Sunday, January 8, 2012

Rebirth of the Women's Plastic Surgery blog

There has been a long hiatus in the posts on the Women's Plastic Surgery blog.  The new website for my practice is nearly complete, and I will be starting to blog again about the following topics:
  • Plastic and Reconstructive Surgery
  • Aesthetic Surgery
  • Non-Surgical Aesthetic Procedures - Botox, Dermal Fillers, "Laser" Procedures
  • Medical-Grade Skin Care
  • Health, Wellness and Beauty
  • Women's Health Issues
  • Breast Cancer and Breast Reconstruction
  • Reconstructive Microsurgery
Blog posts will be linked to and featured on my site.  

Until then, please visit my Twitter feed for regular tweets about these topics!

Karen M. Horton, MD, MSc, FACS, FRCSC

Wednesday, January 26, 2011

FDA Medical Device Safety Communication: Reports of Anaplastic Large Cell Lymphoma (ALCL) in Women with Breast Implants

The FDA's report in its full version can be viewed here.


FDA Medical Device Safety Communication: Reports of Anaplastic Large Cell Lymphoma (ALCL) in Women with Breast Implants

Date Issued: January 26, 2011
  • Health care providers involved in the care of patients with breast implants
  • Hospital tumor boards
  • Breast implant patients and families of patients, including those that have received breast implants for aesthetic augmentation, revision, or reconstruction.
  • Patients considering breast implant surgery
Medical Specialties: Radiology, Pathology, Plastic Surgery, General Surgery, Internal Medicine, Obstetrics/Gynecology, Oncology, Nursing, General Practice

Purpose: The FDA is issuing this communication to inform health care providers and the public about a possible association between breast implants and a type of anaplastic large cell lymphoma (ALCL). Although ALCL is extremely rare, the FDA believes that women with breast implants may have a very small but increased risk of developing this disease in the scar capsule adjacent to the implant. The FDA is also asking health care providers to report confirmed cases of ALCL in women with breast implants to the FDA.

Summary of Issue:The FDA is exploring a possible link between breast implants and ALCL. ALCL is a rare cancer of the immune system, which can occur anywhere in the body. According to the Surveillance, Epidemiology, and End Results (SEER) Program1 of the National Cancer Institute, an estimated 1 in 500,000 women per year in the U.S. is diagnosed with ALCL. ALCL in the breast is even more rare; approximately 3 in 100 million women per year in the U.S. are diagnosed with ALCL in the breast.

As part of its analysis, the FDA conducted a thorough review of scientific literature published from January 1997 through May 2010. From this review, the FDA identified 34 unique cases of ALCL in women with breast implants throughout the world. In total, the FDA is aware of approximately 60 case reports of ALCL in women with breast implants worldwide. This number is difficult to verify because not all cases were published in the scientific literature. Some cases have been identified through the FDA’s contact with other regulatory authorities, scientific experts, and breast implant manufacturers, and it is not clear how many of these are duplicates of the ones found in the literature.

The number of identified cases is small compared to the estimated 5 to 10 million women who have received breast implants worldwide. But based on these data, the FDA believes that women with breast implants may have a very small but increased risk of ALCL. Because the risk of ALCL appears very small, FDA believes that the totality of evidence continues to support a reasonable assurance that FDA-approved breast implants are safe and effective when used as labeled.

The table below describes the characteristics of the 34 published cases of ALCL in women with breast implants:

Characteristics of 34 Published Cases of ALCL in Women with Breast Implants

Age (years)Median51
Type of ImplantSilicone24
Not specified 3
Time from Implant to
ALCL Diagnosis (years)
Reason for ImplantReconstruction11
Not specified4

FDA’s overview, review of the literature and discussion of these cases can be found in the document Anaplastic Large Cell Lymphoma (ALCL) in Women with Breast Implants: Preliminary FDA Findings and Analyses2.

ALCL is Lymphoma – Not Cancer of the Breast Tissue. When breast implants are placed in the body, they are inserted behind the breast tissue or under the chest muscle. Over time, a fibrous scar called a capsule develops around the implant, separating it from the rest of the breast. In women with breast implants, the ALCL was generally found adjacent to the implant itself and contained within the fibrous capsule. ALCL is lymphoma, a type of cancer involving cells of the immune system. It is not cancer of the breast tissue.
Most patients were diagnosed when they sought medical treatment for implant-related symptoms such as pain, lumps, swelling, or asymmetry that developed after their initial surgical sites were fully healed. These symptoms were due to collection of fluid (persistent seroma), hardening of breast area around the implant (capsular contracture), or masses surrounding the breast implant. Examination of the fluid and capsule surrounding the breast implant led to the ALCL diagnosis.

The FDA believes that women with breast implants may have an increased risk of developing ALCL, but also believes any potential risk is extremely low. Due to the rarity of ALCL, the small number of reports, and the incomplete and limited data from these reports, more information is needed to fully understand the possible link between breast implants and ALCL.

Recommended Actions for Health Care Providers and Patients
Health Care Providers: 

If you have patients with breast implants, you should continue to provide them routine care and support. ALCL is a very rare condition; when it occurs, it has been identified most frequently in patients undergoing implant revision operations for late onset, persistent seroma. Because it has generally only been identified in patients with late onset of symptoms such as pain, lumps, swelling, or asymmetry, prophylactic breast implant removal in patients without symptoms or other abnormality is not recommended.

