zones, because these are tricky cases, much more complicated, take longer and take a greater amount of expertise and therefore costs more.

So you’ve done your lipo, you’re about to get a great result. What’s the postop care like in terms of a compression garment? One hundred percent of surgeons in North America nowadays are going to insist on a compression garment, and it’s going to be a nice specialized custom made to measure, form fitted, Lycra spandex kind of combination. They’re breathable, but they get a good 22 to 28 millimeters of mercury of pressure per square centimeter, which results in a nice controlled contraction and retention of your skin while it’s healing to the underlying muscles. So there’s no way of regularities or laxity. So it controls the wound healing process in a good position while that six weeks of healing of neocollagenesis is occurring. So you get it measured before your surgery, it’s usually combined with some foam padding, which is going to give you better compression in certain areas, and the foam padding lasts about a week.

You wear that garment 22 hours a day for three weeks for most practices. Then you can wear it during the day, leave it off at night for another three weeks. At the end of six weeks you can fold your garment up on the shelf and go back to your normal activities like high impact aerobics and exercise.

“When can I return to a high impact aerobic activity or my normal exercise routine after liposuction?” That’s a common question. I tell most patients the first three weeks, brisk walking, keep active. You’ve got your post liposuction garment on, but no high impact arobotic activity, no balancing, running, no pilates or crunches if you’ve done abdominal work. So high impact activity start at six weeks. So you’re back on elliptical, a stair climber at three weeks, you can start to isotonic muscle exercises where you haven’t done lipo, like bicep curls, Thigh Master if you haven’t done lipo in those areas at about three weeks.

High impact activities like jogging, yoga, pilates, crunches, these kind of activities, you’ve got to wait about six weeks so you get some adherence between skin and the underlying muscle, then you can begin those activities. Starting gradually and build up your endurance and your strength over time. Return to swimming typically needs healed incisions and that’s going to be usually around three to four weeks, before that you want to get in the lake or a dirty pool or whirlpool water. And what about flying away, flying out of the city after surgery and going on a vacation? Generally, I recommend people stay around for about a week until some swelling is subsided, the garment compression has worked and it minimizes the risk of a airplane induced pulmonary embolism or DVT. So you want to hang around a week before you travel at 31,000 feet and go off for a vacation.

What about the use of a drain after a liposuction surgery? Typically loose areas like a tummy or very loose upper arm treatment might require a drain, and usually it’s for several days to encourage contraction and coaptation of the skin to the underlying muscle.

So thank you for joining us. Dr Stephen Mulholland here in Toronto, Canada on plastic surgery talk for our weekly podcast series. This one was on liposuction, a deep dive into modern liposuction and all the questions around that. If you found this engaging, interesting, educational, please sign up, subscribe, and comment. See you next time.

PART 3 OF 3 ENDS [00:35:01]

The post PST 044: All About Liposuction appeared first on SpaMedica.

Jun 28 2019

35mins

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Rank #5: PST 036: Learn about Rosacea Treatments

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This week, Dr. Stephen Mulholland discusses Rosacea and what you can do to treat it.  

The post PST 036: Learn about Rosacea Treatments appeared first on SpaMedica.

Apr 10 2019

15mins

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Rank #6: PST 010: Nonsurgical Liposuction & Body Sculpting Options

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A lot of questions that come to the clinic with patients is what can be done to kill the unwanted fat in areas of unwanted areas without surgery? Getting Liposuction surgery is an intimidating endeavour, luckily with the advancement of technology, patients have nonsurgical options available today. In this podcast, we will look at different […]

The post PST 010: Nonsurgical Liposuction & Body Sculpting Options appeared first on SpaMedica.

Apr 27 2018

17mins

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Rank #7: PST 024: Breast Augmentation and Intimacy

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In today’s Plastic Surgery Talk podcast, Dr. Stephen Mulholland will discuss breast augmentation and intimacy in your personal relationships.  

The post PST 024: Breast Augmentation and Intimacy appeared first on SpaMedica.

Sep 05 2018

5mins

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Rank #8: PST 027: Anti-Aging and Skin Rejuvenation

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Dr. Stephen Mulholland welcomes you back to another episode of Plastic Surgery Talk, where he talks about anti-aging and skin rejuvenation.  

The post PST 027: Anti-Aging and Skin Rejuvenation appeared first on SpaMedica.

Sep 13 2018

14mins

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Rank #9: PST 033: Botox for Bruxism

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This week, Dr. Stephen Mulholland discusses Botox treatments for Bruxism and TMJ.    

The post PST 033: Botox for Bruxism appeared first on SpaMedica.

Feb 15 2019

11mins

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Rank #10: PST 035: The Facts on Gynecomastia

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This week, Dr. Stephen Mulholland discusses Gynecomastia and all the facts you need to know.    

The post PST 035: The Facts on Gynecomastia appeared first on SpaMedica.

Mar 25 2019

18mins

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Rank #11: PST 034: All About the Necklift

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This week, Dr. Stephen Mulholland discusses the Neck Lift and everything you need to know about it.    

The post PST 034: All About the Necklift appeared first on SpaMedica.

Mar 19 2019

15mins

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Rank #12: PST 026: The Perfect Time for a Rhinoplasty

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Dr. Stephen Mulholland welcomes you back to another episode of Plastic Surgery Talk, where he talks about the ideal time for a person to undergo a rhinoplasty procedure.

The post PST 026: The Perfect Time for a Rhinoplasty appeared first on SpaMedica.

Sep 11 2018

13mins

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Rank #13: PST 042: PRP for Hair

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The post PST 042: PRP for Hair appeared first on SpaMedica.

Jun 14 2019

16mins

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Rank #14: PST 029: Face the Facts about Facelifts

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Dr. Stephen Mulholland welcomes you back to another episode of Plastic Surgery Talk, where he talks about the Facelift procedure and its various pros and cons.  

The post PST 029: Face the Facts about Facelifts appeared first on SpaMedica.

Sep 28 2018

32mins

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Rank #15: PST 030: EMsculpt: Kill Fat and Burn Muscle

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Dr. Stephen Mulholland welcomes you back to another episode of Plastic Surgery Talk, where he talks about the EMsculpt procedure and its various pros and cons.  

The post PST 030: EMsculpt: Kill Fat and Burn Muscle appeared first on SpaMedica.

Oct 19 2018

12mins

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Rank #16: PST 007: Rhinoplasty Myths and Facts

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What is a rhinoplasty, commonly known as a ‘nose job‘ It is an operation performed by a certified specialist like a plastic surgeon, a facial plastic surgeon, on the nose balancing the craniofacial nasal balance, making the nose look like it fits the face? Nose jobs, or rhinoplasties, can be reductive in nature, which is […]

The post PST 007: Rhinoplasty Myths and Facts appeared first on SpaMedica.

Mar 29 2018

10mins

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Rank #17: PST 045: PRP for Facial Rejuvenation

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Welcome to Plastic Surgery Talk with Dr. Stephen Mullholland, brought to you by Spa Medica.

Hello and welcome. Dr. Stephen Mulholland here in Toronto, Canada. You’re on Plastic Surgery Talk and we’re on our weekly podcast series. If you enjoy these podcasts, you find them educational or if you find them informative, fun, please subscribe, share and comment

So our podcast this week is on a very, very topical area of aesthetic medicine. It’s an area I’ve been doing for years, but has found sort of a place in the sexiest of what’s new and it’s called PRP. PRP is an acronym that we use for platelet rich plasma. We’ve been doing this for quite a long time, I think with social media and the Kardashians and the latest what’s new, the vampire lift got a lot of traction over the last year or two and the vampire lift is a specific way of using platelet rich plasma to create an enhanced aesthetic outcome nonsurgically.

So the topic today is PRP. There’s two kinds of ways we use PRP commonly. We use PRP for hair restoration and hair growth, and we use PRP for anti aging and rejuvenation. So we take a patient’s blood, a simple little venotomy, or like you’re donating blood. We take a small amount, a couple of of syringes, we spin down that blood and we extract from that blood the stem cells and the growth factors. When applied in specific fashions in ways during the aesthetic treatment, either for hair restoration or anti-aging wrinkle reduction, it can amplify and improve the results and the outcome. So as using your own body stem cells, body’s growth factors to improve the outcome of hair growth or anti-aging skin rejuvenation. So what is PRP in the context of facial rejuvenation? And so PRP is taking the patient’s blood, spinning it down in a centrifuge and getting a very sterile collection of stem cells and growth factors.

Unto themselves, if we applied this topically or injected under the skin, it actually does very little. We need to create an inflammatory stimulus. We need to do something to the skin for the growth factors and the stem cells to amplify their production of collagen, to thicken the skin to smooth and wrinkles. So what do we do? We usually will do some type of fractural injury to the skin. The most entry level, done by most medical and day spas is microneedling now onto itself microneedling, which is tiny little needles that oscillate vertically into the skin and create a fractional mechanical injury, this stimulates some mild inflammation. Through the little channels created by the microneedles, the topical PRP can soak into the skin, can get down to where we need new collagen to be produced. We can also inject the PRP under the skin with a microcanula technique to stimulate the deeper aspects of the skin, to lay down more collagen and elastin.

And so if we do a little microneedling as the injury, we can create a more amplified response and get more collagen, more elastin, and a better looking skin rejuvenation with the use of PRP. The most medical use of PRP is following a fractional thermal injury where we take more of a medical approach to fractional injury, fractional carbon dioxide resurfacing, fractional radio-frequency resurfacing, and the thermal ablation creates a significant rejuvenation on its own, whereas microneedling is not very significant improvement, but certainly easier to do and offered by many nonmedical day spas. The fractional CO2, the fractional radio frequency like Fractora, or Infini, or Intensive creates a tremendous thermal experience in the dermis. Again, a fractional injury. If we add topical PRP or inject PRP under the skin or both, we can amplify the collagen response by 20%. We can heal the fractional injury about 30 to 40% faster, and so this is a randomized, double blinded proven benefit of PRP.

We get a better collagen response, we get faster healing. When we add PRP topically or as an injection after creating an inflammatory fractional injury and the combined therapy of fractional CO2, fractional radio-frequency and PRP is the state of the art fractional rejuvenation that we could add to the patient’s experience. What’s the treatment protocol for PRP and skin rejuvenation? Well, quite simply we create a fractional injury in the skin. It can be microneedling or a more medical and more substantive fractional carbon dioxide resurfacing, fractional erbium resurfacing, infrared fractional or fractional RF needle like Fractora.

Once you’ve created the fractional entry, we’ve already drawn the blood and we spinned it down and we extract the elements we need from that blood. We want the fraction and elements that have the platelet rich stem cells and growth factors. Normally we can get about a five cc draw for skin rejuvenation and we do the fractional treatment under a topical anesthesia and laughing gas, so we just Pro-Nox or nitrous oxide to minimize the discomfort of both the fractional treatment and then the topical addition of PRP is painless, so we take usually about 20% of our PRP draw.

We put it on the skin slowly so it’s absorbed through the channels that we created with the fractional injury. Then we take the other four ccs in a very small micro canula, and we inject it directly into and under the dermis. We get a top layer PRP edition and a bottom layer, and the goal is to increase by 20% or more the amount of collagen you’re going to produce and to get the wound healed up to 30% faster by the use of PRP during a fractural injury technique fractionally surfacing in a combined therapy for anti-aging. So it’s going to give you the best acne scar reduction you can probably get, we’re going to get a fractional wrinkle reduction and smoothing, enhanced tightening and even conditions such as dyschromia or brown discoloration, Melasma are going to improve more significantly with the addition of PRP.

So what about pain and discomfort during PRP? Whether it’s PRP for hair restoration, whether it’s PRP for skin rejuvenation, we’re always cognizant to take pain and reduce it to aesthetically acceptable discomfort if not fun pain. And how do we do that? We use number of techniques, topical anesthetic cream. We can use an air chiller, we can have squeezy vibration devices that we grab. We can use a nonsteroidal antiinflammatory. However, the most effective tool that I’ve found over the past a couple of years to make this a fun experience is the use of nitrous oxide or laughing gas. And so we have a whole podcast on the use of laughing gas. The use of laughing gas takes what could be reasonably uncomfortable, both the draw and the application, whether it’s fractional or treatment in the hair and makes it fun pain, acceptable pain. So they use of laughing gas has rendered the the treatment of PRP for male pattern hair loss, female pattern hair loss, and even facial anti-aging if not a much more acceptable, even fun.

Are there any risks associated use of PRP either for hair restoration, male or female pattern hair loss or skin rejuvenation and anti-aging? The answer is very, very few risks which is why it’s so popular. There are risks associated with the treatment of anti-aging, fractional resurfacing for wrinkle reduction, but when you add the PRP either topically or with a small needle, there’s virtually no risk. There’s a small risk of a bruise at the site of the harvest that will go away. The PRP is done in a sterile technique within your physician’s office, so there’s no risk of contamination with another patient’s blood products. The topical application of PRP has essentially no risk to the user and generally we’ll leave it on the skin for about 30 minutes, clean it off before you leave so there’s no risk of other people around you with your topical blood burn products on your face. With the injection of PRP, there’s virtually no risk.

The biggest risk is your expectations exceed what can be done. Yes, the fractional technique or the hair restoration technique should result in a noticeable improvement. Either increase hair density or for rejuvenation, smoother, tighter, firmer wrinkle reduce skin. However, the results, like anything aesthetic medicine, may not quite meet your expectations. So the number one risk is your expectations exceed what the treatment can deliver. After that, there might be some localized bruising or swelling from the injection, but typically it’s one of the lowest risk treatments we have with a very big cost benefit reward, making it so popular.

Who are the best candidates for this in anti-aging therapy? Typically people who’ve got mild to moderate wrinkles or mild to moderate acne scars who have realistic expectations and who want the best amplified result after a fractional treatment. So whether it’s microdermabrasion at the very entry level of fractional invasiveness or fractional CO2, fractional radiofrequency, if you want to get the best possible result, PRP added to that is always going to give you about 20, 25% more collagen, more amplified tightening, and it’s going to be your best result. But again, realistic expectations, your wrinkles are not going to be 100% improved. You’re going to get a nice noticeable improvement and more amplification and more outcome by the simple addition of your own stem cells and growth factors through the application of PRP. Are there any contraindications to anti-aging? Not really, as long as you don’t have any blood coagulation abnormalities such as hemophilia, and we can draw blood and not have risk of ongoing bleeding, and the realistic expectations are really the only two criteria that are important in deciding whether you can do PRP.

If you’ve had a previous skin cancer in the area, that is not a contraindication. If you have an undiagnosed open lesion or sore, clearly that should be diagnosed before we even do the fractional and rejuvenation, let alone the PRP. And so healthy skin, realistic expectations, no bleeding disorder. Those are the best candidates and early aging realistic expectations for wrinkle reduction. Those are the best candidates for a PRP anti-aging therapy. There’s not much recovery associated with PRP in, let’s say, hair restoration or anti-aging wrinkle reduction. Not really. It’s one of the least invasive treatments we have for hair restoration because it’s injected into the scalp and the scalp generally has some hair, even minor bruising or swelling you get from the PRP is camouflaged immediately, so there may be a little bit of swelling that you might notice around the eyes around the temple in the first day or two after PRP, but essentially very, very little downtime.

Occasionally a patient will complain of a bruise that shows up above the eyebrow that drifted down from the scalp, but very, very unusual and you can always blame it on hitting your eyebrow on a car door or some other sort of secondary traumatic event. For anti-aging patients who are having a fractional injury, a fracture resurfacing the skin and the PRP, the downtime is not from the PRP. The downtime is from the fractional treatment, so you might have a little redness from your microneedling for a day or two, redness plus crusting or discharge if it’s fractional CO2 or fractional radiofrequency. Now the cool thing about PRP, it takes that one week of fractional downtime after anti-aging wrinkle reduction and it makes the downtime and the recovery faster. So PRP helps speed up the downtime, but the downtime from anti-aging PRP is the downtime of the fractional injury.

For hair restoration PRP, virtually no downtime. You can go right back to activities. What kind of results can I expect with anti-aging PRP skin rejuvenation? Well, the wrinkle reduction part, the majority of the wrinkle reduction efficacy is going to be related to technique. So let’s say you’re in your mid-fifties, early sixties. You’ve got really significant wrinkles. You’re going to get a very significant improvement with fractional CO2 or or more medical grade fractional RF like Fractora or Morpheus or fractional blade FRF techniques. So that’s where the majority of your wrinkle reduction is going to come. You’re going to get an extra 20% to 25% boost in the smoothening and tightening by the addition of the PRP, so you can expect an amplified improvement over the technique of fractional injury that you’ve purchased. By the same token, if you have significant wrinkles and you buy a microneedling package, you’re not going to expect a huge wrinkle reduction from that microneedling, and so the amplification from the PRP will be less impressive.

So the moral of the story is for anti-aging PRP, purchase the fractional injury technique, that’s the best for your concern, be it acne scars, be it wrinkle reduction, be a skin laxity, Melasma, dyschromia. Purchase the best fractional injury technique, and then have the PRP layered on top of that to get the 20, 25% amplification in healing time and neocollagenesis or collagen production and tightening. What kind of costs can you expect to see for PRP and skin rejuvenation and anti-aging? Well, it depends on the clinic. Typically, if you are purchasing a single treatment program, fractional CO2, a fractional RF, to get the best possible wrinkle reduction, you’re going to have a one-time purchase amplification of PRP. The one-time purchase amplification PRP typically runs between $500 and $900 depending on the clinic, so you have your base costs for your fractional injury technique and then an additional, let’s say, on average $750 to add PRP to get that 25% amplification and collagen and and recovery time.

Some clinics will will offer a series of PRP, similar to hair restoration for anti-aging and where you might buy a less aggressive fractional technique. You’re doing once a month for three months and each time you’re going to put some PRP on top of the skin and under the skin. In those scenarios, you’re typically paying about $500 to $750 each treatment, or you buy a three pack for roughly $1,600 to $1,900 in addition to the fractional injury technique that you’ve purchased or the base injury technique. And so for anti-aging, either single treatment application with more aggressive fractional injury, or if you’re buying a package, you buy a series of three treatments done each time you come in for your less aggressive fractional rejuvenation. So how to best use your PRP provider? Well, clinics like Spa Medica have been doing PRP for a long time, long before it was sexy.

