WOMEN'S PLASTIC SURGERY

Rebirth of the Women's Plastic Surgery blog

2012-01-08T21:42:00.000-08:00

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

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

2011-01-26T11:45:00.000-08:00

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
Audience:

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)	Median	51
Age (years)	Range	28-87
Type of Implant	Silicone	24
	Saline	7
	Not specified	3
Time from Implant to ALCL Diagnosis (years)	Median	8
Time from Implant to ALCL Diagnosis (years)	Range	1-23
Reason for Implant	Reconstruction	11
	Augmentation	19
	Not specified	4

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.

Patients:
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

2011-01-26T11:01:00.000-08:00

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:

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

Anaplastic Large Cell Lymphoma (ALCL) In Women with Breast Implants: Preliminary FDA Findings & Analyses

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.

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Repost of a wonderful article by a Mommy Makeover patient!

2010-12-28T22:54:00.000-08:00

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

By JenBob

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. Realself.com 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!

Nipple-Sparing Mastectomy: The Ultimate Aesthetic in Breast Reconstruction

2010-11-26T14:47:00.000-08:00

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:

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

Upcoming Presentation: RECONSTRUCTION OPTIONS FOR YOUNG WOMEN AFFECTED BY BREAST CANCER

2010-10-09T13:03:00.000-07:00

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 yscnorcal@youngsurvivalcoalition.org and visit http://womensplasticsurgery.com/about_horton.html#571 for more information on my practice.

Hope to see you there!

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

2010-08-23T22:52:00.000-07:00

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!

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

2010-07-27T15:27:00.000-07:00

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

Speaker: Karen M. Horton, MD, MSc, FRCSC

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:

Different types of reconstructive surgeries
The latest research in rebuilding the breast
How to determine the option that is best for you
Microsurgery, nipple reconstruction and immediate versus delayed surgery
The stages of the reconstruction process
What to expect during your recovery

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.

TO REGISTER, CLICK HERE!

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.

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

2010-05-06T12:15:00.000-07:00

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???

By Karen M. Horton, MD - San Francisco Plastic Surgeon

"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!

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

2010-04-28T22:08:00.000-07:00

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.

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

2010-04-18T20:17:00.000-07:00

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

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!

WHAT TYPE OF DOCTOR ARE YOU AND WHAT DO YOU SPECIALIZE IN?

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.

CAN YOU TELL US A BIT ABOUT WHAT HAPPENS TO OUR BODIES. ABDOMENS, BREASTS AFTER PREGNANCY
(especially a twin pregnancy)?

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!

WHEN DIET AND EXERCISE HAVE DONE ALL THEY CAN FOR A WOMAN WHO HAS TRIED TO LOSE THE POST-PREGNANCY WEIGHT, WHAT TYPES OF PROCEDURES SHOULD SHE CONSIDER?

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!

WHAT TYPES OF PROCEDURES ARE AVAILABLE FOR WOMEN WHO WANT TO ADDRESS THE EXTRA SKIN, STRETCH MARKS, AND BELLY BULGE LEFT AFTER HAVING TWINS?

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!

LET'S TALK ABOUT BREASTS. FOR THOSE OF US WHO HAVE BREASTFED OUR TWINS, WHAT CAN WE DO ABOUT THE INEVATABLE SAGGING?

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 BreastImplantAnswers.com 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.

ARE THERE ANY OTHER PROCEDURES OR TOPICS YOU WOULD LIKE DISCUSS?

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.

A FINAL WORD OF WARNING:

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.

WHAT SHOULD WE BE LOOKING FOR IN CHOOSING A DOCTOR TO PERFORM THE AFOREMENTIONED PROCEDURES?

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.

COST WISE, CAN YOU GIVE US A BALLPARK FIGURE ON WHAT WE SHOULD EXPECT TO PAY FOR SOME OF THE MENTIONED PROCEDURES (plastic surgery after twins)?

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?

2010-04-18T11:08:00.000-07:00

"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.

By Karen M. Horton, MD - San Francisco Plastic Surgeon

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.
www.womensplasticsurgery.com

Words of Thanks from a Breast Cancer Survivor

2010-04-04T18:32:00.000-07:00

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

The Psychology of Potential Cosmetic Surgery Patients - The Surgeons' Perspective

2010-04-04T15:14:00.000-07:00

The following was taken from an ASAPS publication, Selling the Invisible: 7 Simple Strategies to Increase Your Patient Census, by Catherine Maley, MBA, Author, Your Aesthetic Practice

Since this is what the Plastic Surgeons who perform cosmetic surgery are reading, I thought it would be useful to post this article for potential patients and the general public to read as well! I welcome comments about its content and its perspectives.

Imagine being an aesthetic patient today trying to swim through the sea of information and options available for cosmetic enhancement. It is often daunting to sort out fact from fiction, hype from reality and marketing from credibility. The aesthetic patient wants to improve something that bothers them and they have to take a big leap of faith to get the result they are imagining.

When you understand how difficult this process can be for the aesthetic patient, you can more easily establish rapport with them and help guide them to make the best and safest decision.

What Is The Patient Buying?

What are your patients really buying? Prospective aesthetic patients want to change something about their appearance and they hope fixing, repairing or enhancing a certain aspect of themselves will make them feel better. They feel vulnerable and are looking for help.

Psychologically, they are buying hope, happiness and self esteem. They are also buying peace of mind. Patients want to avoid making a bad choice. They are considering risks and how to minimize them. Because they do not want to regret their decision, they are looking for reassurance. It is important to them that they are in the right place for the right procedure and that they trust they will get a good result.

Aesthetic Patients are Consumers

Since this target market is using their own disposable income to look and feel their best, they are consumers and have the power and freedom to choose their aesthetic practitioner at whim. Ultimately, aesthetic patients are doing a cost-benefit analysis to determine if what you offer is worth their time, money and effort.

Consumer behavior is a complex subject since it involves emotions, personalities and life experiences so, to simplify, the following concepts should help in your understanding of what your patients want and need.

Your aesthetic patients are consumers. The following are four buying groups they fall into and includes advice on the best approach to reach them:

1. "Tire Kickers"

This group doesn’t know what they want. They seem to have a lot of time on their hands because they will attend your events, eat your food, take your samples and never, ever buy. They may even book a consultation, go through the motions but never book a procedure. Do not exert energy on this group since it’s a waste of time.

2. "Deal Makers/Price Shoppers"

This group is looking for the best deal in town above all else. They have a tendency to regard cosmetic enhancement as a commodity and will spend much of their consultation negotiating with you and your staff. To them, it’s an art form to get you to lower your prices or throw in freebies. Beware of them. Shut them down
on their first attempt to lower your price by firmly restating what it is.

3. "Brand Loyalists"

This is your favorite group. They love you and would not go to anyone else—even if a competitor was half your price! They are your cheerleaders, your advocates and your loyal followers. Treat them well and they are yours for life. Most of your efforts should be concentrated on this group and growing it to include their loyal friends, family and colleagues.

4. "Luxury Innovators/Quality Shoppers"

While this group wants only the best and will pay for it, they can be difficult. They have a tendency to flaunt their money and expect better treatment than your other patients get. While you should treat all of your patients with respect and special care, spending a little extra time and effort on this group can pay off since
like-minded people know other like-minded people and this can be a profitable group to appease.
The Aesthetic Patient’s Decision-Making Process

Aesthetic patients are emotional and act on prejudices and habits much more than knowledge. They reach decisions quickly with emotions and then justify those decisions with logic. And, while it takes a patient a split second to make a decision; getting ready to make that decision can take months or even years.

The answer to bonding with your prospective patients, giving them what they want and closing more procedures, is effective communications. It is most helpful to communicate with each patient the way they can best understand—especially when discussing the invisible. Patients use their senses to take in information and digest it accordingly and, typically, one sense dominates over the others. Keep these in mind when consulting with your patients:

"Looks Right" Patients
These patients make decisions based on what they see and then they visualize how it will look for them so show them lots of before and after photos and/or computer imaging. Paint them a mental picture with words. Draw out what you envision. They trust what they see. They will say things like, “This looks right to me.” or “I see what you mean.”

"Sounds Right" Patients

These people make decisions based on what they hear. When they hear words that make sense to them, they respond well, so tell them about the procedure with confidence and sincerity. Have your staff and other patients tell them about their own experiences. They will say things like, “That sounds about right.” or “I like the sound of that!”

"Feels Right" Patients

These people make decisions based on what they can physically feel so hand them a mirror, give them product samples and let them try on breast implants. Pat them on the shoulder to physically connect with them. They will say things like, “I feel good about this.” Or “This feels right.”

"Makes Sense" Patients

These people need reasons for what they do. Answer the “why” for them. Give them facts, data and reasons so they can justify their decision in their own minds. They respond well to logic. They will say things like, “Well, that’s logical.” or “That makes a lot of sense.”

Steps to Closing More Procedures

When selling the invisible service—which is you—you have no product between you and the patient. You are the product so they have to examine you as they would any other big, disposable investment they make.

Conclusion

Understanding the decision-making process of an aesthetic patient and then addressing each patient individually will improve your closing ratio. Learning to build rapport, communicate effectively, and establish trust with your patients by using the senses, will bond them to you. That means they will consistently choose you over all the others.

Liposuction Q & A with Dr. Karen Horton

2010-04-04T14:11:00.000-07:00

1. How soon will I see liposuction results?

The results of liposuction take at least three months, up to a full year, to be evident. As with any surgical procedure, you can expect some swelling, bruising, numbness and discomfort that will take a few weeks to resolve.