Current recommendations include the steps below. As the FDA learns more about ALCL in patients with breast implants, these recommendations may change.
  • Consider the possibility of ALCL when you have a patient with late onset, persistent peri-implant seroma. In some cases, patients presented with capsular contracture or masses adjacent to the breast implant. If you have a patient with suspected ALCL, refer her to an appropriate specialist for evaluation. When testing for ALCL, collect fresh seroma fluid and representative portions of the capsule and send for pathology tests to rule out ALCL. Diagnostic evaluation should include cytological evaluation of seroma fluid with Wright Giemsa stained smears and cell block immunohistochemistry testing for cluster of differentiation (CD) and Anaplastic Lymphoma Kinase (ALK) markers.
  • Report all confirmed cases of ALCL in women with breast implants to the FDA. In some cases, the FDA may contact you for additional information. The FDA will keep the identities of the reporter and the patient confidential.
  • Develop an individualized treatment plan in coordination with the patient’s multi-disciplinary care team. Because of the small number of cases worldwide and variety of available treatment options, there is no single defined consensus treatment regimen.
If you have breast implants, there is no need to change your routine medical care and follow-up. 

ALCL is very rare; it has occurred in only a very small number of the millions of women who have breast implants. Although not specific to ALCL, you should follow standard medical recommendations including:
  • Monitoring your breast implants. If you notice any changes, contact your health care provider promptly to schedule an appointment. For more information on self breast exams, visit Medline Plus: Breast Self Exam3.
  • Getting routine mammography screening.
  • If you have silicone gel-filled breast implants, getting periodic magnetic resonance imaging (MRI) to detect ruptures as recommended by your health care provider. The FDA-approved product labeling for silicone gel-filled breast implants states that the first MRI should occur three years after implant surgery and every two years thereafter.
If you do not currently have breast implants but are considering breast implant surgery, discuss the risks and benefits with your health care provider. You may also visit FDA’s Breast Implants website4 for additional information.

FDA Activities:

The FDA continues to evaluate all available information to understand the nature and possible factors contributing to ALCL in women with breast implants. In addition, the American Society of Plastic Surgeons (ASPS) and other experts in the clinical and scientific communities have agreed to pursue a collaboration with the FDA to develop a registry to gather additional information to better characterize ALCL in women with breast implants.

While the details of the collaboration are being developed, the FDA is advising health care professionals to test breast implant patients with suspected ALCL according to the recommendations above and to submit findings on confirmed ALCL cases to the FDA. The FDA is also asking breast implant manufacturers to report confirmed cases. The FDA will update the public as new information is obtained.

In an effort to ensure that patients receiving breast implants are informed of the possible link between ALCL and breast implants, the FDA will be working with breast implant manufacturers in the coming months to update their product labeling materials for patients and providers.

As part of its ongoing surveillance of all breast implants, the FDA plans to provide an update on the state of the science on silicone gel-filled breast implants in the spring of 2011. This update will include interim findings from ongoing post-approval studies for silicone gel-filled breast implants currently sold in the United States, adverse event reports submitted to the FDA, and a review of the scientific literature on these products.

How to Report Information to the FDA

If you are a health care provider and you have identified ALCL in breast implant patients, please file a voluntary report through MedWatch, the FDA’s Safety Information and Adverse Event Reporting Program online5, or at 1-800-332-1088.

To help us learn as much as possible about ALCL in women with breast implants, please include the following information in your reports, if available:
  • The term “ALCL Case Report” in section B5 (Describe Event, Problem or Product Use Error) of the MedWatch form
  • Patient age, gender, race/ethnicity
  • ALCL diagnosis: date of diagnosis, anatomic site of ALCL, whether ALCL was primary in this site and pathologically confirmed
  • Clinical presentation
  • Detailed pathology findings
  • Breast implant exposure: date implanted, brand and type of implant (saline or silicone-filled), type of implant surface (smooth or textured), complications, length of time from implant insertion, and history of subsequent revision surgeries
  • Treatment(s) the patient received
  • Name, contact information and medical specialty of reporter
All reports to the FDA are strictly confidential and protect individual patient privacy.

Contact Information:
If you have questions about this communication, please contact the Division of Small Manufacturers, International and Consumer Assistance (DSMICA) at DSMICA@FDA.HHS.GOV, 800-638-2041 or 301-796-7100.
This document reflects the FDA’s current analysis of available information, in keeping with our commitment to inform the public about ongoing safety reviews of medical devices. The FDA will provide updates as more information becomes available.

Report: Possible RARE Association Between Breast Implant Capsules and Lymphoma

PSN Special Bulletin
FDA to issue safety signal on ALCL & breast implants
Today the Food and Drug Administration (FDA) issued a communication to inform health care practitioners and the public about a possible association between breast implants and anaplastic large cell lymphoma (ALCL). Although ALCL is extremely rare, the FDA believes that women with breast implants may have a very small but increased risk of developing the condition. ASPS has been actively engaged with the FDA on this matter. The Society is collaborating with the Agency to develop a centralized registry to collect more information on existing case reports and any new cases that may be identified going forward.

The Agency has posted two resources on its website. The first is a Safety Communication that provides a summary of the issue, recommended actions for physicians and patients, and how to report information to the FDA. The second is a more detailed report of the FDA's preliminary findings and analyses on ALCL in women with breast implants.

Following the signing of a Confidential Disclosure Agreement with the Agency, ASPS was asked by the FDA to comment on both documents. Working with both internal and outside scientific experts, ASPS provided extensive comments, some of which are reflected in the final documents.

The FDA has provided the following links to their documents:

The FDA has issued a press release and is conducting a media conference call and stakeholder call today.

ASPS is executing an aggressive media relations campaign to represent plastic surgery's view and minimize potential false alarms for patients and consumers. ASPS has posted additional resources for members and consumers on its website.

This email was sent to by |  
American Society of Plastic Surgeons | 444 E. Algonquin Road | Arlington Heights | IL | 60005-4664

Tuesday, December 28, 2010

Repost of a wonderful article by a Mommy Makeover patient!

This is a WONDERFUL article written by a woman who has had a "Mommy Makeover" surgery.  

Although I wish I could boast about this being MY patient, it is not.  She is an excellent writer and I feel she sums up her experience in a lighthearted and sincere manner. 

However, I truly believe that anyone considering this type of surgery could benefit from reading this in order to help prepare for their experience!

Karen M. Horton, M.D., M.Sc., F.R.C.S.C.