A good clinic like spa medical will have multiple fractional injury techniques, so you can pick what injury technique for any aging more fits your facial rejuvenation programs. So you can do microneedling, you can do fractional infrared, you can fractional CO2, fractional erbium, fractional radiofrequency. You can tailor the fractional injury to your anti-aging needs. And then of course you can purchase PRP to be amplified on top of that. You want to make sure they’re using an industry standard PRP, there’s different manufacturers. You want to make sure Eclipse, or Arthrex, or Chroma, or Reagent is one of the well-known PRP devices out there. It’s been around for a long time, and that they’ve got a technician that’s licensed or certified or experienced in drawing the blood, handling the blood and topically applying or reinjecting the platelet rich plasma growth factors and stem cells.

Thank you for joining me, Dr Stephen Mulholland here in Toronto, Canada on Plastic Surgery Talk, another weekly installment on our podcast series. This one was on PRP and anti aging and rejuvenative medicine. If you found this podcast and our series of podcasts, in fact, entertaining, educational, informative, then please share, subscribe, and comment. See you next time.

The post PST 045: PRP for Facial Rejuvenation appeared first on SpaMedica.

Jul 05 2019

16mins

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Rank #18: PST 025: Tummy Tuck vs. Lipo

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For today’s episode of Plastic Surgery Talk, Dr. Mulholland talks about the key differences between a tummy tuck procedure and liposuction.

The post PST 025: Tummy Tuck vs. Lipo appeared first on SpaMedica.

Sep 07 2018

10mins

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Rank #19: PST 038: All about Belt Lift

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This week, Dr. Stephen Mulholland discusses the Belt Lift.

The post PST 038: All about Belt Lift appeared first on SpaMedica.

May 02 2019

10mins

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Rank #20: PST 028: Blepharoplasty

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Dr. Stephen Mulholland welcomes you back to another episode of Plastic Surgery Talk, where he talks about the Blepharoplasty procedure and its various pros and cons.

The post PST 028: Blepharoplasty appeared first on SpaMedica.

Sep 21 2018

17mins

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PST 053: The Facts about ProNox

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Welcome to Plastic Surgery Talk with Dr. Stephen Mulholland, brought to you by SpaMedica.

Hello and welcome. Dr. Stephen Mulholland here in Toronto, Canada. Welcome to Plastic Surgery Talk and another installment of our podcast series. This podcast is an interesting topic. It’s on the use of nitrous oxide in aesthetic medicine. Really, it could be about how to manage pain successfully. Pain, not paying. P-A-I-N, pain, patient discomfort in the outpatient aesthetic setting, optimally. So do you have a lot of word-of-mouth referral for comfortable treatments and recurring revenue?

So, today’s podcast is on nitrous oxide, Pro Nox specifically, was one of the biggest vendors in the U.S. and in North America for outpatient clinic. Nitrous oxide. There’s also Nitron Ox and some other vendors as well. So laughing gas. Nitrous oxide and its use in aesthetic medicine. If you find these podcasts entertaining, educational, informative, please share them, sign up, and comment.

So what is Pro Nox? Pro Nox is a manufacturing trade name for nitrous oxide, or laughing gas. Laughing gas has been around in dentistry for 30 years. They cause a lot of pain, dentists. Everybody doesn’t like a dentist. So you don’t want to be viewed as a dentist. You’re an aesthetic physician, aesthetic technician. You want people to tell their friends that it was a painless experience, that tattoo removal, or that energy-based device or that injectable. So the use of laughing gas has been one of the most important additions to my business and my practice I think I’ve made in many, many years. So Pro Nox is laughing gas. Laughing gas is nitrous oxide. Nitrous oxide helps minimize the perception of patient discomfort during an aesthetic treatment.

How does nitrous oxide or Pro Nox, laughing gas, work? Quite simple. Nitrogen is about 9% of the atmosphere that we breathe in every day. When we increased the percentage of nitrogen in our inspiratory gases, in this case we’re talking 50% nitrous oxide. Many dental components and systems use up to 80%. At 80%, nitrous oxide becomes an anesthesia and there are regulatory issues around that, particularly in my practice and your practice. The Pro Nox that I’m advocating, the nitrous oxide or laughing gas, content mixture is 50%. 5-0. At 50%, it’s considered an analgesic. Depending on the state, and virtually every state and province are the same, you can legally drive after eight to 10 minutes of Pro Nox, or nitrous oxide.

So how does nitrous oxide work? You increase the percent of inspiratory gas to about 50%. After about six to eight breaths or one minute, and as a deep breath, hold it and then breathe out. So slow, deep breaths. After six to eight deep breaths, it releases. The nitrous oxide goes from the lung into the bloodstream, bloodstream to the brain, and it releases a sudden surge of endorphins. These are the chemical neurotransmitters in your brain of well-being. The two neurotransmitters that are released, a tremendous surge of well-being, are serotonin and dopamine. So this surge of well-being, of euphoria, washes over the patient whilst they’re getting an energy-based treatment like a tattoo removal, or laser resurfacing, or laser hair removal, or Botox, or filler, or your pre-freezing prior to a surgical treatment.

These experiences then, which are viewed as painful by the hypothalamus, they get corticated. The higher brain with all this serotonin, dopamine goes ah, be quiet hypothalamus, I can hear this pain. I know it’s there, I hear you, but I don’t care. So it creates a disassociation, a euphoria, sense of well-being during discomfort. It’s a very pleasant experience for patients who otherwise would be in a significant amount of discomfort in a lot of cases. It induces a chemical release of natural neurotransmitters of well-being, serotonin and dopamine. That’s what nitrous oxide does. The beautiful thing about it, once you stop inspiring or breathing in the nitrous oxide, within about eight minutes the effect is washed out. Patients are back to their baseline and they can drive home.

So who’s a good candidate for Pro Nox, for laughing gas, for nitrous oxide during your procedure? Well, any patient coming into your clinic who’s medically well, who has no signs or symptoms of metabolic diseases that are in control, like liver failure or heart diseases or uncontrolled respiratory illnesses. Medical illnesses that would not make them a great candidate for cosmetic treatment in the beginning. So medically well patients who are having what is an uncomfortable or painful procedure. Injectables are common, energy-based device are common, freezing for a local anesthesia, face lift, or liposuction. Common indications for modulation of pain, and they understand that there are slight risks and side effects to the nitrous oxide, but not many. These are the great candidates. Those that are going to have a procedure that has some degree of discomfort and you want to take that discomfort and make it a pleasant experience. I call it fun pain. Turning the procedure into fun pain to the use of nitrous oxide. That’s a good candidate.

How’s Pro Nox, nitrous oxide, administered? Well, it comes in a very convenient carrying module on wheels. A tiny module with two little canisters. It’s a mixture of oxygen and nitrogen oxide. 50/50 mixture of 50% oxygen, 50% nitrous oxide. The suppliers of these medical gases are medical gas supplier companies, and those are available in every market. They come in small sizes that slide nicely into the little portable unit on wheels. The regulators hook into a modulator that creates flow, and then the patient simply breathes through a one-way tubing, or obturator. Sort of like they’re snorkeling. They’re swimming in the water, they breathe in, out, in and out through the same tube. There’s the white intake tube, the pink exhalation tubing. The excalation tubing goes to the floor or a scavenger, so there’s no risk of nitrous oxide to the staff or the surrounding ambient region.

It’s in a very portable unit. There’s two mechanisms for inspiration. A mask, which you the patient could use if they’re having a body procedure, let’s say liposuction or a body procedure where local anesthetic is being required, or they’re having a body laser procedure like an energy-based device or a fractional technology.

What are the procedures you can use this? Well let’s divide them into injectables and non-injectables. Injectables, Botox, soft tissue fillers, Sculptra, any kind of injection technique. It’s great for that. Nitrous oxide, laughing gas, as an outpatient Pro Nox is great for injectables. Energy-based devices, lasers, radio frequency devices, laser resurfacing with fractional technology like fractional CO2 or fractional RF with high fluids. That can be uncomfortable, and Pro Nox, or nitrous oxide, is perfect for that. Energy-based devices such as laser hair removal. There can be a real snap or sting to laser hair removal that some patients find uncomfortable. Pro Nox, or nitrous oxide, laughing gas, is perfect for that. Energy-based devices such as laser hair removal. That can be snap, you’re uncomfortable, and it works beautifully for that. Fat destruction through thermal technologies such as sculpture is good for that energy-based device.

So any energy-based device in your practice that has discomfort associated with it, or local anesthesia leading up to it such as the miraDry, which is a microwave use to ablate excess sweating. There’s a local anesthesia for that. Nitrous oxide will decrease the discomfort of the local anesthesia. So energy-based devices, injectables, and leading up to and during a surgical procedure into local. Those are the main indications and procedures during which I found the use of nitrous oxide, or laughing gas, to be invaluable in modulating patient discomfort and making the procedure fun.

What are the benefits of Pro Nox or nitrous oxide? Well, there’s two benefits. One is to the patient, and two is to the practice. First, the patient’s perception is one of euphoria, one of well-being in the face of pain, which is an odd sensation. They feel not altered consciousness as in they’ve been smoking marijuana or some substance that changes cognition. They feel euphoria and well-being, but it’s their same brain. They just feel separated from the pain. The pain is over here. The hypothalamus. They’re thinking about the pain or other things and it’s separated from the pain. So it’s a sense of well-being in the presence of disassociated pain. Uncomfortable procedure that might be ranked as a seven or eight out of 10 by the patient, will be ranked a two or three when they take the nitrous oxide. So the benefit is the patient’s perception. Very few side effects. Patients can drive home right away, and you know there’s really no contra indications, in essence.

The benefits to the practice are huge. Number one, patients find that your technique is painless and they tell patients. So more word-of-mouth referrals from patients who are telling other patients the use of this Pro Nox, or this laughing gas, was an awesome addition to the experience of discomfort making you the provider they want to see. So word-of-mouth referral.

Retention. Patients are more likely to come back for an uncomfortable procedure like miraDry where they need to treatments, or subsequent laser tattoo removal treatments, or fractional treatments, ongoing maintenance injectables when the fear of the pain or the anxiety anticipation of pain is removed. So patient variables, better experience, practice variables. Better outcomes in terms of perception discomfort, and better retention and referral. Ambassadorship when you are the painless practice.

Pro Nox sounds great. This laughing gas sounds great, but are there any side effects or risks that we got to know about? Well, there are some rare syndromes, particularly for the liver, metabolism, where if they’re in fulminant liver failure insufficiency or they have a pulmonary disease such as cystic fibrosis or COPD, they’re not great candidates for treatment anyway and they might want to avoid an inhalational like nitrous oxide. But virtually every healthy, well, cosmetic medicine patient is a candidate for nitrous oxide.

What are some of the side effects? In rare instances, perhaps one in 20 or 5%, patients will experience a little lightheadedness, perhaps a little nausea. They might get a bit of vasovagal from the experience of the nitrous oxide, and that may actually be related to the injectable anyway. But those that have reported side effects in generally, you remove the nitrous oxide, bring the legs up, head back, cool compresses and the sense of nausea or lightheadedness tends to dissipate as they wash out the nitrous oxide is six to eight minutes.

So some limited side effects that generally are self-limiting and go away as the nitrous oxide washes away. In my experience, there’s probably even less than one in 20 or less than 5%. Virtually everybody finds it an enjoyable experience. Sometimes it can be very powerful and patients exercise what I call self-administered Pro Nox. They take a few breaths, remove it, and they can take another puff or two when whatever I’m doing gets uncomfortable again. So it’s titrated to patient levels of euphoria and well-being. You don’t want to force them to breathe the nitrous oxide through the entire procedure. Self-directed, patient administered helps minimize over nitrous oxide in the brain, creating too much euphoria and the side effects that can occur.

What is the cost of Pro Nox to you, the patient who’s getting this treatment? Different physician practices do different things with this. Some just include it as part of the treatment. Generally, these tend to be practices that are generally more expensive. They’re charging more because they perhaps have a better or a more expensive reputation in the market. You’ll find that the cost of the Pro Nox is part of the treatment. Some practices prefer to break out the cost of the Pro Nox. So there’d be cost of the treatment whether it be Botox of soft tissue filler or laser hair removal or a PicoSure, Picoway, and lighten, Picosecond laser tattoo removal, or a fractional laser resurfacing.

There’s the cost of the procedure and some practices break down the items of the costs associated with the treatment. They might charge for the topical anesthesia. They might charge you for the Pro Nox individually. Most practices charge between $50 and $70 per treatment for the analgesic effect of the Pro Nox. So about 50 bucks U.S., different if you’re a non-U.S. market for Pro Nox, as an additional cost to the treatment. You as the consumer can decide, you know what, that 50 bucks for the pain relief was more than worth it. Again, some practices with higher price points to their procedures will tend to bundle it within the treatment itself. So you can see either way. Paying per treatment in addition to the treatment service fee, or rolled into the treatment service fee. Both models are acceptable and it depends on the practice that you pick.

When sourcing out a physician, what do you look for? A clinic or provider? Well, you want to make sure they have a great reputation on for whatever you’re doing. Whatever injectable you’re doing, Botox, filler, or energy-based device treatment, laser hair removal, tattoo removal, fracture resurfacing. Any cosmetic surgery procedure, liposuction physician, facelift surgeon. Make sure they’re good at what they do. Then of course they modulate and cover off on pain and discomfort.

The more modern and up-to-date practices are going to be incorporating nitrous oxide increasingly. I’ve done it for quite a long time and it has become a mainstay and addition to local anesthesia for discomfort. Make sure that Pro Nox is part of their treatment offering, or call the clinic. If you know your doctor well, reach out to them and ask them why haven’t they included in nitrous oxide into the management discomfort? You’ve read online that this is a great technique, and I think you can help them. They might not even know about it. Help them bring something great into their practice. So research your physician or provider on the basis of the quality skills outcome. Before and after, has a photo gallery, lots of testimonials, no medical malpractice lawsuits, litigation and of course their approach to pain and discomfort, and hopefully nitrous oxide, Pro Nox, laughing gas, is a part of that equation.

Thank you for joining me again, Dr Stephen Mulholland, here in Toronto, Canada on Plastic Surgery Talk. For another installment of our podcast series, this was on laughing gas. Nitrous oxide, Pro Nox, the largest brand name, and how we have incorporated that into our aesthetic practice and how you, the consumer, can benefit hugely from the perception of discomfort. You can create fun pain during those treatments and services that right now may be uncomfortable. You can render them, dare I say enjoyable? A fun pain. A fun experience. A way to modulate discomfort in the name of aesthetic beauty and enhancement. If you’ve enjoyed these podcasts, this one in particular, please share, sign up, and comment.

The post PST 053: The Facts about ProNox appeared first on SpaMedica.

Sep 17 2019

16mins

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PST 052: All About the Cheek Lift

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Speaker 1:                           Welcome to plastic surgery talk with Dr. Stephen Mulholland, brought to you by SpaMedica.

Dr. Mulholland:                 Hello and welcome. Dr. Stephen Mulholland, welcome back to plastic surgery talk here in Toronto, Canada. We’re here for our weekly podcast series. This week’s podcast is on the cheek lift.

If you find these podcasts engaging, entertaining, informative, please subscribe, share, and comment.

What is a cheek lift? A cheek lift is the specific and selective elevation of the cheeks. The cheeks are subtended and contain the soft tissue elements called the malar fat pad that exists between the lower lid and the corner of the mouth.

A facelift would include a cheek lift, jawline neck lift, and those elements would be a facelift. A cheek lift is a subcomponent selective elevation, a portion of a facelift, basically, particularly called the midface, a very popular and important treatment, because the cheek is often the very first part of the face that tends to deflate and sag.

It elevates the lower lid cheek junction. The cheek fat pad subtends and falls into the lower parts of the face. We get overhang of the nasolabial fold, descent of the mid cheek down onto the jowl, and then heaviness of the jowl.

Often, it’s the midface that gets elevated first. It may be done in combination with other procedures, but the cheek lift itself is a very selective stealth elevation of the midface, designed to create a more oval shape to the face that’s become a bit boxy.

How is the cheek lift performed? The elevation and creation of the modern cheek lift has undergone some really high tech renovations and evolution. Typically, it’s limited access. What does that mean? Well, I can elevate the malar pad, the cheek fat pad, those little rosy cheek fat pads that sit high up on your cheekbone.

We can elevate when they’ve fallen down by going through the mouth with a little pinpoint incision, elevating the cheek fat pad right off the cheekbone under local anesthesia. We can then close that little pinpoint incision in the mouth with an absorbable suture, and then come from the temporal or the side temple hair region, the hair bearing area, with fixation systems.

There’s different ways to lift the cheek and hold it there. Typically, they all tend to be bioabsorbable, either the Endotine or Ultratine, or passing modern bioabsorbable barbed sutures. These constructs can elevate the cheek, and while it’s healing, hold it in position.

Once the cheek is healed to itself and to the underlying cheekbone, the dissolvable bioabsorbable threads go away, and the cheek holds itself to itself through autogenous fixation.

Modern cheek lift surgery can be done in about an hour, under local anesthesia. Elevation of the cheek fat pad, which softens the jowl, and takes a boxy look and makes it more oval. The fixation system is hidden in the hair so there’s nothing visible.

Typically, these retention devices like a barbed suture go away over about three to four months, leaving the elevated cheek and the more oval looking jowl face junction looking youthful.

Who’s a good candidate for a cheek lift? Well, those patients and individuals, male or female, that have noticed a deflation of the cheek and descent of the cheek. As we get older, there’s three de-aging … deflation, air out of the balloon, then the balloon descends, it falls, and that includes the cheeks.

As the cheeks deflate and descend, we get an elongation of the lid cheek junction, so the lower lid looks evacuated. The cheek itself, or the malar pad looks flat, and old, and hollow. The soft tissue that was formerly high in the cheek descends down onto the corner of the mouth and the jowl, and we get dowdy and jowly.

A candidate is that patient, male or female, that have shown those aging signs of deflation, descent, and deterioration of the cheek and the midface structures. They have a good understanding of what’s involved, the risks and the benefits. They have expectations that are reasonable. They have good hair bearing hair that we can hide the fixation elevation port in, and they’re willing to take at least a week off work to recover from the swelling and the bruising that can occur.

What are the contraindications to a cheek lift? Typically unrealistic expectations, medical conditions that are uncontrolled. Patients should not be pregnant. They should not have implantable devices in their cheeks. It makes it much more difficult if there’s been a previous cheek augmentation with silastic or silicone. There should be no liquid injectable silicone, no injectable element in the way of the elevation.

There should be no periocular pathology that’s been undiagnosed like glaucoma or retinal diseases. Patients should have set aside the appropriate amount of time to recover and not feel rushed back to work. There should be no perioral or dental pathology that’s been untreated, such as an apical abscess or tooth root infection.

If all those things have been met, all this criteria, and the patient has realistic expectations, a cheek lift can be one of the most pleasing facelift operations we have.