Postoperative tissue swelling, known as "edema", tends to persist in the tissues that underwent liposuction. Edema feels like firmness and woody texture to the tissue, sometimes with dimpling of the skin and/or a darker pigmentation. This is entirely normal; edema is the body' s response to injury! (just like a "goose egg" swelling of the scalp with a bad fall). Initially after liposuction, you may in fact gain weight, despite the removal of a few pounds of fat! This is again due to edema - the body holds on to extra water as part of its injury response.

Do not weigh yourself for at least a few weeks after surgery, at least until after the bruising has resolved (2-3 weeks). When bruising is gone, your healing will be well on its way. You will notice your clothes begin to fit differently (better) after the first three months, and every single month you will notice subtle but significant changes. The results are permanent!

Remember to be patient after having any Plastic Surgical procedure! Any type of surgery takes up to a year for every last bit of swelling and tissue edema to go away. Plastic Surgery is an investment in your body. You will need to continue your regular exercise regime (beginning at 3-6 weeks postop, or when you receive permission from your Surgeon), a nutritious and balanced diet, and healthy overall lifestyle.

2. What anesthesia is used with Tumescent Liposuction?

During liposuction, a fluid mixture commonly called "tumescent solution"containing normal saline (sterile salt water), epinephrine (adrenaline) and a local anesthetic (Lidocaine) is injected into the areas of fat that your surgeon has marked for removal before surgery. Tumescent solution functions to help "puff up" the fat cells for suctioning, decrease bleeding and limit bruising, and to make the area numb both during and for many hours after surgery.

After the tumescence is infiltrated, it is allowed to circulate for at least 10 minutes in each area. This is to maximize the "vaso constriction" effect of the epinephrine (to shrink the blood vessels in the fat and under the skin, to help avoid their injury).

The local anesthetic will keep you comfortable after surgery, although this is not the only method of anesthesia used during liposuction in most cases .Most of the time, you are also fully asleep under general anesthesia, or at a minimum under intravenous sedation so that you do not feel or remember anything during surgery.

Next, through tiny "stab incisions" that are placed in natural creases of your body, a thin and blunt-ended wand known as a "cannula" is inserted to permanent suck out fat cells. These incisions are later closed with sutures(stitches), a dressing is applied over each incision, and you are placed in a postoperative compression garment. The purpose of the compression garments is to limit swelling and bruising, encourage skin contraction, and to keep you as comfortable as possible.

3. Who can perform Tumescent Liposuction?

Liposuction is a surgical procedure, and should be performed by a specially trained Plastic Surgeon. Most Plastic Surgeons have completed at least 5 years of surgical Residency at an accredited University, with an additional year or two of subspecialty training. At least two years, and up to six of these years should be in Plastic Surgery for a Physician to call themselves a "Plastic Surgeon".

In the United States, it is important to seek out a Board-Certified Plastic Surgeon who is credentialed by either the American Board of Plastic Surgeryor the Royal College of Physicians and Surgeons of Canada (equivalent licensing Boards). Unfortunately, not all Physicians are Board-Certified. Another good resource is the American Society of Plastic Surgeons (ASPS)and/or the American Society of Aesthetic Plastic Surgeons (ASAPS). Entry to these professional societies is limited to Plastic Surgeons who have been in practice for a minimum number of years, are certified by their respective Boards, and are reviewed and accepted into membership by their peers.

It is up to you, as the patient, to do your homework not only to learn about your surgical procedure, but about your potential Surgeon! Board Certification is unfortunately not a requirement to obtain a medical license in the U.S. In Canada and other countries, Board Certification is a rule; a Doctor cannot obtain a medical license without this certification.

In addition, many non-Surgeons (Family Doctors, Internists, Dentists) or Doctors with other specialties (Oral Surgeons, Ear, Nose and Throat, OB-GYN)take a weekend course on liposuction and begin offering this treatment at a discounted rate to their patients. Beware! Just as you would not go to a foot specialist for open-heart surgery, you should not trust your body and your life to a practitioner who does not have the training and experience in the procedure you are seeking.

Lastly, be cautious of the terminology "Cosmetic Surgeon", and certification and the like. Nearly anyone can call themselves a "cosmetic" anything -most of the time, it means very little! The American Board of Medical Specialties (ABMS) and the Royal College of Physicians and Surgeons of Canada (RCPSC) only recognize University-accredited training programs in Plastic Surgeon for certification.

Again, be cautious and take your time to research your Doctor the same way you would research your nanny, a new school for your child or a contractor for your home. There is only one of you, and you are a very valuable commodity! Be sure to put yourself in the hands of the best practitioner for the job.

4. How safe is Liposuction?

Any surgical procedure carries with it potential associated risks, such as the risks of anesthesia, early risks of surgery, and late risks. Safety is always the number one goal! Most surgeries are performed in the operating room or an accredited out patient surgical facility with appropriate intraoperative and postoperative monitoring to ensure your procedure goes as safely and smoothly as possible.

For liposuction specifically, possible early risks include persistent numbness of the surgical area ("anesthesia" of the skin) that can last weeks to months, pins-and-needles or electric shock sensations of the skin as the nerves are waking up ("paresthesias"), or sometimes unpleasant sensations("dysesthesias") as a temporary experience. Bruising is common for at least 2-3 weeks after surgery, and swelling may persist for 3 months or more.

Potential late complications can include uneven contour of the skin or rippling, darker pigmentation of the treated areas, or asymmetries between sides of the body. Differences between your right and left sides will likely be pointed out by your Surgeon preoperatively. Although symmetry is always the goal, you may never be an exact mirror image from one side to the other - no one is!

As long as the procedure is performed by a Board-Certified, specially trained Plastic Surgeon with a great deal of experience in liposuction, the benefits of liposuction usually far outweigh the risks. You should also be healthy and physically fit enough to undergo surgery and have clearance from your Primary Care Physician before having any elective surgical procedure.

5. What areas are most common body regions treated with Tumescent Liposuction?

Fat deposition is primarily based on genetics. Every woman' s body is different, and your area is likely a little different from your best friend' s.

The most common areas of the body that are appropriate for liposuction are the lower abdomen hips, flanks (sides or "spare tire" area), inner and outer thighs, the upper neck beneath the chin , upper arms and the "butttockroll" (the area immediately below the buttocks). These regions are the trouble spots that most women (and some men) deposit fat and are stubborn to diet and exercise.

Areas that are not appropriate for liposuction include the knees, lower legs, ankles, lower arms, or the face (with the exception of the front of the neck). These areas are not usual areas where fat is stored, and liposuction in these regions is risky for injury to nerves, tendons, blood vessels, and the skin. Liposuction is also not applicable to internal abdominal fat - the fat that is deposited around the internal organs. It is also not a treatment for obesity or for weight loss. Liposuction is for body contouring only!

6. Can I have other operations with Tumescent Liposuction?

Liposuction is commonly performed together with other procedures - for instance breast augmentation, breast lift or reduction, abdominoplasty, or a face lift. So long as the total time under anesthesia is not excessively long (I limit my patients to maximum 8 hours of elective surgery). it is safe to have combined procedures with liposuction.

7. How does the Tumescent technique reduce risk of infection?

Vasoconstriction of the blood vessels may slightly decrease the risk of infection, as the blood flow to the area to be suctioned is reduced temporarily during the operation. However, the risk of infection is very low as a baseline risk for liposuction. Usually, a single dose of intravenous antibiotics is given immediately before surgery in the operatingroom. Oral antibiotics are often continued for a few days after surgery to also prevent infection.

Medicare Participation Among Surgeons - Current Statistics and Forecast for the Future

2010-03-31T14:55:00.000-07:00

Nation’s Surgical Groups Survey Members on Medicare Participation

March 26, 2010

Washington, DC–The results of a new member survey by the nation’s Surgical Coalition shows that the more than 21 percent pay cut to physicians that is scheduled to take effect April 1 will make it difficult, if not impossible, for already financially strapped surgical practices to continue to treat Medicare patients. A majority of the more than 14,000 surgeons and anesthesiologists who responded to the survey indicated that they will be forced to make significant changes in their practices if the cut goes into effect and that timely access to surgical care will be jeopardized if Medicare payments continue to decline. (Read the survey report (PDF))

The survey reveals that while 96 percent of respondents currently participate in Medicare, less than one-third of them will be able to remain as Medicare participating physicians. In addition, respondents indicated that practical realities will force them to stop providing certain services, reduce staff, defer the purchase of new medical equipment, and/or reduce time spent with Medicare patients. Thirty-seven percent said they will change their status to nonparticipating, and another 29 percent said they will opt out of the Medicare program for two years and contract privately with Medicare patients.

When asked, “If Medicare reimbursement to physicians is cut by over 21%, what changes to your Medicare participation status do you plan to make?” Respondents answered:

37 percent will change their status to nonparticipating
31 percent plan on remaining a Medicare participating physician
29 percent will opt out of Medicare for two years and privately contract with Medicare patients
3 percent will remain a Medicare nonparticipating physician

Among those remaining as Medicare participating physicians, three-fourths plan on making some change in their practice in the next 12 months. Respondents stated they would:

Limit the number of Medicare patient appointments (69%)
Reduce time spent with Medicare patients (47%)
Begin referring complex cases (46%)
Stop providing certain services (45%)
Defer purchase of new medical equipment (44%)
Reduce staff (43%)
Defer purchase of information technology (32%)
Significantly reduce workload/hours (17%)
Shift services from office to hospital (16%)
Discontinue rural outreach services (9%)
Close satellite offices (8%)
Discontinue nursing home visits (6%)
Retire (4%)

The payment cuts are the result of a flawed methodology called the sustainable growth rate (SGR) formula that is used to calculate payments for physicians who participate in the Medicare program. The formula contains administrative errors and fails to accurately reflect the costs of sustaining medical practices.

Physician participation is the foundation of a sustainable and functional Medicare program -- now and into the future. Therefore, the Surgical Coalition believes it is crucial that Congress pass legislation to permanently repeal the SGR to prevent the further declines in Medicare payments and to replace the flawed formula with a system that is reasonable and that will lead to a more workable reimbursement system.