10 Things I wish I'd known before a Mommy Makeover

10 Things I wish I'd 
known before a Mommy Makeover After getting a mommy makeover, I came up with a top 10 list of things I wish I knew ahead of time!

1. Guilty as charged.

As most moms do, I tend to put everyone else first. A lot of times that is why women tend to feel like they have lost their identities. It’s hard to spend that much money on yourself, especially for aesthetic reasons. It seems okay to spend it on a car or a trip, but for some reason the thought of spending that money on your body is frowned upon. To some that may seem vain or boastful. For me it was about a self confidence that I had yet to achieve, a love of self that I have longed for my entire life. When I look in the mirror I like what I see now. When I feel good about myself…inside and out…I am a better woman, a better wife, and a better mom. It is absolutely normal to feel guilty about spending money on a mommy makeover and it is okay to finally put yourself first. It is the best money I have ever spent…just ask my family.

2. What to tell the kids.

This was a big one for me. I am a mom of two young girls (5 and 2). I grew up with a horrible body image and the last thing I wanted was to implement that to my daughters. I was concerned about what to tell the oldest, the two-year-old really didn’t understand. I thought about saying, “Well, you and your sister ruined my body while I was pregnant with you both.” But then I thought maybe that was too harsh. (Note the sarcasm). I have tried really hard not to down myself in front of them, calling myself too fat, or commenting on my huge belly. They see me exercise and make healthy choices, but I didn’t want them to know that I didn’t like my body. So I tried to keep it simple. The day before surgery I told my oldest daughter that I was going to have an operation to fix my tummy (I didn’t go into the whole booby thing). She of coursed asked why, I told her because the doctor said so. I was prepared for more questions but she seemed satisfied with that. I was informed by the ladies on this site that the best thing to do with boys, if they are older, is tell them you are having female surgery. They will shut right up and have no more questions. Nothing is more embarrassing than talking female issues with your mom.

3. I’m a big girl now.

Most mommy makeovers include lipo and a tummy tuck. Which probably means you will be lucky enough to wear a skin-tight crotchless compression garment. I, as most women, chose to wear panties over this outfit so I didn’t feel as it all my “stuff” was being squished out. (Think of baboons….ewww, or don’t.) Now, the tricky part here is the first couple of days after surgery. You will spend quite a bit of time on the toilet the first time you try to pee, similar to what it is like after giving birth. After a couple tries, it gets better. However, when you are taking pain medication and muscle relaxers on a regular basis, your mind may be fuzzy a bit. I had the great luck of forgetting I had those panties on and peeing straight through them…twice. Yes, not once, but twice. I was starting to think I might have to revert back to diapers but I graduated and learned how to use the potty like a big girl. Also, you will probably not poop for several days at first, so expect a good 3-5 days worth of poop on your first time. With that being said, consider pulling your garment down for that endeavor. The back to front wiping thing can be tricky in that thing. I’m just saying, not that it happened or anything…..I’m just saying…okay…next subject please.

4. Hello Dolly!

If you decide to get implants please remember that objects may appear larger than they actually are. When I first took a glance at my new girls, I thought “Holy Mary Mother of God, what have I done?!” I looked like Dolly Parton, or for younger ones, Beth from Dog the Bounty Hunter. This is NOT your final look. Please don’t freak out. The swelling takes a while to go down and for the implants to “drop” into place. After about a week your PS will probably give you the go ahead to start massaging them. Massaging the implants will help them soften up and find their final resting place. Your significant other with love this, and surprisingly, so will you. I was shocked to find how much I actually liked touching my own breasts. It sounds perverted, I know, but if you are used to your “ladies” hanging out down by your belly, then you will see how nice it is to hold them, let go, and be fascinated that they no longer fall down so low anymore. I can now understand why men are always holding onto their own “boys”. They are proud of them. I have caught myself with one hand on the remote and the other on one of my breasts. So relax, and let the boobs fall where they may.

5. Phantom of the itch.

I knew going into the tummy tuck part of the mommy makeover that my belly would be numb. It is a freaky and strange feeling. It is almost like you are rubbing on someone else’s tummy. I had heard before about people who have had an arm or leg amputated and still felt the feeling of it being there, the phantom limb syndrome. I was not prepared for that with my belly. Every now and then, I will get an itch, go to scratch it, and realize it is where my belly is numb. Scratching a numb belly doesn’t relieve the itch. Simple right? Well I have a masters degree and it took several times scratching before I got that one.

6. Sit. Stay. Good girl.

Once again, most mommy makeovers include a tummy tuck. This is a huge procedure and as most of you have surely read, it is a good idea to take off as much time as possible from your job. I was fortunate enough to take 2 weeks off from my PAID position. I capitalize paid, because as all moms know, the mom position is considered a “non for profit” position. Rarely do we moms put in a request for vacation from that position, so therefore we tend to work every day of the year, even if we are taking a vacation from our “paid jobs”. As most moms, I am an expert at multitasking. It was killing me to sit there and not do anything. The first 3 days or so you have no choice, your body will not allow it. I will admit that I probably did more than I should have. Looking back, I wish I would have taken more advantage of the quiet time and rested and relaxed. I was convinced that if I didn’t do it, it wouldn’t get done, and it wouldn’t get done right. I was wrong. Trust your loved ones. My husband was amazing. He became Mr. Mom and was pretty darn good at it. I have never given him enough credit in that department. Granted, it may have not been done the way I do it, but he stepped up and took charge. And if you don’t have someone doing those household chores….so what. Just take this time for yourself and give your body a chance to heal.