What are the steps in a cheek lift? Basically, a patient is prepped and draped. The areas of the cheek that have fallen are marked out. The incisional approach, usually transoral or in the mouth, is injected with local anesthesia. The hairline approach is injected with local anesthesia.

We elevate the cheek from inside the mouth, close that little port with a bioabsorbable suture, and then retain the now freed up cheek from above with a temporal support structure, or a temporal hairline support structure such as a barbed absorbable suture.

The postoperative course is generally a bit of swelling and bruising, but not much. The pain is modest, usually like a brow lift, two or three out of 10 versus a tummy tuck or a breast augment. That’s an eight or nine out of 10. Usually most patients can get by with a nonsteroidal antiinflammatory.

Typically, a patient will take about one week off work, during which time the swelling comes down. The pain generally subsides to a mild bruise discomfort. It’s very, very important postoperatively that patients avoid sleeping on their face and putting pressure on their cheek lift, on their midface lift.

Sleeping with a airplane pillow, a type of apparatus around their neck so you can’t turn onto your face or onto your side for about six weeks, until the elevation and fixation of your midface has stabilized, and you can go back to normal high impact activities and sleeping on your side.

What kind of results can you expect from a cheek lift or a midface lift? Typically, a very pleasing and significant elevation of the cheek and the malar fat pad with a lessening of the jowl.

We can take you from looking very boxy, jowl dominant, and reposition the midface and open up the bizygomatic width, the distance between the two arches and make that fuller again with your own tissue, your own fat. We can create a much fuller, more youthful midface.

The lid cheek junction shortens so you look less tired. The midface is elevated, which pulls the jowl out of its dowdy jowly look. You get a more oval, more youthful look. You could do that without the big incisions and scars associate of typical facelift surgery, because it’s done through two small stealth ports in the mouth and through the temporal hairline.

What are the risks and complications potentially with a midface lift? Well, there are substantial risks and complications potentially with this procedure, but done well in well-trained hands, they’re very, very rare.

Undermining under the cheek can sometimes stretch the facial nerve, and there’s a little bit of weakness in the perioral movements of the fine muscles of the lip. There can be some weakness, some difficulty with oral competency if you’re drinking fluids, but that typically lasts two to three weeks and generally will go away.

There could be some numbness from elevating the soft tissue that typically resolves soft tissue infection or abscess. We use preventative antibiotics. The scars are typically not an issue because they’re just not in visible open skin. They’re in the hair and in the mouth.

On the balance of weighing the risks and the benefits, this is a high satisfaction procedure, where the benefits quite markedly outweigh the risks. The recovery is generally within a week, and patients find it to be one of the most pleasing isolated facial elevation elements in our facelift tool of opportunities.

How much does a standard midface or cheek lift costs in North America? It depends on the city, on the surgeon, but in general, you can find ranges in midface cheek elevation prices from $6,000 to $10,000 in the low to mid range, and $15,000 to $20,000 in bigger cities, bigger markets, and surgeons with a tremendous reputation for creating beautiful midface lifts.

One of the benefits of the midface, it does last for a good eight to 10 years. It does take that boxy, older dowdy look and create a more youthful oval. It brings back a more rested look to the lower lid. It just has so many nice benefits that it’s become one of the most popular selective, isolated facelift techniques that we have.

Are there any combination treatments that you can do in addition to supplementing or augmenting, amplifying the cheek lift and the midface lift? Well, the cheek lift midface lift goes very nicely with a lateral tailored brow lift. A brow lift and midface lift gives an upper two third elevation to the aging face.

It can be combined obviously then with the jawline and neck lift, and then that becomes a facelift. One can combine a cheek lift with lip augmentation or a rhinoplasty. Bigger nose, smaller, smaller cheeks elevated. You can combine the cheek lift with a nose job and eyelid surgery to look more rested, a little more feminine, a more refined nasal appearance.

You can combine the cheek lift with fractional laser resurfacing to get a more oval look to your face and smoother skin, particularly if you have wrinkles, acne scars, or macro pores in the T-zone. The midface lift or cheek lift lends itself to combination therapy with many other isolated techniques that can aggregate and amplify the result.

Thank you for joining me. Again, Dr. Stephen Mulholland, here in Toronto, Canada, on Plastic Surgery Talk, another installment on our podcast series. This one was on cheek lift and midface lift.

If you found these podcasts engaging, entertaining, informative, please subscribe, share, and comment. See you next time.

The post PST 052: All About the Cheek Lift appeared first on SpaMedica.

Sep 05 2019

10mins

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PST 051: Morpheus 8 and Everything You Need to Know

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Welcome to Plastic Surgery Talk with Dr. Stephen Mulholland, brought to you by SpaMedica.

Hello, Dr. Mulholland here in Toronto, Canada. Thanks for joining us on Plastic Surgery Talk, and our weekly podcast series. Today is on a very new technology, a quite revolutionary technology. A non-surgical, non-incisional, tightening procedure called the Morpheus 8. If you find these podcasts entertaining, educational, please subscribe, share, and comment.

So what is the Morpheus 8, or we’ll call it the Morpheus. The Morpheus, or the Morpheus 8, as the company calls, is from a very innovative company called InMode. InMode is the company that makes the body tight, the face tight, the neck tight, the cellulite. Devices that work under the skin without cutting away any tissue to get significant contraction. We can use the body tight applicator to get up to 30% area contraction, however it does require local anesthesia, going under the skin, doing a minimally invasive procedure. So what the company did, is they’ve come out with an application, an applicator that works from outside the skin, penetrates and gets a body tight like tightening effect.

So what is the Morpheus 8? A non-incisional, outside the skin device, that tightens, lifts, and firms loose skin anywhere. So it’s the kind of technology now that’s gonna replace our current standards like Ulthera, and like Profound, and other non-surgical tighteners. They’re just gonna become the non-incisional face lift, body, and skin tightening device, without the need for putting anything under the skin.

How does the Morpheus 8 work? The Morpheus 8 works by releasing 24 little tiny electrodes or probes. They are variable in length so the doctor can set how many millimeters they’re gonna protrude from the applicator. These little needles go down, the little probes, go down through the skin, into the subcutaneous fat. The probe, the needle, the little device, the 24 little pins are coated. So there’s no trauma other than the mechanical penetration of the skin. Now once these little needles are in the fat they release a very strong positive charge. That positive charge coagulates and tightens the fat immediately under the skin.

Within that fat are little septae, called the fibroseptal network that connects the fat and the skin to the underlying tissue. That causes a three-dimensional strong, a three-dimensional contraction, so it causes the deep tightening you see with more invasive applicators, like the body tight with a through the skin approach, using 24 little micro electrodes. The RFM flows up the electrode to the external handpiece where it provides a gentle heating, a non-ablative tightening of the skin, like you might see with Thermage, or the Forma, or Venus Freeze, or Ulthera. So you get the external tightening from the inside-out flow, and you get the internal tightening from the penetrating depth of these little electrodes.

The beautiful thing about it can all be done under a local anesthesia and topical anesthetic, without the need for anything invasive. The results of this new technology are really the best in class tightening you’re gonna see without surgery. One.

So who’s a candidate for this new Morpheus 8? Best candidates for a Morpheus 8 treatment are those patients that have some falling soft tissue. Like a gel, or falling cheek, or a little bit drooping of the tail of the brow. Or laxity and an early turkey neck. Or loose skin above the knee, or loose skin of the upper abdomen, or the upper arm. And they’re not willing to do an incisal procedure, like a face lift, arm lift, thigh lift, but they still want a significant result. Those are the best candidates for the Morpheus 8. Of course you need to be medically well, you need to not be pregnant, you cannot have a pacemaker, either heart or bladder. So there’s certain standard contraindications to radiofrequency energy treatments, but basically, reasonable expectations, some falling tissue, and you want a non-surgical, non-incisal lift, the Morpheus 8 is for you.

So how is the Morpheus 8 performed? Well, we select out the area on the day of your visit of the loose and saggy elements. Say jawline, your neck, your face, arm, above the knee, brow line. Anywhere where there’s loose skin. It’s even good for stretch marks, and some cellulite. And so we mark out the areas where the soft tissue needs to be optimized, it’s marked out with a felt pen, you look in the mirror, confirm all the areas are covered. Then we infiltrate with some local anesthesia, like if you’re going to the dentist, we freeze the area with local anesthesia. Here at SpaMedica, we use nitrous oxide, or laughing gas, to make that a pleasant experience. Once it’s frozen, then we can use the Morpheus to start doing the little electrode penetrations and creating that coagulation and tightening.

Most [inaudible 00:05:07] take about an half an hour to treat, so it’s quite fast and efficient. There’s no need for drains, or fancy compression garments after, so you can go right back to your normal activities. And internally, there’s very few risks. The biggest risk, your expectations exceed what the procedure can do. So if you truly want the results of a face lift, the Morpheus can’t replace that. It’ll give you the best possible lift you can get, just less than a face lift without having to undergo a knife, or surgical incision.

Can I combine my Morpheus 8 with other standard procedures? Absolutely. Often, when we see patients, particularly for the Morpheus 8 non-surgical face lift, we’ll talk about the adjunct and simultaneous use of Botox. Of soft tissue fillers to create volume and shape. Of color correction and laser devices like the photofacial. So remember, [inaudible 00:05:55] are growing old, don’t change just ’cause we’re not doing a face lift. You have deflation, descent, and deterioration. And we’re gonna offer you a treatment for each of those D’s. The Morpheus is for the lift, for the descent, the Morpheus gives the lift. It gives the wrinkle reduction, texture improvement, but we still need to do color correction, we still need to add volume in the T-zone, if you’ve had a [inaudible 00:06:15] if you [inaudible 00:06:16] the soft tissue fillers, we still need to correct over-animation of the brow and animated areas of your face.

So we do the following order: We do the Morpheus first, we follow with soft tissue fillers, then we do color correction laser treatments and texturizing laser treatments, and finish with Botox. So the whole treatment for a complete non-surgical facial program, might take one hour. One.

Are there other areas of the face or body you can use the Morpheus on, other than non-surgical face lifting? Absolutely. The Morpheus 8 has quickly become the treatment of choice for mild to moderate cellulite. For loose skin above the knee. For laxity of the inner thigh, the abdomen, the upper abdomen. For stretch marks, post baby stretch marks. Post growth spurt stretch marks, loose skin of the upper arm. All these things can be significantly improved with the Morpheus 8. So it’s not just about a non-surgical face lift, it’s non-surgical, non-incisal body tightening and texurizing softening and smoothening as well.

What are the risks and side effects of the Morpheus 8? Well, you will have some side effects that are not complications. Little swelling, little bruising, little tenderness, for between 7 and 10 days. You can get back to normal activities including exercise right away, that’s not a problem. And there are rare complications such as a thermal injury, a small blister or burn that would heal quite uneventfully like you might get sometimes with laser hair removal. There can be some bruising and discoloration that’s easily camouflageable. And it takes some time for the contraction to occur. So if you have a big event, you’re going away, you want to look great in a bikini, or you’ve got a wedding, you want your face to resolve and improve, give yourself a good six weeks before the event, after Morpheus, to allow remodeling contraction, and the kind of end result you’re looking for.

What kind of recovery time can you expect with the Morpheus 8? The Morpheus 8 generally is a non-incisal, non-surgical lifting procedure of the face and the body. There’s gonna be some bruising and swelling, a little bit of sensitivity, so there’s a short term recovery you need to account for, which is in the nature of five to seven days. After five to seven days you need to wait a full six weeks for remodeling to occur and you start to see the end result. You start to like your results at six weeks, you kind of end up with your sort of finer result at 12 weeks. And then you might drop into basic maintenance. Botox twice a year, soft tissue fillers once a year, some non-invasive heating devices like the Forma, Ulthera, the Venus Freeze, to maintain and protect your Morpheus 8 improvement. One.

What is the embrace? ‘Cause you hear a lot about the embrace online too. The embrace is the power box, it’s what powers the Morpheus, it also powers the [inaudible 00:08:59] and the FaceTite. So the engine for the treatment is the embrace. The little applicator that the embrace powers, that’s the Morpheus. So one’s a handpiece, one’s a power box supply, stands about four feet high, and gives you all the software and energy to make the Morpheus 8 work.

What are the specific and relative contraindications? The relative contraindications to Morpheus 8 treatment are patient expectations. You have to have reasonable expectations. If your expectations are up here, and the outcome’s gonna be there, no matter how good we are with the Morpheus 8, you’re gonna be disappointed. So if you’re thinking real surgical type results, do surgery. If you’re wanting the best non-surgical, non-scalpel based, non-incisal tightening of the areas we mentioned, or cellulite, or stretch mark reduction, Morpheus 8 is your best option. So, expectation management, contraindication would be unrealistic expectations. Then of course contraindications would be medically unwell, a serious medical condition, pacemaker, cardiac or bladder, a pregnancy. There are the absolute contraindications to doing any treatment like the Morpheus 8. The presence of a wound in the area of the treatment, or skin cancer in the area of the treatment would be other strong contraindications to a Morpheus 8 treatment.

What is the cost of a Morpheus 8, non-surgical lift? Well in general, depends on the areas you’re treating. Is it the brow, the brow, the cheek, the under eyes, the neck? Is it the entire abdomen, just the under thighs? So it depends on the size of the zone. In general, a non-surgical, Morpheus 8 treatment, is gonna cost between three and five thousand dollars. Or one-third the price of a standard face lift price in most US and Canadian markets. When you add on Botox, soft tissue fillers, some other treatments there may be some marginal increase over and above that, but generally, very good value for the kind of lift and long term improvement you get.

How to select your Morpheus 8 practice? Well, you should look for a practice that has a physician associated with it. You want to make sure the technician … ’cause there may not be a doctor doing the treatment that’s had a lot of experience. They should be able to show you a photo gallery of their own before and afters, what they’ve been able to achieve. The Morpheus 8 is relatively new, so its innovation is new, no one’s gonna have more than one year experience, but make sure they’ve got a lot of experience under the belt. Make sure you’re not their first patient. Make sure that the clinic itself is good standing on social media sites. Make sure there’s good testimonials patients, make sure that the center hasn’t been sued or have a number of outstanding lawsuits, wanna make sure that the physician medical director hasn’t been reported to the state medical board for unprofessional conduct. You want to do a lot of research, which most of you are gonna do anyway. And when you check off enough of those boxes, that is gonna be your best Morpheus 8 center.

So thank you for joining us again, Dr. Mulholland here in Toronto, Canada with our weekly Plastic Surgery Talk podcast series. Again, if you found this educational, or interesting, by all means please share it on all your social media channels. Subscribe yourself, and comment. Look forward to seeing you in the next podcast.

Welcome to Plastic Surgery Talk with Dr. Stephen Mulholland, brought to you by SpaMedica.

The post PST 051: Morpheus 8 and Everything You Need to Know appeared first on SpaMedica.

Aug 26 2019

12mins

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PST 050: Learn about the Septoplasty

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Welcome to plastic surgery talk with Doctor Stephen Mulholland, brought to you by Spa Media.

Hello and welcome Doctor Stephen Mulholland in Toronto, Canada, plastic surgery talk, and welcome to another installment of our podcast series. If you find these engaging, entertaining, educational, please share, subscribe and comment.

Today’s podcast is on Septoplasty, or the management of airway surgery. The management of airflow, in conjunction with cosmetic Rhinoplasty. So what is a Septoplasty, or what is airway surgery? Airway surgery is the operative intervention on anatomic, or functional obstacles to air passing back and forth through the nose, without obstruction. There are a number of anatomical components that can get in the way, or block the free flow of air and give the sense of inability to breathe through one of your nostril openings and passages. One of the principle anatomical structures is called the septum, or the partition. It’s that partition in the middle of your nose that divides your nose into a right and a left half, and the partition can be straight in which case the air will often flow in a laminar pattern and you’ll have nice air exchange. However, if your septum tends to be deviated, or deflected, on one side or the other it can cause turbulent flow. One side if flowing well and the other is turbulent, and you perceive you can’t breathe through one side or the other. So the septum, or the middle partition, can sometimes block one side or the other, and that will often require correction.

The correction of that septum, where it’s straightening or removal of the crooked part, is called a Septoplasty.

So what do you get out of a Septoplasty, why is a Septoplasty a procedure, and when is it offered? In general, you can get a Septoplasty as a stand alone procedure, with no cosmetic Rhinoplasty or nose job. That kind of airway breathing surgery is generally covered by the manage care and health care plans of most provinces and states, and private insurers. In my practice, as a busy cosmetic nose job or Rhinoplasty surgeon, I don’t offer Septoplastys alone. I offer a cosmetic reduction Rhinoplasty, or a nose job, and if you have airway issues, concerns or blockages, then we offer a Septoplasty as part of the Rhinoplasty procedure.

So a Septoplasty then corrects air flow, and if we make a nose smaller, so particularly during reduction Rhinoplasty making the nose narrower, taking the bridge down, we want to make sure that the four lane highway, which is the air passages, doesn’t become a two lane highway and obstruct airflow. So you can have a straight septum, reduce the nose and still sometimes end up with relative airway constriction. So we take a look at other anatomical structures too, so the word Septoplasty refers to the septum, but often a nasal surgeon like myself will look at other structures like the turbinance, which can encroach from the side wall whereas the septum is in the middle. We may do partial Turbinectomy, or sub terbinectomy which is reduction of your turbinants.

We may look at other internal structures, such as what’s called the internal valve, because your breathing can close off when we do procedures such as Spirographs to open the internal valve. So when I say I’m going to be doing a reduction Rhinoplasty, which includes Septoplasty, it really means airway management surgery, which can be Septoplasty or management of straightening the septum, a Turbinectomy for side wall obstruction, and internal valve surgery and external valve surgery to make sure there’s no functional collapse. So a good nose surgeon, a good cosmetic Rhinoplasty surgeon, is always gonna be very cognoscente and serving your airway as well, and providing airway surgery at the same time. Septoplasty and airway surgery are to ensure after your cosmetic reduction Rhinoplasty, you still breathe well.

So who is a good Septoplasty candidate? Well someone who is undergoing cosmetic Rhinoplasty procedure, that has a deviated septum that either has compromised breathing going into the surgery, or may have compromised breathing if we don’t do the Septoplasty surgery is usually the most common candidate in my practice. So a patient undergoing cosmetic Rhinoplasty that needs reduction of the Septoplasty to ensure, or minimize the risk, of compromised breathing after.

Often the Septoplasty is also done to harvest graft material, so we take the cartilage, the stiff cartilage of the septum, and we make tip grafts, and support grafts, structural support for the cosmetic Rhinoplasty to ensure a long-term, stable outcome and result. So you can be a candidate for Septoplasty for breathing, and breathing surgery, and also harvest of graft material that’s used to structurally support your cosmetic Rhinoplasty patient.