The Surgical Coalition includes the American College of Surgeons and 22 other medical organizations and represents 240,000 surgeons and anesthesiologists.

The survey was conducted during February 2010. The nearly 14,000 surgeons and anesthesiologists who responded represented the following specialty areas: Anesthesiology, Cardio-Thoracic Surgery, Colon and Rectal Surgery, Facial Plastic and Reconstructive Surgery, General Surgery, Neurosurgery, OB-GYN, Ophthalmology, Oral and Maxillofacial Surgery, Orthopaedic Surgery, Otolaryngology – Head and Neck Surgery, Pediatric Surgery, Plastic Surgery, Urology, and Vascular Surgery.

Contact: Cory Petty
American College of Surgeons
cpetty@facs.org
312-202-5328

The New Guidelines for Mammograms and Breast Self-Exams: An Interview with Three Breast Experts

2010-03-15T11:53:00.000-07:00

The following is an article I conducted on the new recommendations and guidelines for mammograms and breast self-exams.

I interviewed three fantastic local (Bay Area) Breast Surgeons with whom I work closely on breast reconstruction cases. Each was asked a short series of questions about their opinion of the new guidelines, and how their practice may be affected.

Read on! (click on each page for a larger, more clear version of the magazine text)

The interview is published in the Junior League of San Francisco's Fogcutter Spring 2010 publication.

The Art of Breast Reconstruction - 9th Annual Breast Conference Conference, Presidio of San Francisco

2010-03-05T20:34:00.000-08:00

I will be speaking this afternoon at the 9th Annual Allison Taylor Holbrooks/Barbara Joe Johnson Breast Cancer Conference: Beyond Breast Cancer - Golden Gate Club, The Presidio of San Francisco, 2:30 p.m.

More slides from my presentation to follow...

What are drains? Why are they used?

2010-03-02T15:14:00.000-08:00

A suction drain is a thin, soft, silicone tube that is inserted into an area of the body where surgery has been performed - examples are following a breast augmentation, tummy tuck or breast reconstruction procedure.

The drain tubing exits through the skin and its purpose is to remove wound fluid during healing. It is attached to a small suction bulb, often in the shape of a grenade (known as a JP, or Jackson-Pratt bulb), that when compressed, applies very gentle suction to the drain tube, and slowly removes fluid from the area of surgery.

Initially, the drain wound fluid appears thick and red, as there is minor bleeding with any surgical procedure. With time (over days to a week), there are less red blood cells in the wound fluid and the fluid becomes more clear and less red. The color changes from dark to light red, pink, orange and finally clear light yellow (known as serous fluid). It is at this point that the drains are ready to be removed.

You will be asked to record the fluid your body is producing on a drain log (see the link for a downloadable form).

Just as when you scrape your knee and it initially bleeds and then weeps fluid for a time, wounds inside the body also make wound fluid. This is a normal part of healing. However, wounds outside the body that are exposed to air eventually dry out and form a scab.

Wounds that are inside the body, such as around a breast implant, or in the area of a tummy tuck, continue to create wound fluid until the body is healed. Bacteria love to grow in wound fluid - this is why Plastic Surgeons usually use drains to remove this fluid as it forms - to decrease the risk of infection and capsular contracture (contraction of scar tissue around a breast implant).

Drains are not painful, and do not hurt when they are removed in the office, usually 3-10 days after surgery. They are held in place by a small drain stitch (suture) that is cut, and the drain is easily pulled out.

After breast implant or reconstructive surgery, I usually recommend that my patients avoid showering while their drains are in place, also to decrease the risk of infection of their breast implants. You may sponge-bathe, shower only the lower half of their body, and either wash their hair in the sink or go to the salon for a wash and blow-dry (and splurge on a mani-pedi while they're there!).

Remember, "drains are your friends!". They are there to help you heal without complications and will be removed when they are ready.

Breast implant massage video - Instruction on how to keep your breast implants soft after breast augmentation

2010-03-01T16:02:00.000-08:00

Following a breast augmentation, is is imperative that women massage their breasts to keep the implant inside mobile and to ensure a soft, natural result!

To watch the Women's Plastic Surgery video on breast implant massage technique, click here.

POSTOPERATIVE MASSAGE INSTRUCTIONS FOR BREAST IMPLANT SURGERY


	MORE INFORMATION: Video: Post Reconstruction Surgery, Implant Massage Techniques Video: Post Breast Augmentation Surgery, Implant Massage Techniques Capsular Contracture Prevention Program Breast Implant Antibiotic Prophylactic Recommendations

We cannot over-emphasize how important your post-op massaging is in order to preserve your excellent results of breast augmentation surgery.

Massaging begins general at a week or two after breast augmentation surgery. You will be taught by Dr. Horton and her staff how to massage directly only your own breast.

DO NOT WORRY, YOU CANNOT BREAK THE IMPLANT. It takes more than 50 times the force of a mammogram to rupture an implant!

You should be able to make your fingers meet through the implant in both the vertical and horizontal directions. You should also move the implant around in its pocket to keep the pocket open. The best time to massage is in the shower or when you are warm and relaxed. You should massage once or twice a day for five minutes.

If you have any questions about the massage technique or whether your implant is hardening, do not hesitate to contact us.

GOOD LUCK AND HAPPY MASSAGING! See the video here: http://womensplasticsurgery.com/video_massage-aug.html.

Eat-Sleep-Plastic Surgery!

2010-03-01T15:31:00.000-08:00

This is my new favorite T-shirt! It sums up my life, from a day-to-day basis.

This picture was taken by one of my patients while I was doing rounds at the hospital one early morning.

Cool T-shirts like this and other custom messages can be ordered at CafePress.com.

Online Article with Dr. Karen Horton of Women's Plastic Surgery - Neko Cheri and NC Mag Online

2010-02-25T23:13:00.000-08:00

I was recently interviewed by Neko Cheri about my experience being a woman Plastic Surgery and in starting my practice and business in San Francisco.

Neko Cheri is the creator of NC Mag, "The intelligent woman's guide to sophisticated living", an online publication for women, by women.

She also hosts a live online talk radio show, Neko Cheri LIVE on Blog Talk Radio. Check her out!

The full article including links to my website and additional information can be read here:

INTERVIEW QUESTIONS DR. KAREN HORTON:

Q: WHAT PROMPTED YOU TO START YOUR OWN PRACTICE, AND HOW LONG HAVE YOU BEEN IN BUSINESS?

I completed a long, but very rewarding 16 year road of University study to become a Plastic Surgeon, and started my private practice in Plastic Surgery in 2006. I am one member of a unique, all-woman Plastic Surgery practice, "Women's Plastic Surgery". See our website www.womensplasticsurgery.com for more information.

Starting your first job at the age of 35 was quite different from many of my friends from college and peers in the community; however I wouldn't have done it any other way! I am exciting to get out of bed each day and to go to work, something that many others can't relate to!

When considering the options for employment, I considered different types of practice, including academic University life, an HMO setting (like Kaiser Permanente), a large group practice, or private practice.

For me, private practice was the best fit, in that it enabled me to develop a specialized practice, focusing on the areas of Plastic Surgery I am most passionate about, and to deliver the best patient care, in a personal setting.

Q. WHAT IS YOUR AREA OF EXPERTISE?

At least half of my practice focuses on breast cancer reconstruction, using new techniques that are not yet widely performed in the United States. One technique for reconstruction of the breast involves a single-stage procedure using an implant, giving women a natural result without the need for multiple surgeries. Another novel technique involves Microsurgery to reconstruct 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, many 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. There are permanent changes after pregnancy such as breast deflation or drooping, loss of abdominal muscle tone, and/or excess skin and fat in the middle section or thighs. Many of my patients are personal trainers, who also need a little help once they are mothers!

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.

Lastly, I see patients for general Plastic Surgery concerns: moles, skin cancers, and other body concerns. Labiaplasty is one procedure I particularly enjoy! Redundant labia minora tissue (inner lips of the female external genitalia) that hangs lower than the labia majora (outer lips) is trimmed for both cosmetic concerns and sometimes for pain during intercourse.

Q: WHAT WOULD YOU SAY IS THE MOST SIGINIFICANT ADJUSTMENT THAT WOMEN HAVE AFTER SURGERY?

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.

Q: IT SEEMS THAT PLASTIC SURGERY IS A MALE DOMINATED INDUSTRY HOW HAVE YOU BECOME SO SUCCESSFUL?

Many women come to see me after doing an internet search 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.

Q. WHAT HAS BEEN THE MOST CHALLENGING PART OF STARTING YOUR PLASTIC SUGERY BUSINESS?

In Medical School and Residency, we are given NO business teaching or training! Subsequently, it is a crash course in self-employment for most Physicians. I am still learning about running a business, managing employees, hiring and firing, overseeing the books, etc! Sometimes I wish I could just wake up with an MBA degree and naturally understand it all. My business aptitude is a work in progress, but I'm enjoying the journey.

Q: WHAT ARE SOME OF THE MILESTONES YOU HAVE ACHIEVED IN THE PAST YEAR?

In the past year, I have helped literally hundreds of women become whole again after breast cancer, feel sexy and youthful again after pregnancy or aging, and to be more comfortable and confident in their own skin. This provides such gratification to me; it's almost a bonus that I get to make a living doing this!

Within five months of starting my practice in July 2006, I was covering my overhead and starting to make a profit, which is a feat in itself! Since then, I have maxed out my practice schedule, and am fully booked in the operating room and in the office. I now officially need to focus on "working smarter, not harder".

Q. WHAT IS THE MOST COMMON MISCONCEPTION ABOUT PLASTIC SURGERY?

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 (no names needed!), look abnormal and have lost their natural beauty. The best Plastic Surgery does not make you look different, does not distort your facial 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".