7. All aboard...the Bi-Polar Express.

This is a BIG one. Having your body cut upon, stitched up, and hung up to dry is traumatic. Throw a few pain meds into the mix and you will turn into an emotional tornado. I was known to go from ecstatic to tears in 6.9 seconds flat. Top that!! Be aware that this will be an issue, and emotions will be crazy. Explain this to your loved ones and the people caring for you so they don’t call the men in white coats with the strait jackets. When I felt teary, I would cry. It’s ok, you have a permit to go crazy, take advantage of it. When I was feeling really down and out, I typically would go to bed and nap it off. Use this site. is full of women who are going through the same thing. Use them to lean on and talk to. The ladies I have met on here have been A HUGE support to me and I couldn’t have gotten through this without them. Well, I would have, but I would have probably been divorced and sitting in a mental institution. Thanks Ladies!!!

8. Let's get physical.

Most people who are looking into plastic surgery are doing so because exercise has not been effective on certain areas of the body. There are only so many chest flies one can do before you realize they won’t make your boobies stand up and say hello. However, there are some who think this is the alternative to diet and exercise. If that is you….you are wrong. I truly believe my fitness level aided in my recovery time. And I know that I will have to work twice as hard to keep my new body looking tip top. The more active and healthy you are before surgery, the better your recovery will be. You will heal faster, feel better sooner, and be back to the gym before you know it. As you heal, stay away from processed and salty foods, soda, and fried foods. You will swell like the Stay Puff Marshmallow Man and be so uncomfortable. When your doctor says its okay, get back into exercising and let your body lead the way. It will tell you what is too much and when to quit.

9. Don't be naive: do the research.

When I decide to do something I go full speed, head first. In this case, you need to know what you are getting into. When I began this journey, I had no idea that there was a difference between a Board Certified Plastic Surgeon and a Board Certified Cosmetic Surgeon. Now, I will not step into the argument of who is more qualified; just know who you are dealing with. Ask around; find people who have used him/her. The doctor will give you referrals, but let’s face it; they are not stupid enough to give you someone who is unhappy with their work. If you know anyone who has had plastic surgery get as much info from them as possible. There will always be someone who is unhappy with a certain PS or procedure they have had done. But there is a HUGE difference between a “well, I just didn’t like his/her bedside manner” or “I just didn’t see a huge difference in my lipo” and the “he completely disfigured me”. Be wary of the flashy salesman. Go with your gut and ask LOTS of questions. The good ones will sit with you and take as much time as needed.

10. Avoid the Debbie Downers.

We all know one….the Debbie Downers, the buzz kill. And most of us will have to deal with a few after surgery. It is really hard when you feel that you don’t have the support from your loved ones. The choice to have a mommy makeover is strictly yours and hopefully you are doing this for you and only you. I have had a few family members of mine that I surprisingly haven’t received support from. It is hurtful, especially since they saw me struggle with my weight and self esteem issues for years. A lot of people will see it as a “waste of money”. I started feeling the need to explain my reasoning for having the surgery. I wanted them to know that it was not out of vanity, or selfishness. But remember the old saying “Those convinced against their will, are of the same opinion still.” It really doesn’t matter. As much as I wanted them to hear me out and understand my reasoning, they won’t. If they love you, they will keep their negative comments to themselves and support you no matter what. But you may have those who love you yet still feel the need to give their opinion even when not asked. My response to those people would be a nod and a smile. (Believe me, I know it’s hard) If you want, throw in a “please keep your negative comments to yourself” or a “if you don’t have anything nice to say…”. But my advice is to steer clear of the “screw you” sort of comment. It is just not worth it. As long as you know why you are doing this that is all you need. For me, being able to look in the mirror, smile and for the first time in my life, love what I see…well that is priceless to me. And for those who can’t see past the money or their opinions, they are missing out on watching someone they love transforming into the person they have always dreamed of being.

For more information or to ask questions directly about Mommy Makeover surgery, visit my website!  

Friday, November 26, 2010

Nipple-Sparing Mastectomy: The Ultimate Aesthetic in Breast Reconstruction

Over the last 10 years, there has been an increasing awareness among General/Breast Surgeons that in many cases, it is not necessary to remove the breast skin along the breast tissue. This is called NIPPLE-SPARING MASTECTOMY (NSM):

Advantages of the NSM and immediate reconstruction technique:
  1. It is a single-stage technique with only one general anesthetic in the majority of cases
  2. There are no visible scars on the breast, unless later mastopexy ("breast lift") is desired or needed
  3. It is performed using an adjustable permanent implant, not a tissue expander, OR a flap reconstruction
  4. The implant or flap is placed over the muscle to avoid animation ("motion") deformities when the pectoralis major muscle flexes
  5. The recovery is shorter and involves significantly less pain than traditional two-stage expander-implant breast reconstruction
  6. This is an oncologically safe, unique mastectomy technique which cores out the nipple on the involved side for additional Pathological tissue analysis
  7. In some cases, it is possible to perform a nipple lift (mastopexy) at the same time as the mastectomy and reconstruction
  8. This technique is the simplest, quickest, most aesthetically pleasing technique for women who are considering prophylactic mastectomy for genetic risk.
  9. There is no delay of radiation or chemotherapy due to a speedy recovery and extremely few wound healing problems

The NSM technique has taken years to refine, but we believe it is the simplest and most aesthetic single-stage implant reconstruction. It is also being used in our practice with the DIEP flap and other microsurgical flaps such as the inner thigh (TUG) flap.
NSM is ideal for women who are carriers of the BRCA-1 or BRCA-2 gene and other women with a strong family history of breast cancer who are seeking prophylactic mastectomy and breast reconstruction. It is also appropriate for women with DCIS and invasive cancer that is at least 2 cm away from the nipple.

For those women who have tumors which are very large, very aggressive, or involving the nipple, single stage reconstruction removing the nipple is still available. This is also done over the muscle in our practice.
NSM is performed through an incision hidden under the breast, in the breast fold ("inframammary fold"), limiting the scar.  Following mastectomy, in the same operation, reconstruction is performed using either an implant or a flap. 

Read about my patient Desdemonia's experience with this procedure!