Patients who have airway obstruction, before their Rhinoplasty who are having reduction Rhinoplasty, or clearly indicated for Septoplasty procedure, and usually we’re good at getting about 90% of patients breathing the same or better after cosmetic Rhinoplasty. About 8% of patients, despite the best Septoplasty and airway surgery that a surgeon can do, management of all anatomic structures and functional valves that might lead to constricted airway and compromised breathing, can sometimes, in 8% of cases, still love their nose job and feel that one or the other side is slightly compromised. So there’s about an 8% risk, despite Septoplasty and other functional airway surgery, that your nose looks great but your airway is slightly compromised, and that’s one of the risks of going into a reduction Rhinoplasty that patients need to be accepting of.

There are very few prior indications to a limited sub-total Septoplasty. The indications are: harvest the graft material for your structural Rhinoplasty procedure, or correction of airway. There are some patients, however, who have very limited septum following college emasculate diseases, and we may need to leave that septum in tact. Patients with bleeding disorders, or platelet scarcity may not be a good candidate for Septoplasty. Patients who have undergone some transnasal abuse of drugs at a younger age, such as cocaine, often have large septo-perpetration, or septo-compromise, and they’re not good candidates. So we sort out anatomic, metabolic and functional reasons why you may not be a Septoplasty candidate. But for primary reduction Rhinoplasty, or making your nose job to form a nasal facial contour that’s smaller, virtually every candidate who is healthy is a good candidate for a Septoplasty. Either for graft material for your nose job, or for preventative or therapeutic intervention on airway obstruction.

So how is Septoplasty performed? There are a couple different techniques. There is Endonasal, or internal Septoplasty, where all the surgery is done through one of the arrays. The lining of the septum is lifted off, and the septum is exposed, and the small piece or the deflected/obstructed part of the septum is removed. Then the flaps over the septum are re-sutured with dissolvable sutures. That’s a Peer Septoplasty.

In general, with reduction Rhinoplasty, the septum is operated on during the Rhinoplasty, so the skin is lifted up if it’s an external approach, the septum is exposed. Enough support is left behind to structurally support the nose after the surgery, but a relatively large segment of the septum is often removed during reduction Rhinoplasty; both to facilitate breathing after, and also to have enough graft material for tip support, structural support of the middle third of the vault, tip grafting, other internal valve structural support. So a lot of ways that we use the septum to support the cosmetic Rhinoplasty, so we take the septum during a nose job, both for form and breathing, and structure of the Rhinoplasty itself. When the nose is closed, the flaps are put back up to the residual septum internal dissolving sutures are used, and you never see any scars from the Septoplasty, they’re all internal.

In general, if you’re undergoing a reduction Rhinoplasty and you’re taking the bridge down, and the side walls in, and you’ve done a preventative Septoplasty for airway flow, you will notice that you’ve had a successful Septoplasty when your reduction Rhinoplasty looks great and your breathing the same, or better. That was only achieved by your surgeon doing an excellent job at airway management surgery, looking at all the relative obstructive legions, turbinants, internal/external valve and septum, and addressing them while making your nose smaller. So you have a smaller nose that you breathe the same through, that’s a great result, and you know your Septoplasty was successful.

You know you’re successful with your Septoplasty if you had airway obstruction that you can’t breathe through one side or the other; you had your nose operated on, and you had your septum operated on as well and you have a nice nose job, and you’re obstruction becomes clear or improved airflow, in the face of a smaller nose. That’s, again, airway flow improved, successful indication that you’re Septoplasty went well.

What’s an indication that it didn’t go as well as anticipated? You have airway obstruction after your reduction Rhinoplasty, there’s one side of the nose or the other that doesn’t breathe as well. That may be due to a variety of factors, septum being one of them, and you’d revisit with your nasal surgeon after about 6 months, because it takes about 6 months for the internal environment to settle and to truly manifest the kind of airflow you’re gonna have after a cosmetic Rhinoplasty.

What’s the recover from a Septoplasty? Well, the recovery period can be measured in short term recovery, and then long term recovery. Short term recovery is the healing of the risk of the septum oozing or bleeding after. So invariably, after a Septoplasty where the linings are quite fragile and we restitch the linings, some type of packing control is performed by your surgeon. Some surgeons use little hollow tubes that they put down each nostril, and suture those to the septum so you can breathe through your nose while compression is placed against the lining of the septum, for five to seven days. Then those are removed, and then the risk of having a post-septoplasty nose bleed is very low, because they can still occur but it’s very low.

Other surgeons still will use more of a traditional technique, where the nose is packed on either side with a soft, vastly impregnated, packing gauze. That gauze is removed on day three, to five. By removing the gauze, you can then breathe again, but you haven’t been able to breathe during that three to five day period, and you’ve been a mouth breather. That would be the typical packing, the traditional packing technique versus the insertion of the compression, open airway nasal tubes. Either way, your surgeon is gonna select with you one of those two techniques to minimize bleeding. So the short term recovery is the removal of the packing technique. Once the packing technique is removed, you still may have a little obstruction because there’s a lot of swelling and edema inside the nasal mucosal; the lining of the nose.

Don’t be alarmed if you’re still a little obstructed, because it takes about 6 months or more for long term recovery, a long term healing which is the resolution of optimal airflow after Septoplasty, Turbinant and maybe internal valve surgery. By about three months, three to six months, the airflow you’re experiencing then will probably be the terminal airflow you can expect after your internal airway surgery, and that’s the long term recovery. Short term; minimizing the risk of bleeding. Long term; optimizing the recovery of airflow after your septoplasty surgery.

So what are the side effects, or the complications of septoplasty surgery? The number one side effect is you may do a septoplasty, or internal airway surgery with turbinents and valves, and you may still have obstruction. So residual or persistent obstruction. You may have a completely normal airway, with patent airflow, during reduction rhinoplasty and functional airway surgery, and have one side or the other that’s compromised. So new onset airway obstruction can occur after airway surgery, including septoplasty. There may be increased risk of minor nose bleeds during the winter months, because you have dry air and you have scar tissue not he septal lining, and it’s not as, it doesn’t make as much mucus. You may have the odd little nose bleed once or twice during the winter months, so have a humidifier in the room, minimize inhalation of dry air. There may also be some areas of pain or discomfort while you’re healing, and with septo-surgery it may actually have some change in smell, and the persistence of certain smells especially if there’s an area of dryness or crusting. You may have ongoing crusting, and nasal cleaning that you need to perform after septoplasty. That can also occur.

Those are the short and long term side effects, most consistently associated with septoplasty; the most common being some residual or re-occurent airway obstruction despite the septoplasty surgery.

Many surgeries do require some maintenance. Botox requires maintenance, soft tissue fillers require maintenance. Nose surgery, a good reduction nose job, is once ina lifetime. You get a good result, and it lasts. Same with septal surgery. If the septum is reduced, maintained in a stable fashion in the mid line of the nose, and you have good airway exchange, there’s not maintenance required for septal reduction surgery, or septoplasty.

If, however, you undergo a traumatic event; baseball to the nose, you slip and fall on the ice, and you break your nose or injure the septum, you may need secondary septal surgery. So care and intention to avoid trauma, clearly some trauma would be avoiding intra nasal chemicals such as cocaine, or other inhalational agents are very bad for your septal and your colas environment. So a properly performed septoplasty, with good airway outcome, is a lifetime of improvement and requires no specific maintenance.

What are some of the common combination treatments with septoplasty? Well we mentioned some of those. We can divide those into combination intra nasal surgeries, and so a good intra nasal rhinoplasty surgeon will look for your turbinents, side wall blockages, will look for functions valves such as the internal/external valve, the septum and it’s position in the mid line, and even post air nasal issues such as pollups, air cell issues, obstruction into the maxillary sinuses or blocked tear ducts. Other ansillery treatments that improve nasal function may be done at the same time as your airway surgery.

The most common adjunctive surgery is reduction rhinoplasty, or cosmetic rhinoplasty, in conjunction with a septoplasty. Then of course other cosmetic facial procedures such as upper lid, lower lid blepharoplasty, brow lift, mid face, face and neck lift, can be done at the same time as a septo-rhinoplasty, as can any body surgery be done. So adjunctive cosmetic surgery, and adjunctive airway surgery are the most common things that we combine with septoplasty procedures.

So cost in recover. Price of septoplasty varies depending on whether it’s private pay or manage care covered. Manage care coverage septoplasty is covered by a ministry of health in almost all provinces, and most states. If it’s private pay, septoplasty surgery itself can run between five and ten thousand dollars. In general, in most countries where there is manage care coverage of airway obstruction, the cosmetic nose surgeon will not charge the patient for the airway breathing or functional part of the surgery. So you’re paying for the cosmetic rhinoplasty, and you’d get the septoplasty functional valve surgery and turbinent surgery at no additional charge because it’s covered by the manage care plans. In general, five to ten thousand dollars for private pay septoplasty is not uncommon, and it’s done for functional reasons for the improvement of airflow. It can be done for cosmetic reasons, as a source of graft material, and preventative in reducing the nose, insuring open passage way after a smaller passage is created.

So thank you for joining me, Doctor Stephen Mulholland, here in Toronto Canada on plastic surgery talk with our latest podcast installment; septoplasty. How do we do it, and where does it fit in the scope of cosmetic rhinoplasty. Again, if you find these podcasts entertaining, informative, entertaining, please subscribe, share and comment. See yeah next time.

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Aug 16 2019

17mins

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PST 049: Learn about the Browlift

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Speaker 1:                           Welcome to Plastic Surgery Talk with Dr Stephen Mulholland, brought to you by SpaMedica.

Dr. Mulholland:                 Hello and welcome, Dr. Stephen Mulholland here in Toronto, Canada on Plastic Surgery Talk. Welcome to our latest installment of our podcast series. This podcast is on a brow lift, the modern approach to brow lift surgery. If you’re interested in these podcasts, you find them interesting or entertaining, please subscribe, share and comment.

So, what is a brow lift? A brow lift is a surgical repositioning of the eyebrows, such that it provides a more aesthetically pleasing upper facial, upper lid and brow unit. It can be subdivided into a full brow lift and repositioning, a tail of the brow repositioning, or even a central brow repositioning.

So, the modern approach to brow lift surgery has been limited access, subtle, to focus repositioning of the droopy or the ptotic, as it’s called. The ptotic meaning droopy elements of the brow that gives a more pleasing look to the eyebrow contour and accentuates the upper lid appearance.

So, how are brow lift performed? Well, it depends on the type of brow lift. Typical brow lift performed in a woman now is going to be a limited port incision. That means small access ports in the hair, so it’s hidden, no longer extending from ear-to-ear, like when I trained in the ’80s. The old bicoronal incisions typically aren’t done anymore, unless it’s a very, very heavy-browed, older patient, male or female.

Typically [means 00:01:36] unlimited access, small port access, undermining of the soft-tissue envelope, and then repositioning and fixation with high tech techniques, such as tying the middle fixation by absorbable screws or by absorbable constructs that hold the brow in place and then dissolve away, bioabsorbable suture suspension threads that hold the elevated brow up until the brow heals to itself, and then that focused elevation brow can be a longterm result.

Who’s a candidate for a brow lift procedure? Well, any patient, female or male, that has droopiness or heaviness of the brows, where the brow itself subtends or descends upon and over the orbital rim, and leads to a very excess folds of skin of the upper lid. It can be combined with or without an upper lid blepharoplasty or upper lid job.

And typically, we start with elevating the brows, and then see how much lid skin or excess flesh remains. And then, take away a little bit of the upper lid skin and tissue, and that’s called an upper lid blepharoplasty. It’s very common to perform those two in tandem.

So, a male or female candidate who are medically well, who don’t have any ocular pathology, such as dry eye syndrome, or lid closure abnormalities, or inflammatory conditions of the eye, or untreated and undiagnosed glaucoma, or macular degeneration. Any of the common medical conditions of the eye need to be treated first.

Most patients generally have to have reasonable expectations of what can be achieved. And typically, they need to have hair to hide even the very small, limited incisions, like the one or two centimeter incision ports we now use.

If a patient happens to be male and completely bald, we do have a brow lift that can be done through the upper lid incision, called a transblepharoplasty brow lift. And the transblepharoplasty brow lift, or TBB, is a nice elegant way to elevate a very hooded tail of the brow on a male patient.

So, the best candidates have reasonable expectations, reviewed the informed consent document for risk and benefits, don’t have any medical, uncontrolled medical conditions, and are willing to undergo a procedure that requires a good week of recovery.

Contraindications to a brow lift would be unrealistic expectations, uncontrolled medical conditions that negate the ability to do surgery. Periocular eye issues that are unresolved, such as medical eye conditions, poor eye closure, dry eye syndrome. These are the common contraindications to surgery.

Of course, a woman shouldn’t be pregnant, and should have no inflammatory conditions in the region of the surgery or undiagnosed lesions in the area of the surgery that haven’t been managed.

So, what are the specific steps of a brow lift? Well, typical brow lift, for a male and a female, is designed to selectively elevate the droopy elements of the brow. Typically, that will be the outer half or third, called the tail of the brow. Elevating that tail of the brow elevates some of the droopy elements of the upper eyelid and that can allow us to be a more limited incision, upper blepharoplasty.

So, we start with local anesthesia. Often, brow lifts are performed under local anesthesia, with some light oral sedation. The subcutaneous envelope of the skin is elevated off the bony aspects and the deep muscle of the brow, and that can be done in several manners and techniques.

Bits of excess brow in the hairline can be excised, and then fixation and stabilization can be occurring through very, very small ports. I typically use a barbed by absorbable sutures to support the brow while it’s healing, then it heals to itself.

And typically, patients need to have their brow wrapped and protected for about five to seven days, so typically, about one week off work until they’re back into makeup.

And again, it is very, very common to combine a brow lift, in a male and female, with an upper lid blepharoplasty. So, we elevate the brow to increase the distance between the eyebrow and the eyelashes, and then remove the unwanted, extra flesh that exists between the eyebrow and eyelash. And that’s called the blepharoplasty.

What’s the recovery from a typical, minimal access, modern brow lift? Typically, about seven days. There’s a little bit of swelling and bruising in the eye area, but typically, that will resolve very quickly. It’s not very painful because a limited access ports and undermining, there’s no numbness in the scalp, no prolonged sensitivity to the scars.

Typically, there’s very little, if any, hair loss, or [to loss fluid 00:00:05:54] or shock hair around the elevation. And patients can look quite good in makeup at one week. It takes up to six weeks for stabilization and elevation to heal, and about three months for the bioabsorbable fixation systems, the tiny little endotines or the bioabsorbable sutures, to go away, and the brow is held together by its own inherent autogenous lifting and wound healing capabilities.

Patients described the postoperative pain as modest. Let’s say, aesthetic surgery could be an eight or nine out of ten with a tummy tuck with muscle work or under the muscle breast augmentation. Brow lifts are typically described as a level one or two out of ten pain, so very tolerable.

Typically, anti-inflammatory medications, all that is required. Occasionally, there will be a drain left under more extensive elevation of the brow, but typically, tail of the brow lifts do not require a drain, and they wear a wrap for a couple of days, that’s removed.

And patient sutures, if they do an upper lid blepharoplasty, come out on day six or seven. The little sutures, the tiny ones inside the hairline, are removed within that one week period, and most patients are back to work on the eighth to the tenth day.

What kind of results can a patient expect from a brow lift? Well, typically, the results are customized to the needs of the patient. Is it a full brow elevation? Is it the middle part? Is it the tail of brows? Or the middle and the tail?

So, we customize the anatomic locations are going to be elevate. We customize the limited incision approach to the access. We customize how many millimeters the tail of the brow actually needs to be elevated, but patients can expect a customized, individualized approach to their elevation.

The brow elevation needs to be pleasing, but not over done. You don’t want to look like a scared, startled deer in a headlight. So, a subtle to modest elevation, anywhere between three and six millimeters of brow elevation is typical.

And then, we assess how much upper lid skin exists after the brow’s been reposition, and that is also customized in how much is excised, whether the fat pads are removed, the extent of the incision and the placement of the incisions.

So, I think patients in nowadays, modern brow lift surgery can expect a very customized, modest to pleasing elevation of the brow with customized eyelid contouring and upper blepharoplasty. And the whole effect should be creating a much more youthful, fresh, rested, non-tired look to the periocular eyebrow and eyelid anatomy.

So, how long will your brow lift last and what is the cost? Typically, a brow lift will last five to seven years. With constant pulling down effects of the muscles of facial depression in the brow, particularly the depressors, with ongoing gravity and age, it’s very important that the brow lift patient commit in concept to the idea of doing Botox, to help protect their brow lift.

The Botox will soften the muscles that pull their brow down, allowing the elevators to exert their effect tonically without competition and will make your brow lift last eight to ten years, by simply doing a simple, periocular, post brow lift, depressor muscle, Botox treatments after your brow lift surgery.

The cost of a brow lift is really relative to the amount of elevation, whether you’re doing an upper lid blepharoplasty, it depends on the market and the surgeon. But, typically in North America, most brow lifts are anywhere between six and twelve thousand dollars.

The upper lid blepharoplasty might be another between four and eight thousand dollars extra. So, combination, brow lift, upper lid blepharoplasty, can cost anywhere from seven or eight to fifteen, sixteen thousand dollars, depending on how much elevation needs to be done, the surgeon’s reputation, the market you live in and the kind of aging change that you’re presenting with.

So, what are common combination procedures done at the same time as a brow lift? Brow lift, upper lid blepharoplasty, for sure. Brow lift, upper and lower lid blepharoplasty. Brow lift with a cheek lift or a mid face lift. Brow lift with neck work. Brow lift with lip augmentation.

Virtually, brow lift with any facial procedures, including facial resurfacing for wrinkle reduction, can be a good combination approach. And so, quite often, you’ll go through the areas that concern you, the upper third, brow, upper lid; the middle third, lower lid, cheek; the lower third, jaw line and neck. And then, decide what combination treatments, renovate the whole home or just do the top floor, makes sense to you.

Are there any brow lift of complications that consumers, potential patients need to think about? Well, there are and you need to think about damage to the facial nerve. The nerve that serves the elevator muscle of the brow. Very uncommon to have that injured. I think I’ve had one or two temporary brow weaknesses from muscle stretching that always return, but there’s the risk of injury to the facial nerve to the brow.

There’s a risk of over elevation, looking startle. There’re risk of under elevation, being too subtle. There’s the risk of a scar in the brow, which is small, usually one or two centimeters in length, leading to lack of hair growth in that area and what’s called traumatic alopecia, or hair loss around the scar, that may necessitate PRP, platelet rich plasma, or even inherit transplantation around that area of hair loss within the scar.