Q. WHAT ADVICE WOULD YOU GIVE TO A YOUNG WOMAN LOOKING TO WORK IN YOUR FIELD?

I had very few female Mentors during my training. My father is a General Surgeon and was a breast cancer specialist, who undoubtedly influenced me, although he was a workaholic and hardly ever around! My mother held a Ph.D. in Biochemistry, and instilled in my sisters and me the conviction that "you can be anything you want in life, except a Daddy!"

I was raised to believe that I could achieve just about any career goals I wished, as long as I received good grades in school and worked hard. My parents encouraged me to investigate other career fields, based on my interests of art and drawing, such as architecture and fine arts. However, medicine and surgery was the best fit for me, based on my fascination with the human body, science and figuring out the way things work!

A career in Plastic Surgery is difficult to enter and is fiercely competitive. In Canada, my birthplace and location of training, only ten training spots are available each year, and the competition is intense. Four years of undergraduate University, four years of Medical School, five to six years of Plastic Surgery Residency, and often a final year of Fellowship training are necessary before you can start your own practice.

I encourage students who are interested in learning more about Plastic Surgery to shadow me in the office and the operating room, and I regularly mentor young females who are considering a career in Medicine.

Q. WHAT IS THE REWARDING PART OF YOUR OCCUPATION?

The most rewarding aspect of my career is helping people in an intimate and emotional way, every single day! Plastic Surgery enables me to use my brain, my hands, my creativity and artistic talents, and my compassion and caring nature in the best possible way. Helping others truly is my calling, and Plastic Surgery is the venue!

Q. WHAT TRENDS TO SEE HAPPENING IN YOUR INDUSTRY?

Many non-surgical aesthetic treatments are increasingly being offered as an alternative to, or as an adjunct to surgery.

Examples are Botox, Dysport and other injectable agents that decrease muscle contraction and eliminate wrinkles, injectable fillers that help to fill lines in the face, that decrease the effects of aging around the eyes, and plump the lips or cheeks, and "laser"-type treatments that can help to tighten skin without surgery and to improve abnormal pigmentation of the skin.

Nonsurgical treatments such as these can be a little less expensive than surgery, and can be a great option for women who are not ready for a facelift or eyelid lift surgery. However, the effects are usually temporary, and over time, the expenses can add up! Surgery sometimes is the correct answer; your Plastic Surgeon can help to determine which options will best achieve your goals!

Q. HOW DO YOU SEE YOUR PRACTICE EXPANDING IN THE NEXT 5 YEARS?

I will always be committed to breast cancer patients, and I intend to continue to perform breast reconstruction for women facing cancer throughout my career. At this point in my practice, I am already extremely busy, I'm tired, but I'm thrilled about this!

I would like to expand my "mommy makeover" cosmetic practice and help many more Moms achieve their body image and self-esteem goals via surgery (once they have achieved their maximal results with a health diet and regular exercise).

I am now ready to train a "Fellow" (fully trained Plastic Surgery graduate) and teach them all I know, and to eventually take on a Junior Associate in my practice! I also plan to hire a Physician Assistant to enable me to be as efficient as possible and to share my responsibility with inpatient hospital rounds, office preoperative visits, phone calls, and weekend call.

I hope to start my own family soon, and having someone I have personally trained and trust to care for my patients in the same manner and degree as I do, will enable me to best juggle work and a family life. I look forward to that challenge!

Q. HOW HAS SOCIAL NETWORKING AFFECTED YOUR FIELD?

There is a great deal of inaccurate information and gossip on the internet, particularly regarding Plastic Surgery.

I am active on Twitter and Facebook, and I use these resources as a way to reach out to other and to educate, inform and empower women (and men!) about what Plastic Surgery is and isn't, to discuss some of the latest controversies in Plastic Surgery, and to get the word out there about new surgical techniques that are the latest and greatest!

I think social networking is great, as long as it is used with respect and professionalism. Many of my patients "follow" me online, and it's important to remember that once an opinion or message is posted, it is out in cyberspace forever!

Step-by-step animation about breast augmentation surgery!

2010-02-25T21:37:00.000-08:00

The American Society of Plastic Surgeons (ASPS) has developed a new series of videos that detail the steps in many different Plastic Surgery procedures.

One of my favorites is the animation on breast augmentation using silicone implants and a subglandular (under the breast approach). This is the technique that I most commonly use for breast augmentation in my patients.

Watch the animation here! (silicone implants, under breast incision)

The ASPS is a wonderful resource for individuals interested in learning more about Plastic Surgery in an unbiased approach, without emphasizing one particular surgeon or technique.

Only Board-Certified Plastic Surgeons can become members of the ASPS. Learn more here.

To see additional before-and-after pictures of breast augmentation, visit our website gallery!

How are breast implants put in the body?

2010-02-22T23:20:00.000-08:00

Breast implants can be inserted through a variety of incisions:

1. In the fold under the breast (inframammary)

2. Around the areola (periareolar)

3. Through the areola and around the nipple (transareolar)

4. Through the armpit (trans-axillary)

5. Via the belly button (trans-umbilical)

Inframammary fold (IMF) incisions preserve the function of the function of the breast, namely breastfeeding and pleasure. I use this incision most commonly for breast augmentation surgery.

When an incision is made in the fold under the breast, the scar lies in a natural crease and does not tend to stretch or be raised, as can happen in other areas. All structures leading to the nipple and areola (milk ducts, nerves, blood vessels) remain intact. In addition, once an implant is inserted, it is probable during a woman's lifetime that another surgery may be required (to change the implant, remove it later in life, perform a breast lift with drooping, etc.). Therefore, the scar is already present and this can be used again as an incision in the future.

Many other incisions used for breast augmentation are only a one-time option, with the IMF incision required in the future. The IMF scar is hidden in bras and even triangle-top string bikinis, and will only be visible up close when the breasts are lifted.

Peri-areolar incisions are usually around the bottom of the areola, the pigmented circle that surrounds the nipple. There are bacteria that live in this area, and vital milk ducts and nerves in this region. By definition, some of these structures will be divided (cut) during surgery, resulting in a higher risk of complications (infection, numbness, inability to breast feed, etc.). In addition, if a woman makes raised scars, they may be visible beneath a tight shirt or through a bathing suit.

Trans-areolar incisions also cut through breast tissue and/or ducts, blood vessels or nerves. Nipple retraction can also result from scar tissue that normally forms after surgery. For these reasons, I would not recommend this for most women.

Trans-axillary breast augmentation makes an incision in the armpit, or axillary area. This is often a one-time incision, that creates a scar in the area where most women shave, and is also a site of normal bacterial growth (hence deodorant use!). The incidence of infection can potentially be higher, and this incision cannot be reused in the future for addition other surgery.

Trans-umbilical breast augmentation (TUBA) is more of a gimmick than routine approach. A long tube and scope with a camera must be tunneled beneath the skin of the belly button all the way to the area under the breast. If there are any complications during surgery such as bleeding, or if the surgeon cannot adequately visualize what they are doing, a second incision must be made in the IMF. Only a tightly rolled up saline-filled breast implant can be used (not silicone implants), it is also a one-time incision, and a long band of scar tissue beneath the skin is possibly visible after surgery - a permanent deformity. I would never recommend this option to any of my patients.

The SAFETY and science of breast implants and SILICONE!

2010-02-18T10:18:00.000-08:00

Most women who come to see me in consultation for breast augmentation have one major question: "Is silicone safe???"

I spend a great deal of time and effort in my practice educating women about their options for surgery, and when discussing breast augmentation, I emphasize that all implants, both saline- and silicone-filled, are SAFE.

In fact, silicone breast implants are the most extensively studied implantable medical device in the history of medical devices!

All breast implants have a silicone shell; the fill material is what differs. For most of my patients, I recommend silicone specifically, because it can have a more natural look and feel.

The website breastimplantanswers.com is an excellent resource for women to learn all about breast implants. I send each woman I see in consultation to this site to do some "homework" and to learn more about this medical device.

Here are some excerpts from the site (I encourage you to also visit the website for additional information):

Silicone is a highly versatile substance that has many medical uses. Different types of silicone have been used for decades in a variety of medical devices, such as pacemakers and artificial joints.

Learn more about the technology and innovation behind silicone and silicone gel-filled breast implants

Silicone gel-filled breast implants are among the most extensively studied FDA-approved medical devices in existence. In the United States alone, Allergan has examined the safety of silicone gel-filled breast implants in more than 80,000 women.

For more detailed information, please read the complete safety information

The United States Food and Drug Administration (FDA) approved silicone gel-filled breast implants after reviewing a vast amount of scientific data. These data consisted of results from extensive preclinical testing, four years of data on 715 women from Allergan's Core Clinical Study, and a European study that evaluated implant rupture prevalence rates beyond 10 years1. In addition, countless published, peer-reviewed studies and research support the safety of silicone and silicone gel-filled breast implants. The FDA also considered in their decision the opinions of advisory panels made up of outside experts.

Read the Core Study results

Breast augmentation is a personal decision for a woman, and one that should not be taken lightly. I encourage all women to educate themselves about the safety and science of breast implants before considering any surgical procedure.

Free bonus gift (value $225) for my patients who choose silicone breast implants!!!

2010-02-18T10:07:00.000-08:00

I am happy to announce that Allergan, the company that manufactures Natrelle silicone breast implants, is offering a free bonus gift to each of my patients who receive silicone breast implants, effective January 2010!

Call my office and speak to Mary at 415-923-3067 for more information.

Power Women Magazine's Blogtalk Radio - Dr. Karen Horton as featured guest!

2010-01-28T20:43:00.000-08:00

I was recently interviewed by Power Women Magazine for a full live hour, discussing the latest in Plastic Surgery for women, both cosmetic and reconstructive.