If an implant is placed, it is located in the exact same space that the breast was, on top of the pectoralis major muscle.  A permanent, adjustable implant is used.  It is inflated approximately 60%-80% of the way at the time of surgery; only one or two additional inflations are required in the office in the 1-2 week period following surgery.  No "expansion" of the breast skin is needed, as the implant is not used to stretch the skin but is used to "fill out the space".  The great thing about these types of implant is that the woman undergoing the procedure is empowered to make the final decision about her desired implant size, not the surgeon!

A flap placed for reconstruction provides the ultimate soft, warm, living tissue reconstruction that has none of the risks and potential complications of implants.  

Please visit our website for more information.

Saturday, October 9, 2010


I have been asked to speak at a free seminar for young women (age 40 or younger at their diagnosis) affected by breast cancer.

I will be discussing the latest in breast reconstruction option, including single-stage breast reconstruction and microsurgical techniques such as the DIEP flap, the SIEA flap and the TUG (inner thigh) flap: 

A few of my patients will be invited to also be there to share their personal stories about their reconstruction experience.

To RSVP, contact and visit for more information on my practice.

Hope to see you there!

Monday, August 23, 2010

Mommy Makover surgery requires at least 6 weeks for a full physical recovery

After any major surgery such as a Mommy Makeover, you need to give yourself the time needed for complete physical recovery.

In most instances, a Mommy Makover includes a breast lift/implants (or breast reduction), a tummy tuck and/or liposuction.

For each of these surgeries individually, I counsel my patients to take 6 weeks off aggressive physical activity such as exercise, and to take at least 2-3 weeks off work, longer if they can!  For combined procedures, the effects can be cumulative and recovery can take a little longer. 

Becoming too active immediately after surgery can increase the risk of complications such as hematoma (bleeding), wound healing problems, increased bruising and pain!  You may also have drains, that require special care and attention until they are removed.  

When at home, rest as much as possible and have friends and family members assist you with your activities of daily living - like making meals, cleaning, child care, and transportation. 

If you need to work from home early on after surgery or at you desk at work, be sure to get up and move around at least each hour to encourage circulation in your legs and lungs, and be able to delegate any lifting more than 5 pounds to others in the workplace or your family for the first 4 weeks.

You are planning to invest a great deal of time, effort, energy and money into your surgery - be sure to also invest the appropriate effort in your recovery!

Tuesday, July 27, 2010

Tomorrow: FREE live teleconference! Breast Reconstruction: Understanding Your Options

Tomorrow, July 28th 2010, at 12:00 p.m. EST (9:00 a.m. Pacific time), I am honored to be speaking at the Living Beyond Breast Cancer's LIVE educational teleconference!

The topic is "Breast Reconstruction: Understanding Your Options".  

Educational Programs

Breast Reconstruction: Understanding Your Options

Our July teleconference will help you learn about your choices for breast reconstructive surgery

Join Living Beyond Breast Cancer for our next free teleconference, Breast Reconstruction: Understanding Your Options, from 12:00 p.m. to 1:15 p.m. Eastern Daylight Time (EDT) on Wednesday, July 28.
Karen M. Horton, MD, MSc, FRCSC, a board certified plastic surgeon with Women’s Plastic Surgery, will help you learn about:
This teleconference will also discuss questions to help you explore whether you want to consider reconstructive surgery.

About Our Speaker
In addition to her board certification, Dr. Horton is a reconstructive microsurgeon. She practices in the Pacific Heights area of San Francisco.

Dr. Horton educates, empowers and informs women about options for breast reconstruction after cancer. Her goal is to use techniques that do not sacrifice major body muscles, enabling women to have reconstruction with the least number of stages. She specializes in microsurgical breast reconstruction, including DIEP flap, SIEA flap and TUG (inner thigh) flap.

Dr. Horton has published review book chapters on breast reconstruction. She presents clinical papers at national and international scientific meetings and has won research awards. Dr. Horton also specializes in "mommy makeover" cosmetic surgery for women.  Read more here!

About the Program
Our speaker will give a brief presentation, followed by a question-and-answer period. To participate, you need only a telephone or computer with Adobe Flash Player or Windows Media Player. Social workers may be eligible to receive continuing education credits; see our registration form for more details.


For those who cannot tune in online tomorrow, it will be recorded and an MP3 and PDF of my slides will be posted shortly on the Living Beyond Breast Cancer website.

Thursday, May 6, 2010

"Skin tightening" quick-fix remedies do not solve the real problems of the post-pregnancy tummy!


Karen M. Horton, MD answers: Non surgical skin tightening for the tummy?

I am a mother of 4 children. I had my first child at the age of 16. I was told that because of my young age my skin stretched a lot, hence all the stretch marks. Ever since I have had a lot of loose skin in that area is there anything that I can do to tighten it without surgery???
"Skin tightening" procedures, namely laser-type therapies or injection treatments, do NOT address the underlying issue of a Mom's tummy after she has had multiple pregnancies:
  • Excess skin and fat
  • Stretch marks
  • "Rectus diastasis" = separation of the muscles of the abdominal wall away from one another, creating loss of muscle tone and a bulge
Only a surgical procedure, abdominoplasty (and/or liposuction in some cases), can address each of these factors.

Beware of smooth-talking salespeople who do their best to get you to sign up for a "package deal" of procedures.

Often, minimally invasive therapies such as these prey on those Moms who are frightened of surgery and are looking for a quick fix with supposedly less downtime and fewer scars.

However, the checkbook can often be the area to suffer the most with non-surgical therapies, together with a general disappointment with results!

Visit a Board-Certified Plastic Surgeon with experience in Mommy Makeover surgery to help determine which procedure(s) will best achieve your goals!

Wednesday, April 28, 2010

Abdominoplasty can also involve liposuction for a contoured waist - as long as it is safe!

Karen M. Horton, MD answers:  

Can liposuction and tummy tuck be done at the same time?

Abdominoplasty has the goals of removing excess skin and fat from the lower abdomen, tightening the abdominal wall contour, and bringing the rectus abdominis muscles back together in the midline.