There is the risk of sensory loss, even those limited incision, sometimes a nerve, sensory nerve, can be injured and it doesn’t return to full functioning, of an area of numbness, or irritation, or itching or even pain, in the scalp.

The biggest risk is suddenly asymmetries, that one side doesn’t look quite like the other. So, discussing the relative merits of differential elevation depending on the height of each uni brow is a very important part of your preoperative evaluation, with you and your brow lift surgeon.

So, thank you again for joining me on our weekly podcast series. Dr. Stephen Mulholland here in Toronto, Canada on Plastic Surgery Talk. Our podcast this week was on brow lift, a modern approach to brow lift surgery. If you found this informative, entertaining, engaging, please share, subscribe and comment. See ya next time.

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Aug 09 2019

11mins

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PST 048: All About BIA-ALCL

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BIA, breast implant associated. ALCL, anaplastic large cell lymphoma.

And so there’s a real association between textured implants, a rough shell of an implant, be it saline textured or cohesive gel textured. A rough surface of the implant is advantageous for tissue and growth to minimize migration of the implant after breast reconstruction or a whole, let’s say, shaped anatomic teardrop in place.

The problem is it leads a chronic inflammation, a low grade inflammation and you have immune cells constantly going after this rough texture. And many of these immune cells are lymphocytes. And a certain percentage of patients, somewhere between one in 4,000 and one in 30,000 will develop an aggregation of aggressively infiltrating proliferative lymphocytes, called a lymphoma.

Now, there’s different types of lymphoma. There’s the blood lymphomas like Hodgkin’s, non-Hodgkin’s where you need chemotherapy and there’s a very high mortality rate in some of those processes. This is not that kind of lymphoma. This is a locally invasive, proliferative aggregation of lymphocytes that are abnormal, or a lymphoma that’s locally invasive and requires surgical removal. The treatment is not radiation, not chemotherapy, but surgical removal. Removal of the implant and removal of the capsular tissue around it.

Now, the incidence of this is about one in 30,000, and it only affects textured implants. So if you have smooth shelled implant, you have zero risk of BIA ALCL. In my practice here at SpaMedica, I have only used smooth implants for the last decade. Only smooth implants, never textured. So for the past 10 years, any SpaMedica Dr. Mulholland patient does not have to worry about advanced, anaplastic, large cell lymphoma because I use only smooth implants, never textured.

In the era of the 90s and the early part of the last millennium, 2002 to 2007 or eight, when textured implants were an issue, there is about a one in 30,000 chance that you may develop BIA ALCL. How do you know you’ve developed it? Almost always there’s a sudden change in symptoms. Your implant gets hard and swollen, red and inflamed. You develop a capsular contracture, usually this comes on between eight and 14 years. You may get sudden pain and discomfort, redness and inflammation. Any of these symptoms should trigger a visit to your plastic surgeon’s office.

We might do some imaging, like an MRI, but clinically, on clinical diagnose of any of those type of symptoms, the treatment is removal of the implant and removal of the capsule and unblock resection, the entire capsule and the implant. And either leave it with nothing, or do immediate re-implantation with a smooth shell device, a smooth shell cohesive gel, or a smooth shell saline.

Again, smooth shell, smooth wall devices, zero risk of BIA ALCL is the anaplastic large cell lymphoma, locally invasive proliferative reaction around a textured implant. Is that fatal? If you do not get it treated and you let it to continue to progress, continue to proliferate, eventually, some of those cells will start to break off and travel to other organs and you will potentially succumb to a metastatic version of this aggressive locally invasive BIA ALCL. But treated promptly and early with removal of the implant and the capsule, curable.

So, if you are exploring Dr. Mulholland at SpaMedica for your breast implant surgery, rest assured you are not going to get a textured implant. For 10 years I’ve used nothing but smooth shell. And there’s absolutely no risk to smooth shell implants. If you’re a patient of mine and you had surgery done in the 90s or the early part of this last millennium and you have absolutely no symptoms, then the recommendation is generally, leave your implants alone.

If you’re worried about developing something like this in the future and you want to remove our implants, it needs to be a total capsulectomy and removal of the implant with re-implantation of a smooth device. However, to go through that kind of extensive surgery if you have no symptoms, no hardening, no seroma, no swelling and to put yourself through that kind of risk? The recommendation is generally, if your implants are textured and they have absolutely no symptoms, we leave them alone.

Remember, the one thing you should be worried about is not BIA ALCL, be cognizant, do your ultrasound screening every year for implant integrity, and that’s what we recommend. Ultrasound your breasts every year. But you really need to worry about breast cancer. Remember, BIA ALCL, one in 30,000. Breast cancer, one in eight. One in eight. One in eight women will get breast cancer in Ontario. And these one in eight women are not thinking of doing preventative mastectomies, or removing their breasts because of a one in eight risk of cancer. A one in 30,000, when you have no symptoms should not concern you, other than, touch base with your surgeon, make sure you’re doing your yearly ultrasound screening. And if you develop any of those symptoms, get your implants removed with the capsules quickly, because that’s cured.

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Jul 30 2019

16mins

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PST 047: Painless Laser Tattoo Removal

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Welcome to Plastic Surgery Talk with Dr. Steven Mulholland brought to you by SpaMedica.

Hello and welcome. Dr. Steven Mulholland here in Toronto, Canada on Plastic Surgery Talk with the latest installment of our podcast series. If you’re finding these podcasts informative, educational, entertaining please sign up, comment and share. Our topic today’s on painless laser tattoo removal. So, why have a talk on painless? Well, clearly we have a whole topic, a whole podcast on painless because the act of laser tattoo removal can be quite uncomfortable. So what happens during laser tattoo removal? We have specialized lasers. Here at SpaMedica, we have a rev light, we have an accolade, we have an infinity, we have a PicoSure, we have a PicoWay, we have five different wavelengths of five different devices. And multiple different wavelengths. All in a very, very short pulsteration called a Pico which is a billion times shorter than a blink of an eye. A trillionth of a second. And having such a short pulsteration means that there’s very little thermal effect. When that laser beam hits the tattoo ink, impregnating your dermas, it shatters the ink into trillionths of little particles. Little grains of sand that your body can remove through it’s own immune system.

And so, even though there’s very little heat built up which is good. That’s one of the secrets of the Pico. Short pulsteration. A photo acoustic effect on the tattooing, shatter it into bite size morsels, so your immune cells come along like little pac-men and gobble up those tattoo particles and take them away to your liver and to the urinary tract where it’s eliminated. Because there’s very little thermal build up unlike earlier generation tattoo lasers, it doesn’t cause a hypopigmentation or as much ghosting as earlier tattoo lasers did. The earlier tattoo generations even I had those back 15 years ago. They cause a lot of hypopigmentation as well as tattoo removal.

The Pico. The PicoSure, PicoWay, the state-of-the-art Pico second pulsteration lasers. They avoid a lot of thermal trauma to the melanin pigment form of cells and shatter the ink particles through photo acoustic, not a heating effect. Now the pain in tattoo removal comes from that shattering effect. When the photon from the laser hits your skin, you hear a pew! An explosion. A photo-acoustic effect, and it shatters the ink part into millions and millions of particles. And for a Pico second, those particles are moving and breaking up and traveling through the skin in what’s called the dermas. And such high-velocity shatter effect or photo-acoustic effect is quite a potent stimulus in the sensory nerve ending. So the shattering of the pigment traumatizes or mechanically stimulates the nerve fibers and it hurts. It hurts because of the photo-acoustic shattering effect of the ink, not from the heat.

And so, it can hurt. In fact, it hurts far more to get the tattoo off than the pain of having a tattoo inserted. So, the challenge on the topic of the webinar. What do we do to give a laser tattoo removal patient a painless experience? So how do we render a painful laser tattoo removal experience painless? Well, multi-modal approach to controlling the pain fibers. So here at SpaMedica, a lot of the doctors out there that have been trained by me or come to my workshops or been on this podcast know that there’s no one thing that’s going to completely eliminate pain, but a multi-modal approach together with an inhalational agent can almost eliminate pain. So one of the ways we take down the pain and discomfort, like all clinics do, is topical anesthetic cream. So we might use some topical benzocaine, lidocaine, tetracaine, topical maxilene, topical five percent lidocaine. A topical anesthetic cream takes some of the sting away; however, it doesn’t penetrate deep enough to take the pain away from the shattered ink particles completely.

So topical anesthetic cream, we use for many years is one modality to reduce the pain, but we need something more than that and so another option is a chilling device. Like the Zimmer five or Zimmer six to force cold air on the skin definitely helps take down the pain when used in combination with a topical anesthetic cream. I would say 50 percent reduction discomfort, but that’s still not good enough. What else do we do? Well, for large tattoos, one’s that are bigger than the size of the palm of your hand. Let’s say a medium size of your hand or bigger, like part of a sleeve. We used something more than a topical and a chiller. And we use very dilute intra-lesional or injected into the skin, lidocaine. We actually inject the anesthetic agent like a dentist would if you’re getting a root canal or a wisdom tooth out. We freeze the skin which takes all the pain away.

So great all we need to do is injectable lidocaine and injectable local anesthesia. The problem is the injection of the lidocaine can hurt a lot. And so, what do we do ultimately to make the whole experience very, very comfortable? We give patients nitrous oxide. Good old fashion laughing gas. It’s been around in the dental offices for 40 years. Now, finally, we have both Health Canada and FDA- approval for a 50 percent medical outpatient clinic treatment. At 50 percent nitrous oxide, you’re legally able to drive in eight to 10 minutes after it’s used. So how do we make this a painless experience? We combine multi-modal options particularly intra-injection, intra tattoo injection of lidocaine. But under the influence of nitrous oxide. So how does nitrous oxide actually work? Well nitrous oxide is a gas. We have 90 percent nitrogen in the atmosphere, so 91 percent oxygen and carbon dioxide. But when we administer medical nitrous oxide, it’s at 50 percent, so 50 percent nitrous oxide, 50 percent oxygen. 50 percent nitrous oxide, and there’s several brands. The most commonly used brand in North America is called Pro-Nox from CAREStream.

So Pro-Nox the most commonly used product. Very simple to use, on wheels, you can take it from room to room, little tank of oxygen, little tank of nitrous oxide mixed together in a simple inhalational obturator in tubing. So the patient inhales six, seven, eight deep breaths. Within a minute, the start to have that nitrous oxide effect. So what does nitrous oxide do? The inhalational agent held for a couple of seconds, six to eight breaths, releases a tremendous amount of intracortical, or intercranial neurotransmitters of well-being. The endorphins called dopamine and serotonin. These neurotransmitters give you an overwhelming since of euphoria or happiness. And so you can feel the injection of the tattoo or the soft tissue fillers, like Juvederm, Restylane, or Botox or laser hair removal. We use it for many different things. You can feel the laser tattoo removal freezing going on, or the tattoo removal itself. But your brain appears so full of euphoria you separate your brain from the painful experience going on in your hypothalamus. Your hypothalamus which registers the pain goes, “That hurts, that hurts.” And your brain goes, “Ah, I don’t care. I’m feeling great. I’m euphoric.”

And so, nitrous oxide or laughing gas doesn’t leave you stoned in the sense of let’s say, medical marijuana would; an altered consciousness. It leaves you very acute and aware but distanced. Almost separated. An out of pain experience what I call fun pain. You know what’s going on, but you don’t care. Very, very fun feeling. In fact, many patients start giggling hence the term laughing gas. So it’s patient administered. Patient’s hanging on to the obturator in tube and it’s spiraling out of the 50/50 mixture of nitrous and oxygen while the technician or the doctor’s injecting, lasing, and treating. And patients find this a tremendously fun and pain diminishing, almost eliminating type of experience. And it’s been such an important object to my aesthetic practice. I would say it’s the single most important technology I brought into my practice in the last three years. It has made so much more money through retention and referral than you can imagine. And as we’ll see later in this podcast, I think it’s one of the most important decisions you might make in 2019 is to bring, if you’re a doctor listening to this podcast, bring nitrous oxide or Pro-Nox in your practice.

If you’re a patient, go to those practices that’s going to give you a great experience. Fun pain with the use of laughing gas. So what’s the big deal? How painful is laser tattoo removal? I mean, it’s got to hurt more to get the tattoo on, right? Wrong. It’s actually far more painful to get the tattoo off. So most patients say they had their tattoo removal and it was tolerable, maybe a four our of 10. But they describe tattoo removal, even with the Pico second pulsteration, PicoSure, PicoWay, that tattoo removal, using a laser can be upwards of eight or nine out of 10 on pain. So it’s one of the more painful laser treatments we inflict on patients. Laser hair removal, laser CO2 resurfacing, laser fractional or resurfacing, laser hair removal, or mirror dry, sweating. These are some of the more painful treatments and anytime we can reduce that pain, and it makes the patient experience more rewarding, less distressful, certainly less painful. We’re going to get a patient who’s going to say good things about us, tell their friends, and come back for more treatments.

Okay, so if laser tattoo removal is going to give you an eight out of 10 pain, which is significant. How effective is Pro-Nox? How effective is nitrous oxide? How effective is laughing gas reducing that? Well, if you ask patients to give you a score out of 10 after they’ve used laughing gas after laser tattoo removal or Botox or soft tissue fillers or laser hair removal. Any of the painful things we do, laser CO2 resurfacing. They will tell you after laser tattoo removal, that pain went from and eight out of 10 down to about a one or a two. So significant reduction. Massive reduction. The perception, the experience, and the processing of that painful stimuli, the patient know it’s there, but the euphoria that washes over their brain by the release of dopamine and serotonin.

With the laughing gas. The Pro-Nox. The nitrous oxide. Eliminates virtually all the pain down to a minimal amount of discomfort that patients basically corticate and evaluate as being insignificant compared to treatments they might have had without laughing gas and nitrous oxide. So a massive reduction of pain making the whole process a desirable and a fun kind of pain that patients are not going to be afraid of coming back for their second, third, fourth, fifth, and sixth treatment. So if it really hurts the first time, the chance of getting them back excited about the second time is diminished. They may not show up because you didn’t take care of the pain. Laughing gas, nitrous oxide helps your attention rate because it eliminates virtually all the pain.

So what are the timelines like? The timeline to starting the inhalational, when you have the pain reduction and relief, and then how long does that pain relief last? In general, when you’ve had a full inspirational eight or nine breaths, you’re going to get a good three, four, five minutes of pain relief. So a lot of patients will take a minute or two of inhalational deep breaths while we’re doing a treatment like laser tattoo removal, and then they might remove the obturator from their mouth and breathe normal room air. When it starts to get painful again, they might again takes some inspired nitrous oxide or laughing gas to again enhance and build up the levels of serotonin and dopamine again.

How long will that last? Generally, about 10 minutes of pain relief when you stopped inspiring. And so, patients can actually do a whole 15, 20, 30 minute procedure simply by taking several deep breaths in a row, waiting, breathing room air, then taking some more when it starts to get more painful. So they can titrate the laughing gas to the needs of their discomfort and have perpetual pain reduction for half an hour, 45 minutes or and hour depending on the length of the laser tattoo removal procedure.

What are the side effects of nitrous oxide? There are very, very few risks. I mean, it’s present in the atmosphere that you breathe in at 90 percent. At 50 percent, very few risks. If you had full minute advanced liver failure, insufficiencies to your kidney failure or significant or unstable heart disease or angina. Clearly, you’re not going to be using nitrous oxide and most commonly you’re not going to be presenting to a cosmetic plastic surgeon, dermatologist, or SpaMedica getting this treatment, so it’s for well medical patients. If you’ve got a well medical body, then nitrous oxide completely tolerable. There are some side-effects in about five percent of patients after some deep inspirations and a great laughing gas effect, they might feel a little light headed. You might feel sometimes a little bit sweaty or even a vague sense of nausea and sometimes even a headache can occur from the nitrous oxide, but 95 percent of the time there are no symptoms like that.

The symptoms of light-headedness, vague sense of nausea, maybe a headache goes away in about five to 10 minutes if you do get those symptoms. So 95 percent of the time, no side effects, no medical contraindications making it one of the best pain relief reduction options I’ve got in my practice.

So who’s a candidate for nitrous oxide, laughing gas, or Pro-Nox? The best candidates for laughing gas are those patients undergoing an outpatient medical treatment that is painful, so medically well. And they’re undergoing a painful laser treatment, like laser tattoo removal, laser hair removal, injectables. Nitrous oxide, laughing gas is great for Botox and soft tissue fillers. Particularly the soft tissue fillers that feel quite uncomfortable. It’s a great treatment for those patients undergoing, let’s say, local anesthetic infiltration. You’re doing some liposuction under local and you want to put the freezing into the fat. It’s great to take the pain away from the freezing, once you’re frozen, you don’t feel the pain of the treatment. So it’s great to provide pain relief while you’re making an area very numb or frozen.

It is great to use during, let’s say, after surgical treatments like removal of staples and sutures in sensitive areas like blepharoplasty eyelid or sensitive areas in the breast or the labial region or abdominal area. Removal of staples and sutures, it’s great for that. There’s so many little applications for nitrous oxide in your practice that you’ll find that if you’re like me, patients seek me out because they know they’re coming to get a great treatment from a great physician who has great nurses, as well. And they’re going to be treated well, and they’re going to get laughing gas or nitrous oxide to make their clinical experience no matter if it’s injectable, laser, post-op care, or intraoperative infiltration of local anesthesia. The laughing gas is going to take 80 percent of the discomfort plus away.

So what should you be looking for in a clinic when getting a treatment you know after your online review you know to be painful? Once you’ve done your Google searches, you look for the top treatment centers in you city. Google and my problem or the type of laser, the type of clinical treatment you want. Botox, my city. Or soft tissue fillers, my city. Or laser tattoo removal, or PicoSure tattoo removal, my city. Come up with the top practices. And if Google has ranked them relevantly in the top one, two, three, or four, they’re going to be the best in that city.

Now what else should you look for? You should be looking for the practice itself. What kind of lasers they use? How long have they been doing it? What’s the experience of the lead physician and his delegees? What kind of experience in terms of pain reduction they’re going to offer you? If you want the painless, current state-of-the-art 2019 going for painless reduction of laser treatment such as laser tattoo removal, you want to see practices that offers you not just topical anesthetic cream, not just an air chiller, not just a local anesthesia, but nitrous oxide, laughing gas.