Click this link to listen to the interview!

Power Women Magazine

Where Power Women can network

Dr. Karen Horton

Dr. Karen Horton has invited you to the event 'Dr Karen Horton' on Power Women Magazine!

Log in to listen to my online radio interview tomorrow (Tuesday) - 9 a.m. PST, PowerWomenMagazine.com!

I will be discussing the latest in Plastic Surgery for women.

Karen Horton, MD, MSc, FRCSC

Time: October 27, 2009 from 11am to 12pm
Location: www.blogtalkradio.com/powerwomenmag
Organized By: Dee Jones

Event Description:
Dr Karen Horton will be speaking on women and plastic surgery

See more details and RSVP on Power Women Magazine:

http://powerwomenmagazine.ning.com/events/event/show?id=2871844%3AEvent%3A6521&xgi=0kl7ziWtD2JBXK

About Power Women Magazine

Power Women Magazine is an online publication about women by women for women and issues important to women worldwide.

392 members
348 photos
9 songs
38 videos

37 discussions
201 Events
108 blog posts

Online Plastic Surgery consultations: Convenience or Trouble?

2010-01-26T11:21:00.000-08:00

A recent New York Times article discussed the potential merits and pitfalls of online consultations for Plastic Surgery procedures.

This led me to think about my own practice. I am currently listed on a number of websites that drive potential patients to my practice, from breast augmentation:

...to liposuction, tummy tucks, and other related sites where people can post questions and hear back from real Plastic Surgeons on their opinion about surgery.

I post my direct email (khorton@womensplasticsurgery.com) on these types of sites, and encourage potential patients to contact me directly with questions or comments.

In response, I always send them a personal email reply with general information about my practice and advice to make an appointment to SEE ME in person, for a formal consultation, a full history and physical examination, and my surgical opinon about whether they are even a candidate for the procedure they believe they are seeking.

Any initial questions about procedure cost and scheduling can be answered by my Patient Coordinator, whom contactees are also encouraged to call.

When I meet these patients in person, often the procedure they were seeking (for example, liposuction of the abdomen) may not in fact the appropriate procedure to achieve their aesthetic goals (an abdominoplasty, or tummy tuck may be indicated if they have rectus diastasis - separation of the rectus abdominis mucles in the midline from pregnancies). Only an in-person evaluation can allow me to make this determination.

Some patients seeking Microsurgical breast reconstruction such as the DIEP/SIEA or TUG flap travel far and wide for surgery, and come from another state or even country for their surgery. My Coordinator in these cases will often ask patients to send confidential photographs of their torso so that I can get a general idea of whether they are even a candidate for a free flap. From here, we would consider asking them to make a trip to see me in the office for further evaluation.

However, patients are still instructed that they will need to fly into San Francisco for a formal consultation and the standard 45-90 minute visit with me and the remainder of the office staff to fully learn about the procedure, its risks and benefits, potential complications and expected outcomes of surgery. They would then plan their procedure and return for surgery in the future.

I feel that giving advice over the phone, over the internet, or via just looking at photographs is not only risky for the doctor or patient, but can provide a false diagnosis or sense of security.

Medicolegally, potential Plastic Surgery patients seen to be seen and examined, in person, for proper documentation and examination, careful planning for surgery, and the best possible results.

How is bra cup size determined???

2010-01-23T21:54:00.000-08:00

With all the press lately on Heidi Montag's current new breasts ('DDD', or 'F'), and her apparent desired increase ("an 'H', for Heidi!" - her words), it was brought to my attention that most people don't know how bra cup size for a woman's breasts is determined!

Many women (and men) don't quite understand the difference between the number (34, 36, 38, etc.) and the letter cup size ('A', 'B', 'C', 'D', etc.)! Eight in ten women also do not wear the correct bra size.

The following will explain how how bra and cup size is calculated:

Measuring Bra Size

1. Bra Size (the NUMBER, or the "band" size)
Measure around your body under your breasts at the level of the breast fold, in inches (in the U.S.). Other countries use centimeters (cm) - see the charts below.

2. Cup Size (The LETTER, or the "bust" size)
Measure around the fullest part of your breasts, also in inches.

This is the tricky part, and the reason why you may fit several different bra cup sizes, depending on the amount of lift that the bra provides. Many women develop droop to their breasts, and may be a 'B' without any push-up, a 'C' with a little underwire, or even a 'D' with some major lift by a bra. See below and try on different styles and types of bras to understand this better!

Bra Size Charts

Based on the difference in inches between your band and your bust circumference, you can calculate your bra cup size in letters:

Keep in mind that as like dress sizes and designer clothes, many stores may fit women's breasts differently. For instance, based on my patients' comments alone, Victoria's Secret often fits women as a 'C', whereas Nordstrom bras often fit the same women as a 'D'!

Custom bras or specialty stores can cost a bundle! However, investing in a good bra can sometimes help to avoid Plastic Surgery, if a simple "lift" in clothes is what you are looking for!

However, if you desire the effect of a push-up bra or additional padding, a breast augmentation may be an option for you. Be sure to visit a Board-Certified Plastic Surgeon with extensive experience in breast evaluation and breast surgery to learn more!

TUG (Inner Thigh) Flap Microsurgical Breast Reconstruction

2010-01-09T20:18:00.000-08:00

The following is an excerpt from a chapter I recently authored for an upcoming textbook. It is written in medical lingo. A version that uses more regular language more suitable for the general public will soon be posted on the Women's Plastic Surgery website. All surgical photographs have been removed, as they may be upsetting to some readers; only diagrams are shown for educational purposes. Read on to learn more about the TUG (inner thigh flap)!:

Introduction to the TUG Flap

The inner thigh skin and fat based on the transverse upper gracilis musculocutaneous (TUG) flap blood supply provides an autologous donor area with several qualities complimentary to microvascular breast reconstruction. The gracilis flap is an exciting alternative to abdominal, back or buttock tissue flaps for reconstruction of a natural looking and soft, shapely breast.

The gracilis muscle has a consistent and reliable blood supply, and has been well described (1, 2). The transverse upper gracilis flap can be shaped to mimic a mastectomy specimen, providing excellent contour and projection to the breast reconstruction. The characteristics and skin color of the TUG flap allow for immediate nipple-areola reconstruction in both immediate reconstruction following skin-sparing mastectomy and in delayed breast reconstruction alike. TUG flap microvascular breast reconstruction is an excellent option for patients who desire autologous reconstruction and who do not have adequate abdominal donor tissue or who do not desire abdominal scars.

History

Use of the transverse upper gracilis (TUG) myocutaneous flap for breast reconstruction was first described as a single breast reconstructive case in 1992 (3). The cutaneous territory of the gracilis myocutaneous flap was demonstrated by anatomic and injection studies to lie perpendicular to the muscle in its proximal third, transverse and parallel to the medial groin crease. Based on the direction of exit of cutaneous perforators in the superomedial thigh region, the transverse cutaneous skin paddle of the gracilis muscle has since been accepted as dominant, much like the lower transverse paddle of the rectus abdominis muscle (3). Perforators extending through the gracilis muscle vascularize the area reaching from over the adductor magnus and sartorius muscle anteriorly to the midline of the thigh posteriorly (4).

Although the vertical paddle of the gracilis has been used for breast reconstruction (5), it is accepted as much less reliable (6), and has a more visible vertical scar. We now offer inner thigh free flap reconstruction using the transverse skin paddle to patients without adequate abdominal donor tissue and to those patients that do not wish to have postoperative scars associated with abdominal tissue harvest.

The transverse upper gracilis flap technique is relatively straightforward, reliable and can be aesthetically superior to abdominal reconstruction in two significant ways: 1) it has the advantage of allowing for immediate nipple-areolar reconstruction, negating the need for secondary surgery and 2) coning of the flap into a projecting breast shape is simpler than for abdominal flaps. By using a semi-lunar construction of the skin paddle, this flap provides excellent dimensions, good projection and can be contoured for immediate nipple areola reconstruction. The aesthetics of this type of reconstruction can be excellent.

Transverse Upper Gracilis Flap Design

The TUG flap is designed with a semi-lunar skin paddle transverse to the longitudinal axis of the gracilis muscle in the inner thigh (Figure 1) The superior aspect of the flap is marked approximately one centimeter below the groin crease anteriorly and centrally, but extends well into the gluteal crease at the most posterior aspect. Placement of the incision slightly below the crease avoids distortion of the labia majora with related symptoms, as can occur in medial thigh lift (7).

The anteroposterior length of the flap extends up to 28 centimeters. The width of the flap is judged by pinching the inner thigh tissue with the thighs in adduction, using the maximum width that can be easily closed without tension. The flap has been designed it as wide as 11 centimeters at the central axis over the gracilis muscle (Figure 6). A pencil Doppler probe is used to confirm the location of perforating vessel(s) over the gracilis muscle and into the skin paddle (Figure 7).

The procedure is performed with the patient in the supine position, with the thigh abducted and the knee flexed. The flap is harvested with the patient in well padded OB-GYN operative stirrups, which facilitates dissection and closure of the posterior aspect of the wound.

The anterior thigh incisions are made first. The posterior branch of the saphenous vein is harvested with the flap (Figure 2), and any anterior venous branches are left in situ although they can be included in the skin paddle if needed. Lymph nodes are avoided and are left in situ to avoid the risk of lower extremity lymphedema.

Anterior flap dissection proceeds superficial to the muscular fascia until the medial/posterior edge of the adductor longus is encountered (Figure 3). Beveling of subcutaneous adipose tissue is used to maximize the bulk taken with the flap. The deep fascia is incised longitudinally and the space between the adductor longus and gracilis muscle is separated and the vascular pedicle to the gracilis is identified. Pedicle dissection proceeds proximally to the origin from the superficial femoral artery. Posterior dissection then continues superficial to the muscular fascia, entering the deep fascia at the posterior aspect of the gracilis. Pedicle length ranges from 6 to 8 cm.