On the other hand, liposuction simply removes excess fat in areas where it is deposted in excess.  Sometimes, these two procedures are combined for the most aesthetic result. However, this must be done in the safest way possible, without creating additional risks.

I usually perform the abdominoplasty portion first.  This removes most of the lower abdominal and pubic area fat by direct excision, and liposuction is not needed for these regions.  I then evaluate whether there is any additional fat remaining that may be appropriate for liposuction - for instance in the flank and/or upper abdominal regions.

Of course, other areas of the body such as hips, inner or outer thighs are often addressed at the same time as an abdominoplasty, as complimentary procedures.

Next, if considering liposuction to enhance the abdominoplasty procedure, I will infiltrate the tumescent solution into the remaining abdominal regions.

Tumescent solution functions to temporarily constrict the blood vessels in the area and decreases the risk for bleeding and bruising with suctioning of fat. If any of the abdominal skin appears to have a compromised circulation, then I will stop here and not perform liposuction, to avoid the risk of wound healing problems.

However, if the abdominal skin appears to be healthy and pink, without any circulatory compromise, I may also perform a careful and limited amount of liposuction, usually to the flanks and possibly upper abdomen and/or pubic area at that time.

In Plastic Surgery, healing is based on having a good circulation to the tissues. It is always wise to do the safest procedure and avoid complications, rather than power ahead and risk "doing too much" at one time!  Safety first!

Karen M. Horton, M.D., M.Sc., F.R.C.S.C.

Sunday, April 18, 2010

Mommy Makeover Surgery - Rejuvenation of the Breasts and Body for Moms, Especially After Twins!

For Moms, a "mommy makeover" can be an empowering experience, particularly for mother who have had a twin or multiple pregnancy.  The following is an online article I gave for the incredible website Twin Pregnancy and Beyond.  I was interviewed by its creator, Kellie:

Plastic Surgery After Twins
Getting Your Body Back

plastic surgery after twins We were so lucky to get some of the best information on plastic surgery after twins from a Board-Certified Plastic Surgeon. This informative article covers our interview with Karen Horton, M.D., and her advice on getting your body back after twin pregnancy via plastic surgery.

Her knowledgeable, straightforward counsel will help anyone who is interested in what's commonly referred to as a "Mommy Makeover". You will definitely get a better grasp on what's involved, recovery and costs. She also dicusses what happens to our bodies after twin pregnancy, as well as what to look for in a plastic surgeon and other available procedures. A must read!


Karen Horton MD I am a Board-Certified Plastic Surgeon and Reconstructive Microsurgeon, practicing in the Pacific Heights area of San Francisco. I specialize in both reconstructive surgery and cosmetic surgery for women, and in particular, Moms! Please visit my bio for additional information.

At least half of my practice focuses on breast cancer reconstruction, using new techniques that are not yet widely performed in the United States: (1) Single-stage procedure using an implant, giving women a natural result without the need for multiple surgeries; and (2) Microsurgical reconstruction of the breast using the body's own tissue, usually from the lower abdomen or inner thigh area. This option avoids the use of implants, and provides a permanent, soft and living tissue reconstruction, while adding the benefit of a tummy tuck or a thigh lift!

The other part of my practice focuses also on women, most of them Moms! The "mommy makeover" spectrum of procedures rejuvenates a woman's body after she has completed childbearing. This type of surgery usually focuses on the breasts and body.

Many women who come to see me after doing an internet search say they feel more comfortable because I am a woman Surgeon. I think many women feel most comfortable discussing their bodies, their body image and self-esteem, and their personal goals for surgery with another woman - with the same anatomy, and who can relate to them as a peer as well as their doctor.

I give every single patient who walks through the door or my practice my full attention and absolute care. I get to know my patients intimately, and strive to understand them as a whole person. I explore how their desire to modify a part of their body will affect their life, health, wellness and spirit, and I encourage realistic goals and objectives for surgery. Each of my patients is given my personal cell phone number, and my patients are encouraged to contact me directly with any questions or concerns, no matter how big or small.

(especially a twin pregnancy)?

twin pregnancy stretch marks Many women find their abdomens have permanent changes following pregnancy, including stretch marks, loss of abdominal tone, excess skin and extra fat deposits that have accumulated since having babies.

Most mothers do not have complete recovery of their bodies after children. Many of my patients are personal trainers, who also need a little help once they are mothers!

Regardless of whether you breastfeed or not, having babies "suck the life right out of them" (your breasts)! The breasts are usually more and more deflated with each subsequent pregnancy.

This loss of volume is usually addressed by a breast augmentation, and sometimes a breast lift is incorporated to move the nipple and areola up to a more aesthetic position and to tuck excess breast skin. Twin pregnancies and multiple births can amplify the changes to a Mom's body.

Often the abdominal skin and rectus muscles are stretched so far apart that a hernia occurs, which is visible when you try to do a sit-up as a protruding bulge in your midline. This is repaired in a standard abdominoplasty, together with tightening your muscles and removing excess skin. There is no substitute for this incredible operation, which is one of my favorites to do!

How a mother feels about herself as a mother and a woman is integral to her self image and self esteem. For a mom to want to take care of herself and feel youthful, sexy and confident is NOT self-centered or vain!


A Mommy Makeover can include a breast lift, breast augmentation or breast reduction, depending on the changes of pregnancy and your specific aesthetic goals.

Because the muscles of the abdominal wall are permanently separated after pregnancies (particular after multiple children or twin pregnancies), a million sit-ups will not help! A tummy tuck (abdominoplasty)and/or liposuction is often recommended to bring the abdominal muscles back together in the midline, and to recreate a flat belly.

A "mommy makeover" surgical procedure should only be considered at least 6 months after the birth of your last child so that your body has the chance to recover as much as possible and to enable you to achieve as much as you can on your own, with a healthy diet and regular exercise.