Laughing gas with the integrated aforementioned techniques and the painful laser treatment like tattoo removal will take you from an eight out of 10 down to a one. Making the pain fun pain. The kind of pain you don’t mind coming back for. The kind of discomfort aesthetically acceptable discomfort that leaves you thinking, “Okay. I can do a series of treatments and I actually enjoyed this. I’m looking forward to coming back.” And that’s the kind of practice you’re looking for. The practices committed to pain reduction of it’s customers, clients, and patients. And nitrous oxide is going to be an extremely important part of that decision and you go forth in 2019 and 20. The best practices are going to have laughing gas.

So thank you for joining me here. Dr. Steven Mulholland in Toronto, Canada on Plastic Surgery Talk. Where our podcast today was on painless laser tattoo removal using laughing gas or nitrous oxide. If you found this podcast entertaining, informative, and educational please share it, sign up and comment.

The post PST 047: Painless Laser Tattoo Removal appeared first on SpaMedica.

Jul 22 2019

17mins

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PST 046: Painless Laser Hair Removal

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Welcome to Plastic Surgery Talk with Dr Steven Mulholland, brought to you by SpaMedica. Hello and welcome Dr Steven Mulholland in Toronto, Canada. And we’re at our weekly podcast on Plastic Surgery Talk. This week is on laser hair removal and it’s one of the most common requested laser procedures. In fact, after doing this now for 20 years, laser hair removal still remains in one of the top four or five treatments we do in the medical spa and it still is associated with significant discomfort. Huge benefits, smoothless, shimmery, silken hair-free skin, but there are some discomfort in getting that laser energy into the skin. So this week’s podcast, like similar podcasts in the past, is how to achieve painless laser hair removal. If find these podcasts entertaining, engaging, educational, informative, please subscribe, share and comment.

First and foremost, how does laser hair removal work and why is there a discomfort or pain associated with it? Laser hair removal involves the use of a laser, a medical device, an energy emitting device that pumps out little bundles of the energy, electromagnetic energy called laser or photons. These photons are bundles of light that travel like a sound wave in a wave pattern. And when they hit the skin, they’re looking for a target. And so the target that laser hair removal is looking for is melanin or pigment forming cells, not the melanin and pigment forming cells we see on the surface of the skin, although we’re going to be cautious in treating that, but the melanin down the hair shaft.

So it heats up the hair shaft, creates heat that radiates out to the growth centers and kills the growth centers. Now in exchanging the heat with the hair shaft, it photo-coagulates the hair shaft. So if you’ve had laser hair removal, you smell that smell, that faint smell of singed hair. That’s the photo-coagulation of the shaft that then sends the heat out to the growth centers, and the heat acts as a suicide bomb, a suicide bomb of thermal energy for the growth center. So it kills the growth centers dead. But in creating that heat, the heat can create some collateral discomfort or pain.

And so we do several things to reduce the pain or perception of pain during laser hair removal. Number one, we have dynamic cooling systems. The best laser hair removal lasers are super fast. They often slide on the skin. They cool the skin as they go, which reduces the discomfort. Often they pre cool, cool during the pulse and post-cool. We also can use topical numbing cream to numb the sensory nerve fibers that are getting heated during the interaction of that photon in the skin. There’s cold air systems. We can hold cold air that blows on the skin and numbs the nerve endings, sort of like on a cold winter day, your face can feel numb. We use that same principle to minimize the discomfort during laser hair removal.

We can use the cryogen spray that hits a skin and numbs the skin just before the laser pulse. But what I found the most effective in addition to any one of those number of topical techniques is the use of nitrous oxide or laughing gas. The use of laughing gas or nitrous oxide can take a discomforting feeling like laser hair removal and make it fun pain, converting the pain that you actually dissociate from and find the whole experience euphoric and full of happiness. Not only for the outcome, but that sensation of discomfort is modulated.

So what is the severity of discomfort or pain during Laser hair removal? What’s the pain score? If 10 is the most painful thing you ever do an aesthetic medicine or treatment sort of waxing or having sort of a tummy tuck or something that works on your muscle, those are an eight, nine or 10 out of pain. No pain would be something like a microdermabrasion or a gentle bulky radio-frequency treatment like the form or the Venus. Laser hair removal, depending on your pain tolerance is somewhere in between this. It’s about a five or a six. Some sensitive areas like a guy’s back may be seven or eight out of 10 in pain.

So it’s moderate in discomfort to moderate to strong. And so anything we can do to decrease or modulate that sense of discomfort during laser hair removal makes it way more tolerable for the patient. And for the physician practice it’s going to facilitate more referrals, more patients that are compliant with returning for their multiple treatments because it’s often five to six treatments once every six or more weeks to get 75 to 80% reduction. So you’ve got your patients coming back up to five or six times. You want to make sure it’s a comfortable experience.

So how does nitrous oxide or laughing gas work to reduce or eliminate the pain and discomfort of laser hair removal? Well, first what is nitrous oxide? It is laughing gas. The atmosphere, what we breathe in every day has about 9% nitrogen. This is 50% nitrous oxide, NO2. And it’s 50% pure oxygen. So when you have that concentration of inspire laughing gas or nitrous oxide, there’s a sudden release of serotonin and dopamine, the two neurotransmitters of euphoria. They are the neurotransmitters released when you exercise and you work out. They’re like our endorphins and they swamp our brain with great feelings of wellness and wellbeing and euphoria. So even though the treatments being done, the lasers being fired, we’re singeing the hair, we’re killing the growth centers, your pain is processed in the center in your brain called the hypothalamus and your hypothalamus is going this hurts, this hurts. But your brain, which is above the hypothalamus, it’s euphoric and it looks at that pain center and it says I don’t care.

So sort of dissociate you from the discomfort. And it’s not that you alter your consciousness, it’s not like you are feeling stoned as if you had a narcotic substance or if you’re in Canada, a non-narcotic substance like marijuana. It doesn’t alter your perception of reality. It distances your brain in its reality from the pain. And so it’s like pain that you don’t care about. Kind of fun pain. And so this rush of endorphins or euphoria happens in about seven or eight breaths. And then once you’ve stopped having your laser hair removal, you stopped using the nitrous oxide that washes out, you’re back to normal in about eight minutes. So 10 minutes later, you can legally drive. How much does it reduce the pain? It can take a six or seven, eight out of 10 laser hair removal pain and make it a one, virtually eliminating it.

So what is the temporal sequence? What’s the flow when you come into Spa Medica or another laser hair removal center that uses laughing gas or nitrous oxide, Pro-Nox or nitrox? So you’ll come in, you check in, you’re having your treatment that day. We disrobe, we make sure you shave your hair area down to a stubble. We might put a little topical anesthetic cream on, but generally we don’t need help from anesthetic cream when using Pro-Nox or nitrous oxide. And then the treatment begins. We start with six to eight deep breaths of nitrous oxide. Hold it for about three seconds, allowing it to fill your lungs, get into the capillary membranes and the bloodstream of your lung. That takes it right to your brain and boom releases all that good stuff. The dopamine and the serotonin, the sense of euphoria washes over you and then we begin the treatment.

Laser hair removal treatments now are super fast, whether they’re using high-speed diode like the Triton or the Dilaz or the Vectus or the Soprano or an Alexandrite YAG laser like the Gentle Max Pro. We can often do large zones like a full leg, half leg in 10 minutes or so. A whole back, a chest again in 10 to 15 minutes. We do have the topical sliding glide water cooled tips of the diodes, the eight 10 nanometer diodes, and often the cryogen spray of the Alexandra [inaudible 00:08:25] or the air chiller. In addition to our nitrogen oxides, we have a quick treatment. Patients can self administer the laughing gas during the treatment. They can take a minute or two break if they want or they can continue to breathe throughout the treatment.

In general, there’ll be the separation of euphoria and pain. Patients often are quite separated from the discomfort. They comment that they didn’t even feel it. They were aware of it, but they were distanced from it and it was a one out of 10 experienced for discomfort. Some say I don’t even call it discomfort. They actually had fun or it was pleasurable to have that euphoric sense for the period of time during the treatment. Then after the laser treatment, we clean off the ultrasound gel or whatever topical you may have on, we go through the laser hair removal post treatment instructions and you must wait about eight minutes before you can legally drive. And you come back again in your prescribed time, six, eight, 10 weeks later and do your next treatment again under the benefit of nitrous oxide.

The risks or side effects of using a nitrous oxide for laser hair removal or any other aesthetic treatment? Well, they’re divided into absolute contraindications. For example, a pregnant woman, someone who has respiratory disease or liver failure or primary organ decompensation, kidney failure. And then the relative contraindications, some unrealistic expectations for the treatment. Patients who are prone to nausea and vomiting or have had nausea or vomiting while getting nexus oxide during a dental procedure. Individuals that have contraindications for treatment of that technology in the treatment zone. So there’s relatively few contraindications. The number one contraindication is patient’s expectations for the treatment are unrealistic and therefore doing the treatment with or without nitrous oxide does not make any sense. Individuals who are prone to nausea and vomiting after anesthesia should be cautious when using nitrous oxide, but in general, super well tolerated, virtually no contraindications other than the rare circumstances we just listed.

And it becomes one of the most important elements of your aesthetic practice whether it’s injectables, whether it’s a laser like laser hair removal or radio frequency treatment, ablative treatments, pre freezing for surgery. You’ll find nitrous oxide insinuates and situates itself in your practice and very elemental important junctures, the interface of the pain and to patient, patient and pain. When you put nitrous oxide in between those two, the experience of the patient, the return visit frequency, the referral of other patients blossoms. So you really need to look at nitrous oxide as a method to grow your practice and have your patient experiences far superior.

So who’s a candidate for nitrous oxide or a Pro-Nox or Nitrox? Any patient undergoing a medical aesthetic treatment, whether it’s discomfort or pain involved that doesn’t have a contraindication and is willing to wait the eight to 10 minutes before driving a motor vehicle is absolutely a great candidate for nitrous oxide. I started out using nitrous oxide mainly to use during my local anesthetic face lifts and liposuction when I’m [inaudible 00:11:43] or freezing an area. And then I expanded to injectables like soft tissue fillers, Botox, painful laser treatments, virtually anywhere where there’s discomfort. Pro-Nox or nitrous oxide has become a big part of the practice. And so what’s an indication? A patient having a treatment that’s uncomfortable.

So what would the costs be to you, the patient or you the physician if your physicians watching this podcast? Well, first to the patient, most practices adopt one of two models. The first model is that the nitrous oxide is rolled into the price and there’s no additional costs. Then there’s the cost to the doctor. Cost to the doctor is the cost of the tubing, it’s often 15 to $17 US and the cost of the nitrous oxide, which is about I estimate about 10 to $15 every 10 minutes. And so $25 for the average cost of goods and services to the doctor. And if you have a high average selling price procedure like a face lift or liposuction or multiple fillers, mirror dry treatment, you might consider just rolling that into the price of the service.

If however you have a lower priced procedure, a small amount of botox or a one or two syringes of filler, you might pass that $25 to $70 US cost onto the patient as an additional benefit for bringing that euphoria, that disassociation in the discomfort from the treatment through the use of laughing gas onto the procedure price. And so you can layer it on the price. So you can charge per use. You can roll it into the price and and keep the costs hidden. Either way, it’s essentially you offer this to the patient. It’s affordable, and most patients when asked would you spend 25 or more dollars to have a painless aesthetic treatment like that? Most would say absolutely.

So what to look for in a laser hair removal practice if you’re a patient? Well, first of all, look for a clinic with experience. Many, many years doing laser hair removal. Now, if they’ve had a lot of experience like the Spa Medica, we’ve been doing laser hair removal for over 20 years. An experienced center like mine that’s successful is not going to have just one wavelength. You’re going to have multiple wavelengths. We have an eight 10 diode, two or three of them that we can use on light skin with dark hair and even brown skin and dark skin with dark hair. They’re going to often have an Alexandrite, a 755 nanometer Alexandrite laser, which is great for white skin and dark hair. You’re also going to need to have a long pulse YAG for the most part at 10 64 nanometer. A long pulse device that’s very safe on dark skin with dark hair. And so you’re gonna have options.

And if you’re a center like Spa Medica, you’ll even have a Triton, which is like the god of [inaudible 00:14:22] where you get all three wavelengths in one box. In fact, you get fusion of wavelengths. You can treat a light skin, dark haired patient with a 755 8-10 combo or Fusion wavelength where both the Alexandrite and the diode are hitting the skin simultaneously, optimizing permanent reduction of some hair follicles that might be sensitive to one wavelength, not the other, or these follicles sensitive to the diode and not the Alex. You get broader coverage, you get more terminal, thermal exchange with growth centers and you get after three treatments, upwards of 85% perimeter reduction. The best permanent hair reduction ever reported.

On the other side of the spectrum for darker skin, we can combine the 10-64 YAG along false YAG and the diode, and again after three treatments get 81% perimeter reduction of women of color, which is amazing because we often have to turn down the energy on skin types of color to minimize interacting the laser hair removal with the skin brown tones. And so look for multiple wavelengths. Look for a center with lots of experience, look for a beneficial pricing, look for great testimonial patients on rating and review sites like Google+, Facebook, Twitter, Instagram, Real Self and Radium DS, Yelp. Make sure that people are saying good things about this practice, particularly with their laser hair removal.

Check the colleges of physicians, of surgeons in Canada or the medical boards to make sure that there’s a licensed physician that looks after/owns the clinic and that has no medical legal actions successful against them, particularly in a hair removal. And then just go in for a consultation and make sure, hence the topic of today, they have adequate discomfort management, particularly the use of nitrous oxide, Pro-Nox or Nitro knocks to make your laser hair removal experience not only efficacious but comfortable.

So thank you for joining me, Dr. Stephen Mulholland here in Toronto, Canada on Plastic Surgery Talk. Our podcast today was on laser hair removal. Specifically, how is it done? What’s involved? What are the indications? Contraindications? What kind of outcome? We’ve never been this good at it. Three treatments, 85% perimeter reduction for patients with light skin, dark hair, and three treatments, 81% perimeter reduction if you have dark skin, dark hair. How do we make it comfortable? Nitrous oxide or laughing gas. Yet another indication for nitrous oxide in the experience, the optimized experience of an aesthetic patient, laser hair removal. So if this podcast was entertaining, was engaging, mostly and importantly informative, and you want to see more, please sign up, comment and share.

The post PST 046: Painless Laser Hair Removal appeared first on SpaMedica.

Jul 12 2019

17mins

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PST 045: PRP for Facial Rejuvenation

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Welcome to Plastic Surgery Talk with Dr. Stephen Mullholland, brought to you by Spa Medica.

Hello and welcome. Dr. Stephen Mulholland here in Toronto, Canada. You’re on Plastic Surgery Talk and we’re on our weekly podcast series. If you enjoy these podcasts, you find them educational or if you find them informative, fun, please subscribe, share and comment

So our podcast this week is on a very, very topical area of aesthetic medicine. It’s an area I’ve been doing for years, but has found sort of a place in the sexiest of what’s new and it’s called PRP. PRP is an acronym that we use for platelet rich plasma. We’ve been doing this for quite a long time, I think with social media and the Kardashians and the latest what’s new, the vampire lift got a lot of traction over the last year or two and the vampire lift is a specific way of using platelet rich plasma to create an enhanced aesthetic outcome nonsurgically.

So the topic today is PRP. There’s two kinds of ways we use PRP commonly. We use PRP for hair restoration and hair growth, and we use PRP for anti aging and rejuvenation. So we take a patient’s blood, a simple little venotomy, or like you’re donating blood. We take a small amount, a couple of of syringes, we spin down that blood and we extract from that blood the stem cells and the growth factors. When applied in specific fashions in ways during the aesthetic treatment, either for hair restoration or anti-aging wrinkle reduction, it can amplify and improve the results and the outcome. So as using your own body stem cells, body’s growth factors to improve the outcome of hair growth or anti-aging skin rejuvenation. So what is PRP in the context of facial rejuvenation? And so PRP is taking the patient’s blood, spinning it down in a centrifuge and getting a very sterile collection of stem cells and growth factors.

Unto themselves, if we applied this topically or injected under the skin, it actually does very little. We need to create an inflammatory stimulus. We need to do something to the skin for the growth factors and the stem cells to amplify their production of collagen, to thicken the skin to smooth and wrinkles. So what do we do? We usually will do some type of fractural injury to the skin. The most entry level, done by most medical and day spas is microneedling now onto itself microneedling, which is tiny little needles that oscillate vertically into the skin and create a fractional mechanical injury, this stimulates some mild inflammation. Through the little channels created by the microneedles, the topical PRP can soak into the skin, can get down to where we need new collagen to be produced. We can also inject the PRP under the skin with a microcanula technique to stimulate the deeper aspects of the skin, to lay down more collagen and elastin.

And so if we do a little microneedling as the injury, we can create a more amplified response and get more collagen, more elastin, and a better looking skin rejuvenation with the use of PRP. The most medical use of PRP is following a fractional thermal injury where we take more of a medical approach to fractional injury, fractional carbon dioxide resurfacing, fractional radio-frequency resurfacing, and the thermal ablation creates a significant rejuvenation on its own, whereas microneedling is not very significant improvement, but certainly easier to do and offered by many nonmedical day spas. The fractional CO2, the fractional radio frequency like Fractora, or Infini, or Intensive creates a tremendous thermal experience in the dermis. Again, a fractional injury. If we add topical PRP or inject PRP under the skin or both, we can amplify the collagen response by 20%. We can heal the fractional injury about 30 to 40% faster, and so this is a randomized, double blinded proven benefit of PRP.

We get a better collagen response, we get faster healing. When we add PRP topically or as an injection after creating an inflammatory fractional injury and the combined therapy of fractional CO2, fractional radio-frequency and PRP is the state of the art fractional rejuvenation that we could add to the patient’s experience. What’s the treatment protocol for PRP and skin rejuvenation? Well, quite simply we create a fractional injury in the skin. It can be microneedling or a more medical and more substantive fractional carbon dioxide resurfacing, fractional erbium resurfacing, infrared fractional or fractional RF needle like Fractora.

Once you’ve created the fractional entry, we’ve already drawn the blood and we spinned it down and we extract the elements we need from that blood. We want the fraction and elements that have the platelet rich stem cells and growth factors. Normally we can get about a five cc draw for skin rejuvenation and we do the fractional treatment under a topical anesthesia and laughing gas, so we just Pro-Nox or nitrous oxide to minimize the discomfort of both the fractional treatment and then the topical addition of PRP is painless, so we take usually about 20% of our PRP draw.