The gracilis muscle is transected superiorly and inferiorly, commonly taking only a portion of muscle lying directly beneath the flap (Figure 4). Additional inferior muscle length may be optionally included for enhanced flap volume. Usual flap elevation time is approximately 45 minutes or less.

Following pedicle division, absorbable sutures are used to maintain flap coning and achieve projection (Figures 5 and 8). The gracilis muscle may additionally be used to increase projection by securing it posteriorly behind the adipose tissue, with predictable postoperative muscle atrophy. In immediate reconstructions, the mastectomy specimen is weighed and measured for comparison with the TUG flap, typically an appropriate match in terms of volume and dimensions. Flap projection has often been greater than the native mastectomy specimen (Figure 9).

The flap is deepithelialized except for an areolar circle in immediate reconstructions (Figure 9d and Figure 10), and completely deepithelialized in nipple-sparing mastectomy. An areolar circle is created and accentuated by a circumareolar incision for delayed reconstructions, deepithelializing and burying of the superior flap beneath the native mastectomy skin (Figure 11).

Microvascular anastomosis is usually to the internal mammary system beneath the third or fourth costal cartilage. Following coning, the pedicle enters the undersurface at the center of the flap, enabling inset of the flap in any orientation desired (Figure 12). Postoperative flap assessment includes clinical and external pencil Doppler monitoring if the flap is exposed, in addition to continuous implantable venous Doppler probe monitoring.

The inner thigh donor area is closed with interrupted sutures in the deep fascia (7), interrupted deep dermal and continuous subcuticular skin sutures over a suction drain exiting from the superior aspect of the thigh wound.

Immediate nipple-areolar reconstruction is performed by folding the semilunar flap and accentuating the apex of the resultant standing cone as the area of maximum projection using interrupted horizontal mattress sutures (Figure 10). Care is taken not to create excessive suture tension to avoid circulatory compromise to the nipple reconstruction. An areola circle is drawn, and skin surrounding this circle is deepithelialized and buried beneath the mastectomy flaps prior to microvascular anastomosis. The naturally darker pigment of inner thigh defines the areolar reconstruction.

Patients are placed on post-operative aspirin as an anticoagulant for one month and allowed to ambulate at two to three days postoperatively. Hospital stay averages five to seven days.

Discussion

Autologous abdominal soft tissue reconstruction after mastectomy, although becoming more common, comprised less than a quarter of breast reconstructions performed in the United States in 2008 (8). The deep inferior epigastric perforator (DIEP) free flap was performed in only 7.5% of reconstructions in that year.

The reason for the relative scarcity of soft tissue reconstructions relative to implant reconstructions is not clear; however the complexity of microsurgical reconstruction and the technical difficulty of perforator flap harvest may contribute to the lack of widespread acceptance. Many patients do not need or desire abdominoplasty at the same time as having a breast reconstruction. As such, the potential aesthetic perk (9) of abdominal perforator flap harvest may be considered a drawback. In addition, abdominal flap scars are not insignificant, including the umbilical scar which is visible in currently fashionable low-cut jeans and swim suit bottoms.

Advantages of gracilis muscle as a microvascular transplant include low donor-site morbidity, a concealed donor scar, constant anatomy with large-diameter vessels, and the potential for a neurosensory flap as well as a large skin paddle. Anatomic studies (3, 6) have revealed the angiosome of the upper gracilis muscle to lie at right angles to the muscle, in a transverse direction. As such, the generous size of the transverse skin island that can be harvested with the gracilis allows for shaping of the flap in a circular and cone-like fashion, more closely mimicking natural breast anatomy than the relatively flat projection of abdominal flaps (10). The inner thigh flap also avoids the relatively visible scar on the lower abdomen together with a numb area below the umbilicus, sequelae of abdominal perforator flaps (11). The quality of inner thigh tissue is soft and similar to abdominal flaps and breast tissue, unlike the firm, fibrous and stiffer texture of buttock flaps. Some patients' body habitus clearly favors the inner thigh flap over abdominal flaps, based on their natural depostion of adipose tissue (Figure 13).

The conical apex at the central portion of the folded inner thigh flap constructs nipple projection using subdermal fixation sutures at the time of reconstruction. The resulting nipple areola in our opinion can be aesthetically superior to those reconstructed with local flaps or skin grafts. Inner thigh skin naturally has slightly darker pigmentation than the skin of the chest or torso, and when contracted and allowed to pucker slightly it can appear even darker. This color difference with breast skin allows for a natural areolar reconstruction that can be later augmented using medical tattooing if desired (Figures 14 and 15).

Early reports of the TUG flap described coverage of defects in the head and neck, lower extremity and thoracic region (12). Schoeller (13) described a ‘medial thigh lift free flap’ for bilateral autologous breast augmentation after bariatric surgery. Arnez (14) reported 7 immediate TUG flap breast reconstructions, for ‘small’ or ‘moderate’-sized breasts with sufficient medial thigh tissue, who declined scars in other donor sites. Wechselberger and Schoeller (15) performed 12 TUG flaps in 10 patients for immediate breast reconstruction. Fansa (16) reported 32 flaps and Scheoller (11) published a large series of 154 flaps for breast reconstruction in immediate and delayed settings for breast reconstruction, without immediate nipple-areolar reconstruction. For bilateral reconstructions, the transverse gracilis flap has been suggested to surpass the DIEP flap because of a better concealed donor scar and easier harvest (11). We have also recently submitted our early data for publication (12).

Inner Thigh Flap Donor Site

Although other autologous tissue reconstruction options are available to patients with previous abdominal tissue harvest or in very thin patients (18), in many of these patients, the inner thigh flap can be used. Unlike loss of the rectus abdominis muscle, loss of the gracilis muscle is not associated with the risk of abdominal hernias, bulging or functional donor site complications. The greatest drawback of the inner thigh flap is the inner thigh scar; yet its location near the groin crease is readily concealable in all clothing except swim suits or underwear (19) (Figure 16).

Tissue expanders and breast implants, latissimus muscle flaps with implants, the inferior gluteal artery free flap, and superior gluteal artery free flap have all been well described as alternatives to abdominal flaps, and the inner thigh flap presents an additional option to these choices. It is inherent that all autologous soft tissue reconstructions require creation of a donor site and donor area scarring, to some degree. Certainly, wound complications at the inner thigh donor site necessitating dressing changes are an annoyance for patients as are seromas, and although frequent, this complication is relatively minor. Patients receive preoperative counseling and full informed consent about this possibility. In all cases, our patients have been quite satisfied with the final results of their TUG flap reconstructions.

Gracilis Perforator Flaps

The inner thigh skin can be harvested as a perforator flap based on the vascular pedicle to the gracilis muscle (19-22). However, donor site hernia and functional loss are not accepted complications of gracilis muscle flap harvest and are not compelling indications to spare the gracilis muscle. Despite reports of successful transfer of gracilis perforator flaps, inclusion of the gracilis muscle in the TUG flap has been suggested to potentially provide more tissue volume, to increase safety of monitoring the skin paddle, and to allow rapid harvest with minimal functional donor site morbidity (15). Anatomic studies of the proximal cutaneous perforator vessels of the gracilis muscle (23) suggest that it is safer to include the gracilis muscle for transfer of tissue in the TUG flap distribution.

Gracilis perforator flaps are smaller than the dimensions available for TUG flaps, unless an extended dissection including some gracilis muscle is performed (22). These authors do not support a clear clinical advantage of preserving the gracilis muscle. The clinical indication and advantage of the perforator flap is therefore a thin and pliable flap (22), perhaps better suited to extremity coverage. Although safe applicability of gracilis perforator flaps have been demonstrated, the required longer and more tedious dissection should be weighed against the rapid, easy and routine dissection of a more bulky musculocutaneous gracilis flap.

Gracilis perforator dissection would potentially spare loss of donor muscle in the thigh, but functional advantages are not clear, and there may be increased risk to flap circulation as well as increased operating time. Inclusion of gracilis muscle in TUG flap is suggested to provide more tissue volume, increase safety and allow rapid flap harvest with minimal functional donor site morbidity (23). In addition, the gracilis muscle does add some bulk to the reconstruction, an advantage in patients with minimal thigh subcutaneous fat. Certainly, harvesting this flap as a perforator flap is an option, but one that we do not currently see as advantageous.

It has been recommended that the saphenous cutaneous venous system be harvested with the perforator flap to enhance venous drainage (19), but we have only required the saphenous system for venous outflow in one patient that had poor internal mammary drainage. This outflow may have been helpful in our other patient that developed some delayed venous insufficiency. Nevertheless, saphenectomy can be a cause of morbidity (24) while the need for secondary venous drainage in this series has been rare.

Summary

The transverse upper gracilis flap can be used for microsurgical breast reconstruction in patients with previous abdominoplasty, inadequate abdominal tissue, or in patients that object to abdominal or buttock scars. The inner thigh flap offers an autogenous tissue reconstructive option after mastectomy with excellent projection, the potential for immediate nipple-areolar complex reconstruction, and a favorable donor scar position and quality.

The TUG flap has significant advantages in addition to its pleasing final reconstructive appearance. The gracilis muscle pedicle and harvest are extremely reliable and straightforward, and are familiar to most Microsurgeons. No intraoperative repositioning is required as often for flaps from the buttocks or back, and a two-team approach is facilitated by dissection of the contralateral thigh during mastectomy. Since TUG flap design allows immediate nipple areola reconstruction, the need for tattooing, local flaps or skin grafting may be obviated. In some patients, the medial thigh lift may be considered an aesthetic perk of this procedure. The inner thigh flap has become a favorite in our armamentarium of microvascular breast reconstruction choices.