I encourage each of my patients to become as physically fit as possible before considering any major surgery. If you are athletic and your body is used to being stressed physically, with endorphin release and a good heart and lung workout, then surgery will be much less of an insult to your body. If you are a couch potato and do no physical activity at all, then surgery will be a huge stress to your system and your recovery will be much more difficult.

Any Plastic Surgery operation is a major deal. Each procedure involves cutting and sewing, bruising, downtime, discomfort, and healing time. Reality shows and celebrity gossip magazines often portray Plastic Surgery in an unrealistic light, minimizing the downtime and sensationalizing the results.

In addition, many Hollywood celebrities who have had more than their share of cosmetic procedures look abnormal and have lost their natural beauty. The best Plastic Surgery does not make you look different, does not distort your features, and is not overtly obvious to any passer-by. Most women seeking surgery in my office want a natural result, without looking "fake" or "done". Most Moms usually just want their pre-pregnancy bodies back, or perhaps to look even better than they did before!


Two main Plastic Surgery procedures apply to the post-pregnancy tummy:

(1) Liposuction will remove excess fat in areas that are stubborn to weight loss, such as the abdomen, flanks, pubic area, and thighs. Liposuction will not address excess skin or stretch marks, and will not help to tighten abdominal tone.

(2) Abdominoplasty or "tummy tuck" addresses both the inside and the outside of the abdominal wall, in a three-dimensional manner:

Tummy tuck surgery not only removes excess skin and fat from the lower abdomen (including some stretch marks), but it also tightens the muscles of the abdominal wall through "rectus plication". This step of surgery "corsets" the fascia overlying your abdominal muscles together in the midline and truly decreases the diameter of your waist from the inside! The bulge of pregnancy ("rectus diastasis", separation of the rectus abdominis muscles) is an integral part of this operation.

Depending on your particular situation, either liposuction or a tummy tuck, or both, may be recommended to achieve your specific goals.

An abdominoplasty has major downtime and recovery, and will require 4-6 weeks off of exercise and heavy activities that raise your heart rate or blood pressure, including carrying your children. You will need to have help with the activities of daily living during the immediate postoperative period, and ensure that you take care of yourself during this time, with others helping to care for your family!


should I have a boob job Loss of breast volume after having children is corrected by placing a breast implant behind the breast tissue to fill out what has been lost.  

Breast augmentation can help restore a woman's sense of proportion to her body, and in many cases can improve a Mom's self-esteem and confidence. Breast implants are placed either behind the breast tissue (subglandular position) or behind the breast tissue and the pectoralis major muscle (submuscular position). There are proponents for each technique, based on opinion and surgical training.

Regardless of the placement of the implant, the fill material and the size, having breast implants does not interfere with breast self-examination, physician breast exams, mammograms, ultrasound, MRI or any other cancer detection techniques.

Breast implants are safe! All implants have a silicone shell; silicone breast implants are the most widely studied medical device in the history of the FDA. To read more about the science and safety of all implants, visit the website.

Breast augmentation using implants will not interfere with breast cancer detection. Implants of all shapes and sizes have a shell made from silicone, which is an inert solid and is used in many implantable devices. The fill can be either saline (sterile salt water) or silicone gel. Sizes range from 125 cc to 800 cc, and implants may be smooth-walled or textured, round or shaped.

If you are "happy in a bra" and do not usually wear padding in your bras to achieve your aesthetic goals, a breast lift alone may be your answer for sagging breasts. Breast lift surgery (known as mastopexy) can restore droopy breasts to a normal size and shape. This operation, although similar to breast reduction, is considered cosmetic and is rarely covered by insurance.

A mastopexy reshapes and lifts the breasts, removes excess skin from stretched-out breasts, lifts the nipples and areolas to a more youthful position, and makes the diameter of stretched areolas smaller. Breast lift surgery creates scars that are permanent, but which fade with time, and are hidden in a bra and even a triangle-string bikini top. If you desire both replacement of lost volume and a lift to your nipples, a combination augmentation-mastopexy may be indicated.


I also see women with concerns about excess tissue in their external genitalia region, the labia minora. Hanging or redundant labia skin can cause embarrassment, pain with intercourse, or friction or sores when walking or doing exercise. One procedure I perform to correct this is called labiaplasty.

Labiaplasty surgically reduces excessive large labia minora tissue to create symmetry when it is lacking, and to make the labia appear more cosmetically appealing. Occasionally excess tissue around the clitoral hood is also carefully trimmed, without any injury to the nerves that provide sexual stimulation.


It is important to realize that any body-modifying surgery can have a major impact on body image and self-esteem. Hopefully, the change is a positive one!

However, just like a drastic haircut, there can be a "body image adjustment" period or temporary feeling of remorse after surgery. I counsel my patients at their initial consultation that this adjustment period of potential feelings of uneasiness, anxiety or "what have I done?" is completely normal and common after surgery. It can take some time to adjust to your body after any surgery, and the most healthy approach is to acknowledge how you are feeling and to communicate this to your loved ones who are assisting you after surgery.


team of doctors A Mom should do her homework when seeking a Plastic Surgeon! You will be trusting your body to this person! Do your 'due diligence'. The surgeon should be Board-Certified and a member of the American Society of Plastic Surgery (ASPS - if in the United States) or another major professional society, and should be current in their Board Certification and training.

They should have a great deal of experience in the procedure you are seeking, and should show you multiple before-and-after photographs of their results - not just the best outcomes, but "average" results in body shapes and types just like you! Ask to speak to some of their patients who have had surgery with the Surgeon, and don't be shy about asking them all about their experience - you need to know the good, the bad, and the ugly!

Bring a list of questions with you, and bring a friend to act as another listener and objective observer. There should be a "good fit" between you and the physician - in terms of personality, aesthetic goals for the procedure, office staff atmosphere, etc.