We put it on the skin slowly so it’s absorbed through the channels that we created with the fractional injury. Then we take the other four ccs in a very small micro canula, and we inject it directly into and under the dermis. We get a top layer PRP edition and a bottom layer, and the goal is to increase by 20% or more the amount of collagen you’re going to produce and to get the wound healed up to 30% faster by the use of PRP during a fractural injury technique fractionally surfacing in a combined therapy for anti-aging. So it’s going to give you the best acne scar reduction you can probably get, we’re going to get a fractional wrinkle reduction and smoothing, enhanced tightening and even conditions such as dyschromia or brown discoloration, Melasma are going to improve more significantly with the addition of PRP.

So what about pain and discomfort during PRP? Whether it’s PRP for hair restoration, whether it’s PRP for skin rejuvenation, we’re always cognizant to take pain and reduce it to aesthetically acceptable discomfort if not fun pain. And how do we do that? We use number of techniques, topical anesthetic cream. We can use an air chiller, we can have squeezy vibration devices that we grab. We can use a nonsteroidal antiinflammatory. However, the most effective tool that I’ve found over the past a couple of years to make this a fun experience is the use of nitrous oxide or laughing gas. And so we have a whole podcast on the use of laughing gas. The use of laughing gas takes what could be reasonably uncomfortable, both the draw and the application, whether it’s fractional or treatment in the hair and makes it fun pain, acceptable pain. So they use of laughing gas has rendered the the treatment of PRP for male pattern hair loss, female pattern hair loss, and even facial anti-aging if not a much more acceptable, even fun.

Are there any risks associated use of PRP either for hair restoration, male or female pattern hair loss or skin rejuvenation and anti-aging? The answer is very, very few risks which is why it’s so popular. There are risks associated with the treatment of anti-aging, fractional resurfacing for wrinkle reduction, but when you add the PRP either topically or with a small needle, there’s virtually no risk. There’s a small risk of a bruise at the site of the harvest that will go away. The PRP is done in a sterile technique within your physician’s office, so there’s no risk of contamination with another patient’s blood products. The topical application of PRP has essentially no risk to the user and generally we’ll leave it on the skin for about 30 minutes, clean it off before you leave so there’s no risk of other people around you with your topical blood burn products on your face. With the injection of PRP, there’s virtually no risk.

The biggest risk is your expectations exceed what can be done. Yes, the fractional technique or the hair restoration technique should result in a noticeable improvement. Either increase hair density or for rejuvenation, smoother, tighter, firmer wrinkle reduce skin. However, the results, like anything aesthetic medicine, may not quite meet your expectations. So the number one risk is your expectations exceed what the treatment can deliver. After that, there might be some localized bruising or swelling from the injection, but typically it’s one of the lowest risk treatments we have with a very big cost benefit reward, making it so popular.

Who are the best candidates for this in anti-aging therapy? Typically people who’ve got mild to moderate wrinkles or mild to moderate acne scars who have realistic expectations and who want the best amplified result after a fractional treatment. So whether it’s microdermabrasion at the very entry level of fractional invasiveness or fractional CO2, fractional radiofrequency, if you want to get the best possible result, PRP added to that is always going to give you about 20, 25% more collagen, more amplified tightening, and it’s going to be your best result. But again, realistic expectations, your wrinkles are not going to be 100% improved. You’re going to get a nice noticeable improvement and more amplification and more outcome by the simple addition of your own stem cells and growth factors through the application of PRP. Are there any contraindications to anti-aging? Not really, as long as you don’t have any blood coagulation abnormalities such as hemophilia, and we can draw blood and not have risk of ongoing bleeding, and the realistic expectations are really the only two criteria that are important in deciding whether you can do PRP.

If you’ve had a previous skin cancer in the area, that is not a contraindication. If you have an undiagnosed open lesion or sore, clearly that should be diagnosed before we even do the fractional and rejuvenation, let alone the PRP. And so healthy skin, realistic expectations, no bleeding disorder. Those are the best candidates and early aging realistic expectations for wrinkle reduction. Those are the best candidates for a PRP anti-aging therapy. There’s not much recovery associated with PRP in, let’s say, hair restoration or anti-aging wrinkle reduction. Not really. It’s one of the least invasive treatments we have for hair restoration because it’s injected into the scalp and the scalp generally has some hair, even minor bruising or swelling you get from the PRP is camouflaged immediately, so there may be a little bit of swelling that you might notice around the eyes around the temple in the first day or two after PRP, but essentially very, very little downtime.

Occasionally a patient will complain of a bruise that shows up above the eyebrow that drifted down from the scalp, but very, very unusual and you can always blame it on hitting your eyebrow on a car door or some other sort of secondary traumatic event. For anti-aging patients who are having a fractional injury, a fracture resurfacing the skin and the PRP, the downtime is not from the PRP. The downtime is from the fractional treatment, so you might have a little redness from your microneedling for a day or two, redness plus crusting or discharge if it’s fractional CO2 or fractional radiofrequency. Now the cool thing about PRP, it takes that one week of fractional downtime after anti-aging wrinkle reduction and it makes the downtime and the recovery faster. So PRP helps speed up the downtime, but the downtime from anti-aging PRP is the downtime of the fractional injury.

For hair restoration PRP, virtually no downtime. You can go right back to activities. What kind of results can I expect with anti-aging PRP skin rejuvenation? Well, the wrinkle reduction part, the majority of the wrinkle reduction efficacy is going to be related to technique. So let’s say you’re in your mid-fifties, early sixties. You’ve got really significant wrinkles. You’re going to get a very significant improvement with fractional CO2 or or more medical grade fractional RF like Fractora or Morpheus or fractional blade FRF techniques. So that’s where the majority of your wrinkle reduction is going to come. You’re going to get an extra 20% to 25% boost in the smoothening and tightening by the addition of the PRP, so you can expect an amplified improvement over the technique of fractional injury that you’ve purchased. By the same token, if you have significant wrinkles and you buy a microneedling package, you’re not going to expect a huge wrinkle reduction from that microneedling, and so the amplification from the PRP will be less impressive.

So the moral of the story is for anti-aging PRP, purchase the fractional injury technique, that’s the best for your concern, be it acne scars, be it wrinkle reduction, be a skin laxity, Melasma, dyschromia. Purchase the best fractional injury technique, and then have the PRP layered on top of that to get the 20, 25% amplification in healing time and neocollagenesis or collagen production and tightening. What kind of costs can you expect to see for PRP and skin rejuvenation and anti-aging? Well, it depends on the clinic. Typically, if you are purchasing a single treatment program, fractional CO2, a fractional RF, to get the best possible wrinkle reduction, you’re going to have a one-time purchase amplification of PRP. The one-time purchase amplification PRP typically runs between $500 and $900 depending on the clinic, so you have your base costs for your fractional injury technique and then an additional, let’s say, on average $750 to add PRP to get that 25% amplification and collagen and and recovery time.

Some clinics will will offer a series of PRP, similar to hair restoration for anti-aging and where you might buy a less aggressive fractional technique. You’re doing once a month for three months and each time you’re going to put some PRP on top of the skin and under the skin. In those scenarios, you’re typically paying about $500 to $750 each treatment, or you buy a three pack for roughly $1,600 to $1,900 in addition to the fractional injury technique that you’ve purchased or the base injury technique. And so for anti-aging, either single treatment application with more aggressive fractional injury, or if you’re buying a package, you buy a series of three treatments done each time you come in for your less aggressive fractional rejuvenation. So how to best use your PRP provider? Well, clinics like Spa Medica have been doing PRP for a long time, long before it was sexy.

A good clinic like spa medical will have multiple fractional injury techniques, so you can pick what injury technique for any aging more fits your facial rejuvenation programs. So you can do microneedling, you can do fractional infrared, you can fractional CO2, fractional erbium, fractional radiofrequency. You can tailor the fractional injury to your anti-aging needs. And then of course you can purchase PRP to be amplified on top of that. You want to make sure they’re using an industry standard PRP, there’s different manufacturers. You want to make sure Eclipse, or Arthrex, or Chroma, or Reagent is one of the well-known PRP devices out there. It’s been around for a long time, and that they’ve got a technician that’s licensed or certified or experienced in drawing the blood, handling the blood and topically applying or reinjecting the platelet rich plasma growth factors and stem cells.

Thank you for joining me, Dr Stephen Mulholland here in Toronto, Canada on Plastic Surgery Talk, another weekly installment on our podcast series. This one was on PRP and anti aging and rejuvenative medicine. If you found this podcast and our series of podcasts, in fact, entertaining, educational, informative, then please share, subscribe, and comment. See you next time.

The post PST 045: PRP for Facial Rejuvenation appeared first on SpaMedica.

Jul 05 2019

16mins

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PST 044: All About Liposuction

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Welcome to Plastic Surgery Talk with Dr. Steven Mulholland, brought to you by Spa Medica.

Hello, and welcome. Dr. Steven Mulholland here in Toronto, Canada on Plastic Surgery Talk. Welcome to our weekly podcast series. If you enjoy these podcasts, you find them entertaining, engaging, informational, please share, subscribe and comment.

Today’s podcast is on a very popular topic: liposuction. Liposuction is the number one surgical procedure, cosmetic surgical procedure performed in North America. Last year alone there was over one million liposuctions in North America. In fact it’s so common between men and women that now forms about 5% of all elective surgery is removing fat and contouring figures. So it’s very, very common.

Now, there has been a real evolution and a renaissance in liposuction from the crude, traumatic liposuction you saw back in the days of nip and tuck and Christian Troy, and it’s become a much more refined and sophisticated way to tighten skin and contour shape. So in this podcast today we’re going to analyze what are the new forms of liposuction? How are they performed? Who’s a good candidate and is it right for you?

So how do I know if lipo is the right choice for me? Well, first of all, the best liposuction candidates are those patients that have tried virtually everything on their own. They’ve tried diet and exercise, they’ve worked out, they’re fit, they’ve got a reasonable diet. They may have even tried non-surgical techniques, non-surgical liposuction techniques like Core Sculpting, SculpSure, BodyFX, Vanquish, Ultra Shape, [X-Less 00:01:53], Venus Freeze. These are a number of different non-surgical techniques that purport to kill small amounts of fat.

Once you’ve tried all those things, diet, exercise, technology and you still have annoying, excess, localized fat collections, you are probably then, if you’re medically well, a good candidate for liposuction. What are those annoying collections? They come often with cute, annoying names like the saddle bag for fat on the outer thigh, the trochanter saddle bag. The inner thigh, the bat wing or the arms, the abdomen or the pot, the love handles, the bra line, the double chin, the inner thigh and the inner knees. These are the most common liposuction areas on men and women. Guess for men also, the 50 year old [gynacomasture 00:02:41] male boobies.

So you’re a good candidate if you’ve got localized excess collections of subcutaneous fat, if you’re … tried diet and exercise, got to the best possible weight and fitness you can get at, you may have tried even non-surgical lipo techniques, and you want to do some localized contouring to make a difference in your measurements in centimeters. It’s not about weight. We’re not making difference in pounds. We’re making difference in shape, figure and form. Centimeters. Then you may, if you’re medically well and realistic, be a good candidate for liposuction.

So what is this modern approach to liposuction? What has the evolution been in the last 10 years? Well, it’s been the addition of energy to the fat just prior to the lipoaspiration or the removal. So one of the problems with lipo. You have a little pot or a double chin or an arm, and the fat has tented the skin and the skin is tight. You remove the fat, and the skin is orphaned of that fat support and it goes bleurgh and your skin just droops. So loose, saggy skin is the big enemy of lipocontouring of liposuction sometimes. So the big advance over the past 10 years has been initially the advent of internal ultrasound, which gently liquefies the fat and creates less bruising and less swelling and viable fat cells, but not a lot of tightening.

After Vaser in the mid part of the last millennium, 2005 and 6, we had internal laser, which is internal laser heat. The heat allowed a tightening, a degree of tightening of the skin up to 17, one seven, percent area contraction by doing laser lipolysis or smart lipo followed by suction contouring. So we heat the fat, get the skin tighter, and then remove the fat we want to give you optimal contour, and rely on the heat at the time of the laser to give contraction and shape.

The most modern advance over the past 10 years has been the transition from laser to radiofrequency and the internal probes of RF. The bipolar technique tightening the outside and the inside part of the skin is called BodyTite. BodyTite made by InMode mix a number of applicators. BodyTite for large body areas, NeckTite, FaceTite, AcuTite, LidTite. All different site, bi-polar radio frequency probes that coagulate and liquefy and heat the fat and tighten the skin simultaneous. The advance of BodyTite applicators has meant that we, as surgeons, can get up to 35% area contraction. Tremendous shrinkage without the need necessarily for tummy ticks or arm lifts or thigh lifts. Excisional surgery.

So BodyTite has become the king of the industry in terms of soft tissue tightening. Then at the end of that coagulation, which takes about 10 minutes per zone, we have to end up removing the fat like we always have. So liposculpting or lipocontouring happens after the BodyTite heating. I liken it with patients to having a raw hamburger patty sitting on the grill. It’s going to shrink right in front of your eyes over 10 minutes, significantly. Up to 25%. Same things happens with your subcutaneous tissue and your fat. It shrinks after we apply the heat, and the heat itself is applied in a very safe and monitored way so that the risk of a thermal injury or a burn is essentially minimized to next to zero.

So BodyTite has become the most advanced version of lipocoagulation and tightening. We do have Vaser still if you want to preserve fat cells and use that for fat grafting. Laser can still have its advantages in small areas, tiny areas where there’s less fat and less skin to tighten.

How to know which device? Vaser, smart lipo, BodyTite? Well, if you want basic aspiration removal of fat with the tightest possible contoured skin on the tummy, on the arm, on the double chin, on the chest, on the inner thigh, on the bra line, after you remove the fat, make sure you use BodyTite because it contracts and tightens the best. When might you use Vaser? Well, Vaser and I have all three devices.

Vaser can be used when you want to preserve the fat. So let’s say you want to take a little bit of fat before you remove it. Don’t damage it with a hot laser or a hot BodyTite, but you want to save that fat, spin it down and reinject it for better coaugmentation like the Brazilian butt lift or fat grafting to the [inaudible 00:06:59] of the face. Then you use a low energy, gentle system like Vaser to cause a discohesion or separation of the fat cells, remove the fat cells, purify them, spin them down, wash them, whatever preparation techniques the doctor uses, and then reinject them. That’s where Vaser’s big niche is.

Laser, not as powerful nor as fast not as effective as BodyTite, but good for tiny little areas like small like areas of the inner thigh or the upper arm. So if you still have a laser system, you can still use them on small areas. BodyTite can be used on all areas where you use contraction. They have small applicators and large applicators. It just destroys the fat, so it’s not good for transplantation. So that gives you a sense of BodyTite, NeckTite, FaceTite, LidTite, when to use the BodyTite family. Vaser for fat grafting. Laser, if you still have one and you have small zones, it can provide a reasonable amount of contraction and tightening.

What is the cost difference between non-energy based liposuction and energy based? Energy-based liposuction means applying energy. Vaser, which is ultrasound, laser, which is smart lipo, or RF radio frequency, that’s BodyTite. Those are the three energy-based devices that are used to get advantages of contraction or fat graft preservation.

What’s the difference in price between that and your basic old school lipo? If you’re young and healthy, you have super tight skin, you don’t need the fancy, newer technology. That’s if you’re older, weight loss, weight gain, few kids, have loose skin. You really need to do the modern BodyTite approach to lipo. The difference is usually around $2000 a case when you apply energy. So whatever the base line price of a lipo in your city is. It could be 4000 per zone, 3000 per zone, 6000 per zone. Generally you’ll find the BodyTite practices charge a premium of about $2000 to ensure that 35% area contraction, like a scarless tummy tuck or arm lift of neck list, and usually it’s worth it for that extra 2000 because you get massive amounts more … 35% area contraction for the upsell and the technology and the procedure.

Basically physicians will offer you those if they have them in their practice. A busy liposuction surgeon is going to have to have some type of BodyTite procedure in the modern era. If they hope to contour older women, larger women, women with weight loss, weight gain or multiple kids, you need a BodyTite in your practice.

What’s the difference between non-surgical lipo techniques and surgical liposuction techniques? Well, the non-surgical lipo techniques are led BodyTite technologies where you don’t have to go to an OR. There’s nothing going under your skin. There’s nothing invasive. It’s done as an outpatient, and it can be done in medical spa type non-invasive for dermatologic environments. The number one non-surgical lipo technique or body sculpting technique, which is reduction of localized fat areas or without surgery, the number one technique in North America is called Cool Sculpting.

Cool Sculpting is suction coupled and non-suction coupled cooling or hypothermia, that if you expose that fat to minus five degrees for about 45 to 60 minutes, you’re going to get a small amount of fat that will die. So if you want a really … the best contour of your love handle or those localized areas, don’t do Cool Sculpting or non-surgical because you’re only going to get about a centimeter to two centimeters reduction. But if you have eight centimeters of fat, you’re going to still be frustrated. That’s why liposuction, modern liposuction is still your best bet.

However Cool Sculpting, if you’ve got a modest amount of fat expectation and reduction, kills fat permanently, consistently, one to two centimeters of pinchable fat. Cool Sculpting can be a very viable option. It’s less expensive than lipo. There’s no recovery. There are some side effects, but they’re reasonable and they’re tolerable, and so it’s very popular.

The next most popular after Cool Sculpting is a technique called SculpSure. SculpSure is non-surgical, non-invasive. Again like Cool Sculpting it does … as an outpatient in a medical spa. It’s the application of laser heat on the outside of the skin. Doesn’t go inside, just like Cool Sculpting. That’s called SculpSure. That again is non-invasive. You can kill one to two centimeters. It’s less expensive than Cool Sculpting, but it doesn’t give you the definitive contour which is still the domain of liposuction.

There’s some other technologies that kill fat, like BodyFX, which uses electroporation and RF to kill fat. electroporation damages the cell membrane. You can get a good two, three centimeters of reduction. It takes three or four treatments over six weeks, whereas Cool Sculpting or SculpSure is two treatments. One at the beginning, one at the end of six weeks. BodyFX, again. Cool Sculpting, SculpSure.

True Sculpt is using non-suction coupled radio frequency with skin cooling to kill fat. We have the Vanquish, which is placing the extra fat of the thighs or the tummy under a microwave technology which will oscillate the fat molecules using a hypothermia technique, but with microwaves, not a laser, will kill fat. That’s a permanent reduction technology. Then we have some ancillary techniques that are not as commonly used, but those are the big four or five. Cool Sculpting, SculpSure, BodyFX, Vanquish …

PART 1 OF 3 ENDS [00:12:04]

… CoolSculpting, SculpSure, BodyFX, Vanquish, truSculpt, proven fat killers. Multiple treatments, non-invasive, two centimeters of pinchable fat reduction. If you select your patients well, if you want two centimeters with no risk, those are your best bets.