Candidates for the inner thigh gracilis flap include patients desiring autologous breast reconstruction; those with sufficient superomedial thigh tissue; previous abdominoplasty or DIEP, SIEA or TRAM flap harvest; previous abdominal surgery precluding use of abdominal tissue for reconstruction; or very thin or athletic patients without sufficient abdominal or buttock donor tissue.

References (see full publication - to be posted)

How do you reconstruct a nipple and areola after breast cancer?

2010-01-09T18:55:00.000-08:00

I am scheduled to have nipple reconstruction in May, and know there are various options available. Can you comment on the differences in cosmetic outcome when utilizing tissue from another part of the body, skin from the flap itself or tattooing alone?

The nipple and areolar complex (NAC) reconstruction involves two components, the nipple prominence and the areolar circle. Sometimes the nipple reconstruction is performed first, with the areola done at a later date; at other times, they are performed together. NAC reconstruction is the finishing touch of a breast reconstruction, and is the "icing on the cake" to complete the breast!

Nipple reconstruction usually involves a local flap procedure where wings of tissue (skin and fat) from the breast reconstruction itself are rotated in place to create a nipple prominence. Some surgeons also add some additional tissue inside the local flaps (soft or firm) to try to improve projection of the nipple reconstruction. After surgery, the nipple reconstruction is expected to shrink between 30% and 50%. The ideal nipple prominence matches a natural nipple at rest. It will not have the capacity to become erect with stimulation or cold temperature.

The areolar circle can be made using either a medical tattoo or a skin graft. Natural flesh-colored medical tattoo pigments (ranging from tan, to pink or brownish or black) are available and can be mixed together to very closely match a natural nipple and areola. The nipple prominence is also tattooed to match the other side. Tattooing can be done either in the operating room or in the office of your Surgeon under local anesthesia, and is usually done by the Plastic Surgeon or occasionally a specially-trained surgical Nurse.

Skin grafting for areolar reconstruction involves taking a full-thickness graft (all the layers of the skin, requiring closure of the "donor site" with stitches) from another area of the body. Common sites for harvest of a skin graft for areolar reconstruction include the groin, the other breast's areola (if a balancing breast reduction or a lift is also being done), or rarely, the labia (external genitalia). Skin grafts may heal with either lighter or darker pigmentation than expected, and by definition, require creation of a scar at their donor location. For this reason, I usually use a tattoo for the areolas I create.

Constipation is very common after any surgery!

2010-01-03T20:30:00.000-08:00

Any surgery that involves taking narcotic pain medication (intravenous or pills) and/or being under anesthesia can cause temporary constipation.

I advise each of my patients to expect some constipation after surgery and to start taking an over-the-counter stool softener immediately after surgery. An examples of a medication I often recommend is called Colace (Docusate).

Your local Pharmacist can recommend what is appropriate for you, given your specific medical history and current medications you are already taking.

You may not have a bowel movement for 3-5 days after surgery. This is not dangerous, just uncomfortable!

Start with one stool softener, and considering adding a natural laxative such as Senna (also over-the-counter) after a day or two if you have still not had a bowel movement.

Remember not to overdo it - "more" is not always better! Taking too much of any medication can create other serious problems.

Be patient - it will take some time for your body to recover and return to normal after surgery.

In addition, be sure to drink plenty of fluids and to continue a regular diet with good nutrition (including vitamins and minerals) and lots of fiber.

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

Personal beauty tip from a Plastic Surgeon: Keep it simple

2009-12-28T17:12:00.000-08:00

The following is an except from an article I was interviewed for in Health Magazine:

Natural Cures - Anti Aging Solutions

The Best Anti-Aging Secrets

From Health magazine

We've all been there:

That moment midappointment when you catch yourself shamelessly staring at your hairdresser, dermatologist, or dentist and thinking, How the heck does she pull it off? What's the secret to her great hair, pore-free complexion, or flawless teeth? Well, we decided to go straight to the source and find out, once and for all, how to get that ageless look—naturally.

We asked the beauty industry's most-sought-after stylists, aestheticians, and MDs to divulge their tricks for stopping the clock. If there's no fountain of youth, their unexpectedly simple advice might be the next best thing.

MY ADVICE: Keep it simple!

"Because I'm a plastic surgeon, companies send me so many skin-care samples—and some of them have 10 different steps! But I'm realistic, so there's no way I'm going to sign up for some huge beauty system that costs hundreds of dollars and requires a commitment that I'm not willing to make.

Honestly, here's my daily skin-care routine: I go home, wash my face with a drugstore cleanser, put on a moisturizer, and fall into bed. I find that this simple regimen works well for me."

—Karen M. Horton, MD, Plastic Surgeon and Reconstructive Microsurgeon at the Women's Plastic Surgery Center, San Francisco

I would also add that a healthy, nutritious diet, regular exercise, lots of sleep and a healthy home and work environment are also very important in health overall, and to beautiful skin!

You should be at your ideal weight and fitness level before a "mommy makeover"

2009-12-20T15:52:00.000-08:00

Karen M. Horton, MD answers: Tummy Tuck for skin, fat, and stretch marks after pregnancy?

I'm 5'11 and 249 lbs. After pregnancy, I have a hanging mass of skin, fat, and stretch marks. I went from 186 lbs to 277 lbs. I have zero elasticity, and 1 week after I had my daughter, I had dropped from 277 lbs to 231 lbs. I am still overweight and currently trying to lose the weight, but I have this hanging mass on my stomach of stretch marks and fat. It's horrific. I want a tummy tuck and have done a lot of research, but how much will it cost me? How much do I need to lose before I should have the surgery? I don't accept blood at all, is that a concern?

By Karen M. Horton, MD - San Francisco Plastic Surgeon

For any Mom considering Plastic Surgery such as a "mommy makeover", I always advise women to achieve their weight loss goals prior to seriously considering surgery.

You should have lost as much weight as you feel is reasonably realistic, be physically fit, and have healthy nutrition as part of your lifestyle.

There should also be "calmness" in your personal and/or professional life. Chaos is never a good fit with surgery!

Most Moms seek a full abdominoplasty (tummy tuck), which removes excess lower abdominal skin and fat (including some stretch marks!), tightens the muscles of the abdominal wall back together, and decreases the waist line. Sometimes liposuction of the flanks and/or upper abdomen are added to the procedure, if needed.

For women who have not yet reached their ideal weight but who have a large overhang of skin and fat (a "pannus") in their lower abdominal region, it is possible as an interim procedure, to do a limited "panniculectomy". This will only remove the overhang but will not address the abdominal muscles or the upper abdomen.

Be sure to visit a Board-Certified Plastic Surgeon with a great deal of experience in these types of procedures!

Karen M. Horton, MD, MSc, FRCSC

Alloderm with the use of implants - is it safe?

2009-12-11T12:57:00.000-08:00

The following is an excerpt from questions submitted by the Young Survival Coalition. I have been asked to answer questions on breast reconstruction as an expert.

How safe is the use of cadaver tissue (Alloderm) in breast reconstruction with implants?

Alloderm is one brand name product of human cadaver (donated by dead people) dermis, which is the bottom strength layer of skin. It is sometimes used in reconstructive surgery to potentially add another layer of tissue to thicken the mastectomy skin, to help hold submuscular implants in place, or to decrease rippling of implants.

Alloderm is a "graft", which by definition does not have a blood supply. This is in contrast to a "flap", which has a blood supply and may be either attached to a muscle ("pedicled"), or "free", which involves microsurgery to disconnect and then reconnect tiny blood vessels under the microscope.

If the breast skin has been radiated already, the use of Alloderm adds the additional risks of infection, wound healing problems, and/or the need for implant or Alloderm removal. This is because the radiation interferes with blood vessels growing into the product, and slows the rate of incorporation of the product.

I unfortunately have removed much more Alloderm (inserted by other surgeons) in my patients that I have ever put in myself. I personally do not use this product, but understand that many surgeons do.

Template for a Letter Regarding Cosmetic Surgery Tax ("BoTax")

2009-12-07T23:32:00.001-08:00

The Aesthetic Society and all of organized Plastic Surgery present a united front to fight the unfair Cosmetic Surgery Tax!

The Society leadership strongly disagrees with this discriminatory tax and is very concerned with the role of the surgeon as tax collector. Additionally, we see potentially devastating consequences to patient safety, as some may choose to have surgery abroad, seeing physicians who may not have comparable training certification or surgical site standards up to those of ABMS Board-certified Plastic Surgeons.

The following is the template for a letter that patients can use to express their opinion and dissent toward the proposed cosmetic surgery tax:

You can find your elected representative by clicking here: http://www.senate.gov/general/contact_information/senators_cfm.cfm

Dear Senator ______,

HEALTHCARE PLAN IN THE SENATE WILL UNFAIRLY DISCRIMATE AGAINST US!

I am writing you today about an issue that affects everyone who utilizes plastic surgery services for anything from Botox to Tummy Tucks.

The healthcare bill approved by the US Senate this weekend, Page 2045 Sec. 9017, Excise Tax on Elective Cosmetic Medical Procedures included in the “Patient Protection and Affordable Care Act.

This dense legalese translates to a tax on all cosmetic procedures as partial payment for the healthcare overhaul our current administration is attempting to implement.

The problem is that we would be paying this tax, the FIRST time this country has levied a tax on patients for medical procedures. This Bill is objectionable in many ways, including:

· This is a discriminatory tax. According to the Aesthetic Society Annual Statistics, 91% of all cosmetic procedures are requested by women

· This will not have considerable consequences on the wealthiest patients but, as usual, affects the middle class. We working women, soccer moms, and scores of others who carefully save and budget to improve our appearance and self esteem will be penalized for doing so.