I don't usually discuss the costs of surgery - this is left up to my Patient Coordinator Mary, who spends time with patients once they have completed their consultation with me, which usually lasts 45-60 minutes on our first visit. Mary then reviews the procedures we have discussed and provides an estimate of the total costs of the procedure(s), which include a surgical fee, operating room time, anesthesia fees, and sometimes an overnight stay in the hospital.

Estimated costs for the doctor's fee for some common procedures include:
* Breast augmentation $ 4,200 - 5,000
* Breast lift $ 6,000 - 8,000
* Breast reduction $ 6,000 - 8,000 (some cases may be covered insurance)
* Abdominoplasty $ 6,000 - 10,000
* Liposuction (per site) $ 2,000 - 3,500
* Labiaplasty $ 3,500 - 4,000

Keep in mind that when multiple procedures are done at the same time, the overall cost is less and discounts are given. I usually recommend no longer than 6-8 hours under anesthesia, and mandate an overnight stay for any procedure longer than three hours.

Karen M. Horton, M.D., M.Sc., F.R.Cf.S.C.
Womens's Plastic Surgery
San Francisco, California

Full "tummy tuck" closure with DIEP flap breast reconstruction... A good idea?

"It is possible to do rectus plication with DIEP flap donor site closure for a full abdominoplasty result"

Karen M. Horton, MD answers: Possible to do full tummy tuck while doing diep flap procedure?

I understand that the diep flap benefit of a real 'tummy tuck' is not covered by insurance. Is it reasonable to ask for the cost of a full tummy tuck (sewing together muscles, etc.) while the surgeon is performing a diep flap procedure? My surgeon seems very reluctant to even discuss outlying procedures such as abdominoplasty and liposuction, which I believe are both necessary to achieve the best final results. If I'm willing to pay for these procedures out of pocket, I don't know why my surgeon won't discuss them. Any insight appreciated.
Karen M. Horton, MD

When the DIEP flap (deep inferior epigastric artery perforator flap) is used for microsurgical breast reconstruction, usually a small split is made in the muscle fascia (thick layer of collagen over top of the rectus abdominis muscles) to dissect out the blood vessels used for transplantation of skin and fat from the tummy to the breast.

Usually, the fascial split is simply closed, and the overlying anterior abdominal wall (sheet of skin and fat over the muscles of the trunk) is pulled tighter and closed, resulting in a tummy tuck scar.

It IS possible to perform rectus fascial plication (corsetting of the rectus abdominis muscles of the abdominal wall towards each other in the midline AT THE TIME of DIEP flap donor site closure.
However, doing so may change the pressures inside the abdominal cavity (i.e. on the stomach, intestines, diaphragm, etc) and may increase the risk of complications to the flap circulation in the short term. The worst case scenario would be to perform cosmetic steps during surgery and to lose the flap altogether!

Performing a full tummy tuck closure with the DIEP flap is something I HAVE performed successfully on a number of occasions, but patients must be very carefully selected and we would all have to be willing to accept an increased risk for complications.

I am currently reviewing my results on this combined procedure and will be presenting my work at upcoming meetings and in the form of a scientific paper, to be published on my website.

Often, the best solution is the simplest. On the day of your DIEP flap, it is usually best to focus only on microsurgical success. "Touch-ups" can be done any time in the future, including liposuction contouring of the abdomen (done in most of my patients) together with their nipple and areolar reconstruction, and/or rectus fascial plication, if needed.

See the photographs below of an example of rectus fascial plication done either at the time of DIEP flap donor site closure.  Trust your Microsurgeon to make the best decision for you, and to ensure a SAFE and SUCCESSFUL breast reconstruction as the #1 goal!

Karen M. Horton, M.D., M.Sc., F.R.C.S.C.

Sunday, April 4, 2010

Words of Thanks from a Breast Cancer Survivor

The following is a message from one of my patients who underwent bilateral skin-sparing mastectomies and immediate reconstruction using the DIEP/SIEA flap.  

Words like hers are the exact reason why being a Plastic Surgeon and Reconstructive Microsurgeon is so absolutely rewarding...

Dear Karen,

    My breasts are so beautiful. My torso, too. I'm overflowing with affection, appreciation and feelings of indebtedness towards you. This is so personal. YOU led me here. Not you, the doctor. Not you because this is your job. But the loving, caring, giving you. 

   Your training and gift as a surgeon are your vehicles but it's your heart and your soul that speak to the patient.You gave me the chance to put aside fear, stale ideas, and martyrdom (from childhood! YIKES! I didn't even know it was still there until all of this,) to reach in and stretch my uninformed "normal" view. When Dr. Richards first mentioned "reconstruction" I thought I had misunderstood. I had cancer. What does reconstruction have to do with that? Of course, everyone is familiar with breast cancer and, afterwards, reconstruction,  but these are remote concepts to those who have never experienced it.  

     "Let's just get rid of the cancer," I said to myself. "I don't need new boobs. They haven't been cute since I was last breast feeding. I'm already settled in with older-ish woman boobs, anyway. My middle-aged persona has been developed with older-ish woman boobs playing a key role. WHAT are they all talking about?" Now, I have breasts and they are lovely!

    When I met you, I was scared. Maybe you were the first person ever to say, " Joanne, What do YOU want? This is for you. Only you. What do you want ?" Maybe I was very receptive at that time in my life to consider such a question. My body, my choice. In those days, I would have been satisfied to get rid of the cancer, but I did consider your question . You gave me an open door to think about it. I did think about it. A lot. Before long I was able to decide that I did want new boobs. You know the rest of the story.

    Now that you've completed your magic on me, I feel so new. So alive. So complete. I haven't been swimming for awhile. Now I can't wait for summer.  My sexuallity was dormant. Now it is reawakened! I was a bit reclusive. Now I'm not. Each moment of my life has been improved, deepened, and is more satisfying since having received your care.

    I will be thanking you for the rest of my life for the most awesome and generous gift I have received from you. 

    Karen, I am so eternally grateful to you for staying with me at a time of great despair.

    With love, gratitude, and appreciation,

    Thanks so much, ~joanne