If you want the best option and you want all fat gone in that localized area, liposuction. Then decide to add energy not if you need skin tightening, and the contour of coagulation, and contraction, BodyTite being your best option.

The two big fears of liposuction are, “Will I have excess skin,” or, “Will I have indentations or irregularities?” Excess skin, that’s when we make the wrong assessment and we take the fat. What’s left behind is loosey goosey, wiggly jiggly skin. How do we minimize that? Well we add the right energy device to get good soft tissue contraction. BodyTite with radiofrequency energy. Smartlipo with laser energy. These can provide internal contraction to compensate for the risk of loose skin.

Now if the skin is too loose you’re not going to have enough compensation, 35% isn’t enough. You need to know which patients are going to benefit from BodyTite or Smartlipo, lipo coagulation, and aspiration, and skin removal. Like a skin pinch tummy tuck, or a mini arm lift, or a mini behind the ear neck lift in addition to liposuction. We have three options when it comes to the risk of loose skin after lipo.

Have excellent skin, have the right technique, get good contraction, the skin tone should be fine. If you have compromised skin you may do the BodyTite lipo, get 35% [aeric 00:13:32] contraction and a modest, mini skin removal procedure, like a mini behind the ear neck lift, or a mini arm lift, or a mini C-section size tummy tuck, or inner thigh lift in combination with lipo. Some patients have such loose skin that the right physician, with the right experience, is going to be able to tell that patient, “No, you’re not a lipo candidate. You need a formal tummy tuck. You need a formal face or neck lift. You need a formal arm lift. You need a formal thigh lift. You can not get away with lip, even energy based lipo like BodyTite, alone. You need real surgery.”

How to avoid loose skin? Pick the right surgeon who has the right energy devices. Pick the surgeon that has experience. Pick a surgeon that’s going to be able to tell you whether you can get away with BodyTite lipo versus an excisional surgery like a tummy tuck.

The next most common feared side effect of liposuction is irregularity or indentations. Indentations are the lumpy bumpy appearance of the skin after lipo. You see that with some of the Instagram posts from some of the stars who have been caught in Mexico, or in southern California, or the beaches of Hawaii with indentations or irregularity. Most famously the Tara Reed tummy with multiple indentations or irregularities. Those are lipo contour defects from over aspiration. A zone of over sucking leads to an indentation.

Again, how do you minimize that? Well sometimes it happens even in the best of hands but you want to pick out a surgeon with a lot of experience. The more experienced a good body contouring surgeon is the less likely they’re going to leave you with very noticeable irregularities or asymmetries. There’s always some slight imperfections but they’re subtle. So pick the right surgeon. The surgeon with the right technology. Making sure you have access to BodyTite, Vaser, energy based devices that help him contour and contour symmetry.

Then post operative care. Most body contour liposuction surgeons are going to put you on suction coupled heating devices like BodyFX, Venus Freeze, the FORMA Plus, the tripolar, devices that bulk heat the skin and get tighter, smoother skin after the lipo. You usually start those treatments around six to eight weeks.

Indentation and irregularity, loose skin, the two most common side effects you want to watch out for. Most are mitigated by the selection of the right surgeon who picks the right procedures for you.

What are the contour indications to liposuction surgery. Number one contour indication, unrealistic expectations. Make sure your patient is realistic about the kind of outcomes they can get. Patients out there who have medical illnesses. If you have advanced cardiac disease, or hypertension, or uncontrolled diabetes, or breathing problems, COPD, emphysema, asthma, you’re not a good candidate for even a minimal invasive treatment like liposuction. You’ll need to consider non-surgical lipo techniques.

If you have really excess loose skin and you need an incisional procedure, not a candidate for liposuction. If you have a pacemaker or have a bladder of the heart, you’re not a candidate for any kind of energy device and you might not be a candidate for liposuction. If you have a lesion, a sore, an undiagnosed non-healing wound in the area of the treatment you want to make sure that’s not a skin cancer, you’re not a candidate for liposuction. If you’re pregnant. If you are pregnant you are not a candidate for any surgical procedure, liposuction being one of them. You need to wait till you’ve had your baby, and your skin has retracted, and you’ve recovered from … Pregnancy has subsided, which takes about a year, six months post-breastfeeding. Then you could consider liposuction to some problematic post-baby areas in a mommy makeover.

What is the safest methodology of performing liposuction in the modern world? Well generally safety will involve avoiding a general anesthetic with intubation, and ventilation, and paralysis, and pretty serious medications, if possible. Well trained liposuction surgeons should now be able to offer you non-general anesthesia lipo, where it’s done under a twilight sedation, usually oral, subcutaneous, light IV sedation. Then I use a lot of laughing gas or nitrous oxide, so we use the laughing gas or a nitrous oxide while we put the localized anesthesia, the local freezing. Once your fat is frozen and there’s no feeling you don’t feel the liposuction procedure being done so you don’t need any kind of heavy anesthesia, just that light twilight sedation.

The anesthetic technique has evolved from everyone getting general anesthesia 10 years ago to out-patient, ambulatory, local anesthetic liposuction cases. Where we can then add the right local anesthesia with laughing gas, and some intravenous, and oral sedation. Then using gentle techniques. Techniques that heat the fat, liquefy, coagulate so the fat comes out easily and induce a nice contraction. That’s usually BodyTite or other technologies like Smartlipo or Vaser. It’s a combination of technology and technique that leads to the safest possible lipo contouring results.

Then, of course, don’t take too much. You don’t want to take over five liters of combined aspirate. Make sure you replenish the fluids, through the IV, that you’re taking out through lipo. Adequate fluid resuscitation. Making sure the patient’s well volumized. Thinning the blood by using some specialized blood thinners like Lovenox or Heparin minimizes the risk of a DBT. These are all the elements that you bring to a very safe liposuction procedure. Many of which the patient doesn’t even know what’s happening, in order to keep it as safe as it has become.

What to look for in a liposuction surgeon, a liposuction facility, that keeps it as safe as, and efficacious, and quality as possible. Well first and foremost you want to make sure that the surgeon is a surgeon. Many physicians in North America perform liposuction and they’re not always surgically trained. Now there’s some very good liposuction surgeons that are not surgeons, that are family doctors or internists that have garnered a tremendous amount of experience, but if they’re not surgeons they should belong to a surgical society like The American Academy of Cosmetic Surgery. They should have done hundreds of cases, have a lot of experience, and a good reputation with good online testimonials, but make sure you have a surgeon. A board certified plastic surgeon or a cosmetic surgeon who may not be a board certified plastic surgeon but belongs to a surgical society and liposuction’s a big focus of their business.

Number two, make sure your surgeon’s done lots of cases. Make sure they’ve got hundreds of cases under their belt. They can show you lots of before and afters. They have lots of testimonials. Then go outside their practice online to rating sites where the surgeon can’t control the messaging, to see that there’s lots of liposuction patients that sing the praises of the quality and the experience of the facility you’re exploring.

Make sure they have a high quality certified liposuction OR that is certified because many states require certification for liposuction over a certain amount, under local anesthesia, under an IV sedation or general anesthesia. A certified OR by a regulatory body, a state medical board, or a national OR certification like AAAASF, or some certification body. Make sure that the physician keeps a log of complications. Ask them what complications they’ve had with liposuction that they kept for their state medical records and how they manage those complications.

You want to make sure that the operating facility has all the resuscitation, the 911 equipment and a 911 protocol that would be needed if there was an adverse event like a cardiac arrhythmia in your case. What’s the 911 protocol and transfer to a tertiary hospital protocol in place for that physician? Does the physician have hospital privileges or did have hospital privileges in a hospital for liposuction because that means they’ve been vetted by a regulatory body, like a medical board, that assesses their qualifications and vets their skillset being able to perform liposuction safely.

These are the things I would look for. Look up the state medical board records or the college records. See if the patient’s been disciplined for liposuction or any surgical procedure. Make sure there’s no medical legal actions by looking up medical legal malpractice suits in your state or province.

Then, at the end of the day during your interview, make sure there’s a confident sense that this physician and their team is going to offer you comprehensive care post-op followup, to minimize the risks of complications, which can happen to any procedure and with any physician. Make sure you setup all the odds in your favor by having the best physician and the best facility.

Okay. The liposuction is done. You’re on the table. You’re going to get a great result but in that canister, in the aspiration canister or canisters, you got a number of CCs of your fat. Sometimes one, or two, or three, or four milk bags, which are liters and liters of your fat. What can you do with this fat? Do you throw it all away? Most of the time yes. We just dispose of it through a certified biological waste company. However, in certain circumstances patients can re-deploy that fat. They can re-inject that fat and make it work somewhere else for you. Steal it from Peter and use if for Paul.

Where are the three most common areas we inject fat, where there’s needs for fat? The number one area is the breast and the buttock, so body areas. Fat grafting the buttock is called the Brazilian butt lift or BBL. When done in the subcutaneous fat, not in the deep muscle, it can be very safe. It can add a nice, modest, round muscular look to a bum. Give a bit of a bum lift by using fat you’re going to throw out anyway. Steal from your hips and put in your butt. Number one area.

Number two area is the breast. The upper pole of the breast. After weight lose, weight gain, multiple breastfeeding, multiple children, age, you get a pfft or deflation of the fullness of that upper pole. Fat grafting to the breast is never going to replace a cohesive gel gummy bear breast implant. That’s still your best option for breast fullness but you can get a nice half cup improvement, little fullness in that upper pole, by fat grafting to the breast. Fat grafting to the breast, number two.

The number three area for fat is the face. Facial fat grafting. Marionette lines, smile lines, under the eye, across the cheeks, along the jawline, lips and nose. These are the areas that I commonly will fat graft. That’s another area where you can re-deploy fat that’s destined for the garbage that given you a nice contour on your body for enhancement or …

PART 2 OF 3 ENDS [00:24:04]

Nice contour on your body for enhancement and rejuvenation in your face. Lastly and less commonly would be fat grafting to previous liposuction defects. So areas we’ve got indentations and concavities we can use release and fat grafting techniques to smooth in your post liposuction irregularities.

Consideration of use of fat, redeployment, ecologically sound, environmentally friendly, and aesthetically pleasing. You’ve probably read about liposuction, scars, or ports. Where do we go? Where did they go? Where do we put them? How do we hide them? Women have gotten very sophisticated now. They know what little lipo marks look like, those little three millimeter scars that are in the open tummy or in the bra line or the flanks are a no-no nowadays. We want to hide those little three millimeter, four millimeter lipo port insertion areas. The access ports in creases where possible, between the gluteal fold, out the top of the gluteal fold, under the bum crease, in the groin crease, in the belly button, under the chin point, under the breast fold, areas where people typically are not going to see a mark in the open area of your skin.

So gone should be the days of obvious liposuction marks. Through judicious use of creases and longer probes and cannulas, we can always keep those incisions hidden so you can keep them guessing, “Did she or didn’t she? Is that all hard work and personal trainer and diet and exercise commitment, or that plus a little help with lipo?”

What about numbness after liposuction? Because you read a lot about the numbness that can occur in everybody after lipo get some numbness. Because undermining that fat and traumatizing the fat damages those little sensory nerves and you can get numb skin. Fortunately, unlike a scar or a tummy tuck or a general surgery tummy scar or breast augmentation lifts scar, these scars often stay numb forever. With liposuction, the skin that is numb usually comes back within 6 to 12 months, there’s a natural return.

Now, what can you do as an adjunctive technique to improve your liposuction result that’s nonsurgical? Most good liposuction surgeons will have after care treatments starting at around the 10th to the 12th week if you’re not too tender to, number one, tighten your skin using noninvasive bulking technologies such as Forma Plus, Venus Freeze, Exelis. These are the big three that are used to heat your skin to 42 degrees and get you even more tightening than BodyTite skin will give you. So you get maybe 35% under the BodyTite, another 10% from your noninvasive technologies. So series of treatments once a week or once a month for about four to six treatments after your liposuction to get tighter skin.

We can also deploy other technologies if you have a little extra fat on one hip or one side, not quite symmetrical, which is very common after lipo. We don’t want to leave indentations, but it’s not uncommon to have a little bit of fat asymmetry between one side and the other.

We can use our nonsurgical killing techniques such as Body Effects, Cool Sculpting, Sculpture, Vanquish, non-surgically, starting at 10, 11, 12 weeks to kill additional fat.

Last but not least, we’ve added other technologies to work on the next layer, skin, fat, and now muscle. So we can work on a six pack. Once you’ve done that abdominal lipo and you’ve revealed, and thin that fat layer on top of the rectus abdominis, we use something called the Emsculpt, which increases the muscle mass, increases the muscle definition and tone after a series of four to six treatments after lipo. So, Emsculpt, additional fat killing technology, and skin tightening technology, all noninvasive, can be performed on your lipo areas starting around 10 weeks after surgery to get an even better result than we’ve ever had before.

A lot of patients ask me, “Can I freeze my fat and use it next year if I take it out?” Unfortunately, no, you cannot store your fat. Although it’s possible to do it, you cannot store your fat to redeploy it later. That would require in every state in the United States, every province in Canada, to have a very expensive and complex transplant center, a center that uses fat and tissue banking and needs a tissue banking license to have these auto transplantation. So tissue banking is very regulated. No private plastic surgery office is going to have a tissue banking license in order to facilitate freezing your own fat. So you use it or you lose it. Use it when it’s fresh, reinject it, or we’ve got to throw it away.

Let’s say I have some loose skin and I want to combine my lipo, my BodyTite Lipo with a mini skin removal procedure. That’s done all the time. Rather than a great big long tummy tuck or extended tummy tuck incision from hip to hip, we can do shorter scars and BodyTite Liposuction with good contraction of the upper belly. We can do BodyTite in combination with little armpit lifts rather than a full brachioplasty, little anterior thigh groin crease lifts rather than a full thigh lift, or under the chin and neck with neck tight and a behind the ear limited neck lift scar. So the combination of Lipo contouring with energy based thermal devices such as BodyTite, NeckTite, FaceTite, AccuTite, and limited excision surgery is one of those hybrid procedures that’s found a good niche because it gives an even better result than BodyTite Lipo or energy based lipo without the big scars.

So let’s say you’re interested in Lipo. You find the right surgeon, great safe facility, good reputation. What are you looking to pay, usually? Most surgeons in North America will charge lipo by zone. And in general you pay anywhere from 2,500 to $3,000 for a zone in less expensive markets or cheaper practices, and upwards of 4,000, 5,000, 6,000, $7,000 for the first zone, and 4,000 or 5,000 for every zone thereafter. And those are the range in prices you see in North America.

Generally, the guys that are very busy, very experienced, own three or four image based technologies have a good market reputation, are going to charge a little more per zone than less experienced individuals with less notable reputations. You also pay a little more per zone if you’re bigger. So you have a tummy and you weigh, let’s see, a BMI of 34 and you have another patient with a BMI of 24 and a small amount of pinchable fat, that tummy is going to cost the smaller patient a little less than the bigger patient. So there’s large zone prices as well.

And then there’s sometimes quite often an upsell for energy based technology, like the addition of BodyTite or Vaser or Smart Lipo. These are usually upsells for the advantage of that tightening you get. One of the energy based devices that typically doesn’t cost you more is something called power assisted. Power assisted, or PAL, is a cannula with no energy, basically basic liposuction cannula, that’s motorized. So it goes back and forth about 1,000 times a second, and the surgeon’s arm is moving about one cycle per second and it removes fat much faster, speeding up the procedure, making it safer. And so, those are the prices you can see in North America in general.

And the last category is secondary lipo. These are patients who’ve had lipo before, they have irregularities, indentations, laxity problems. They usually are going to pay more for secondary lipo, upwards of sometimes 8,000 or 9,000 or 10,000 for the first zone, and it can easily cost them 14,000, 15,000, 16,000 for two or three zones, because these are tricky cases, much more complicated, take longer and take a greater amount of expertise and therefore costs more.

So you’ve done your lipo, you’re about to get a great result. What’s the postop care like in terms of a compression garment? One hundred percent of surgeons in North America nowadays are going to insist on a compression garment, and it’s going to be a nice specialized custom made to measure, form fitted, Lycra spandex kind of combination. They’re breathable, but they get a good 22 to 28 millimeters of mercury of pressure per square centimeter, which results in a nice controlled contraction and retention of your skin while it’s healing to the underlying muscles. So there’s no way of regularities or laxity. So it controls the wound healing process in a good position while that six weeks of healing of neocollagenesis is occurring. So you get it measured before your surgery, it’s usually combined with some foam padding, which is going to give you better compression in certain areas, and the foam padding lasts about a week.

You wear that garment 22 hours a day for three weeks for most practices. Then you can wear it during the day, leave it off at night for another three weeks. At the end of six weeks you can fold your garment up on the shelf and go back to your normal activities like high impact aerobics and exercise.

“When can I return to a high impact aerobic activity or my normal exercise routine after liposuction?” That’s a common question. I tell most patients the first three weeks, brisk walking, keep active. You’ve got your post liposuction garment on, but no high impact arobotic activity, no balancing, running, no pilates or crunches if you’ve done abdominal work. So high impact activity start at six weeks. So you’re back on elliptical, a stair climber at three weeks, you can start to isotonic muscle exercises where you haven’t done lipo, like bicep curls, Thigh Master if you haven’t done lipo in those areas at about three weeks.

High impact activities like jogging, yoga, pilates, crunches, these kind of activities, you’ve got to wait about six weeks so you get some adherence between skin and the underlying muscle, then you can begin those activities. Starting gradually and build up your endurance and your strength over time. Return to swimming typically needs healed incisions and that’s going to be usually around three to four weeks, before that you want to get in the lake or a dirty pool or whirlpool water. And what about flying away, flying out of the city after surgery and going on a vacation? Generally, I recommend people stay around for about a week until some swelling is subsided, the garment compression has worked and it minimizes the risk of a airplane induced pulmonary embolism or DVT. So you want to hang around a week before you travel at 31,000 feet and go off for a vacation.

What about the use of a drain after a liposuction surgery? Typically loose areas like a tummy or very loose upper arm treatment might require a drain, and usually it’s for several days to encourage contraction and coaptation of the skin to the underlying muscle.

So thank you for joining us. Dr Stephen Mulholland here in Toronto, Canada on plastic surgery talk for our weekly podcast series. This one was on liposuction, a deep dive into modern liposuction and all the questions around that. If you found this engaging, interesting, educational, please sign up, subscribe, and comment. See you next time.

PART 3 OF 3 ENDS [00:35:01]

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Great info

By Musikiscool - Jun 29 2019
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Love the info. The audio quality is a little off but love the info