· Procedures such as breast reduction that have been cited in the literature for improving self esteem and quality of life would be taxed as well.

· Our doctor as tax collector: This provision places physicians in the role of tax collector and holds physicians liable should an individual fail or refuse to pay the tax. That is not the relationship we want with our medical provider!

Please, do not allow this portion of the tax bill to pass!

Sincerely,

______________________

Federal Health Care Reform - Concerns of the California Medical Association

2009-11-21T19:00:00.000-08:00

November 21, 2009

Special Alert: Federal Health Reform

Today the United States Senate will vote on “cloture” to begin debate on health reform. CMA is opposed to the proposal currently before the Senate and has communicated our position and concerns to both California Senators. I and Immediate Past-President Dr. Dev GnanaDev will speak directly to Senators Feinstein and Boxer on Monday to make clear our concerns with the current proposal. In CMA’s view the current version does not improve patient care and could in fact, substantially harm the doctor-patient relationship. CMA is committed to working with our Congressional Delegation to substantially improve this legislation.

It is our hope that we will be able to support a final product that protects what currently works well for patients and fixes what is broken. The CMA Executive Committee and Board of Trustees will review any final legislative agreement and, with input from CMA member physicians, make a decision as to our final position.

Please stay tuned for more updates; CMA will provide a more detailed summary of our concerns shortly.

J. Brennan Cassidy, M.D.
CMA President

Research, Stem Cells and Microsurgery - Working toward growing breast tissue in the lab

2009-11-16T11:09:00.000-08:00

The following describes exciting new research on "growing" breast tissue in the lab, using stem cells, tissue engineering and technology!

Breast 'regrowth' trial planned

Researchers in Australia plan to test a medical "scaffold" designed to stimulate natural breast tissue to regrow following surgery.

Doctors from the Bernard O'Brien Institute of Microsurgery in Melbourne, will test the technique next year in a trial involving six patients.

The team say that the permanent fat found in breasts can be grown inside this contoured scaffold. They claim to have successfully tested the device in pigs.

The results of that experiment were presented at a plastic surgery conference in Sydney. The researchers recently announced on the institute's website that they had received funding from the Australian government to carry out the human trial.

If this is successful, they hope to develop it into a breast reconstruction technique that avoids using silicone.

Breast scaffold

The teams says that when the "empty chamber" is implanted, fat tissue will naturally fill it to form a new breast.

It's at such an early stage, it is not yet clear whether it will work in people - Dr. Lesley Walker, Cancer Research UK.

This chamber will also contain a gel made using the patients' muscle cells to "induce fat tissue production".

Professor Anthony Hollander, an expert in tissue engineering from the University of Bristol in the UK, said the attractions of this approach were its simplicity and the fact that the tissue growth occurred inside the body.

"At the time of implanting the cells the surgeon redirects the vasculature of the body which keeps a good blood supply to the implant. That is in itself nothing new, but combining it with a cell implant is an interesting step," he said.

He said that the technological advance was the use of a biomaterial cage used to trap the cells in the right place.

In future, the team plan to make this cage biodegradable so it does not have to be removed.
"If it's tried and it works that will be a really nice approach," Professor Hollander said.
But he cautioned that there was "still some way to go".

"This procedure is first likely to be used on cancer patients," he said. "[The team will] have to be able to demonstrate a technique that guarantees that all the cancerous cells are removed and none are grown up in the process, so there is still some way to go."

Dr Lesley Walker, director of cancer information at Cancer Research UK, said: "We know that having a mastectomy can be a very difficult experience for many women and so research to try to improve breast reconstruction after surgery is important.

"[But] it's at such an early stage, it is not yet clear whether it will work in people. Even if this surgery proves to be effective, it will be a number of years before it can be used in the clinic."

The Jakarta Post Article - The Brave New World of Plastic Surgery

2009-11-11T17:40:00.000-08:00

I was recently interviewed by San Francisco freelance writer, May-lee Chai, for an article in the Jakarta Post, Indonesia.

Click on the images for a full-size version of this article on Plastic Surgery.

Local Heroes in Medicine: Women Pioneers that Shaped Medicine in San Francisco

2009-11-07T18:33:00.000-08:00

The following is an article from the September 2009 San Francisco Medicine publication:

www.sfms.org

Local Heroes in Medicine

Pioneers that Shaped Medicine in San Francisco
by Nancy Thomson, MD

“Women should not be expected to write or fight or build or compose scores. She does all by inspiring men to do all.” —Ralph Waldo Emerson (1802–1882)

In 1948, when I started college at Stanford University, my physician father discouraged me from preparing for medical school, saying that I would take a man’s place, then marry and never practice. Lois Scully, MD, a San Francisco internist, Stanford graduate, and 1979 president of the American Women’s Medical Association, ran into the same bias at about the same time when the
Stanford physician who interviewed her told her to go home, marry, and have five children.

In the early 19th century, Lucy Stone (1818–1893) wanted a good education, but the only college in the world that accepted women at that time was in Brazil. Luckily, Oberlin University was founded in 1835 in Ohio, the first U.S. college to accept both women and African-American students. Stone enrolled and graduated in 1847. However, when it came time to seek a profession, the only field open to women was teaching. In 1849 (the year Elizabeth Blackwell graduated from Geneva Medical College in New York), Lucy Stone wrote, “We believe that if the system of educating females for physicians be generally adopted, a great amount of suffering and death will be saved.”

In fact, the number of female medical school graduates rose steadily from 1849 to 1900. By 1900 in Boston, women represented 18 percent of practicing physicians. However, by 1903 women’s participation in medicine began to decline, as most of the women’s medical schools established in the previous 50 years were closed or merged with male dominated schools, which continued to reject women applicants. This situation generally prevailed until the 1970s, when the feminist movement and antibias legislation brought about an increase in women attending medical schools.

In 1970, female admissions to medical schools were at 9.2 percent; in 1980 they had risen to 27.9 percent, and they are at almost 50 percent today. The decline in economic potential for physicians (which was historically one of the foremost motivations for male medical students) is given comparatively little importance by female students, who cite longtime interest in medicine and science, the desire to help others, and dissatisfaction with other types of work among
their reasons for choosing medicine.

The following time line highlights women’s place in the medical history of San Francisco.

Historical Time Line

From the time of landing at Plymouth Rock, women as well as men practice medicine in New England, often after an apprenticeship with a practicing physician. However, when American medical schools are established, they follow the European pattern of barring women from
seeking medical degrees.

1863
Elizabeth Pfeifer Stone, the first woman to practice medicine in California, settles in San Francisco. Probably German-born and -trained, she previously practiced in New York.

1873
University of California acquires Toland Medical School in San Francisco, and since U.C. is already coeducational, Lucy Maria Field Wanzer, a thirty-three year-old teacher, is accepted as its first female medical student. However, the dean suggests to her fellow students that they “make it so uncomfortable for her that she cannot stay.”

1874
Charlotte Blake Brown applies to the San Francisco Medical Society for admission. Some members of the membership committee feel strongly that females are mentally, physically, and morally unfit to study medicine, let alone practice the profession. On advice of mentors, Brown
withdraws her application.

1875
Following the model of Elizabeth Blackwell’s New York Infirmary for Indigent Women, Pacific Dispensary for Women and Children is founded by three women, all educated on the East Coast: Charlotte Blake Brown, Martha Bucknall, and Sarah E. Browne. This outpatient clinic, initially located at 510 Taylor Street, is intended to provide opportunities for women physicians to obtain internship experience.

1876
San Francisco Medical College of the Pacific accepts its first female student, Alice Boyle Higgins, who graduates in 1877.

1877
Having been admitted to the California Medical Society along with four other women in 1876, Lucy Wanzer becomes the first female member of the San Francisco Medical Society.

1880
Founders of Pacific Dispensary create the first nursing school west of the Rockies. Its one-year course becomes a two-year curriculum in 1882.

1887
The Pacific Dispensary moves to a new two-story building at California and Maple Streets and becomes Children’s Hospital. Interns and residents can be either male or female, but there are no men allowed on the medical staff.

1895
Citizens of San Francisco raise money to build the Little Jim Building for pediatrics at Children’s Hospital.

1896
One year after X-rays are discovered, Elizabeth Fleischman-Aschheim, an engineer, opens the first X-ray laboratory in California, at 611 Sutter Street.

1896
William Randolph Hearst leads the campaign for the Eye and Ear Pavilion at Children’s Hospital.

1904
Dr. Charlotte Blake Brown dies at age fifty-eight. Her daughter, Adelaide Brown, MD (1868–1933), carries on her mother’s work at Children’s Hospital but also serves on the Stanford faculty at Lane Hospital. She fights locally and nationally for clean milk, sanitary garbage disposal, maternal and child welfare, visiting nurse services, and clinics offering cardiac care and birth control.

1906
The San Francisco earthquake forces the demolition of the 1887 Children’s Hospital building.

1911
A new, four-story brick Children’s Hospital building opens at California and Cherry Streets.

1912
The Contagious Disease Pavilion opens at Children’s Hospital, with money donated by William Randolph Hearst, to care for diphtheria, scarlet fever, measles, TB, and, later, polio.

1915
Children’s Hospital affiliates with the University of California for the teaching of medical students.

1915
The American Medical Association admits its first female member.

1916
Henries Hagar Duggan, MD, becomes a pioneering medical anesthesiologist. She works at various hospitals but settles at Children’s for twenty-five years, retiring after the end of World War II.

1938
UCSF pediatricians Mary Olney and Ellen Simpson found summer camps for children with diabetes.

1946
Marian Yueh Mei Li arrives in San Francisco, having completed medical school in Shanghai. She eventually opens a private practice and becomes the first Chinese female ophthalmologist to practice in Chinatown.

1952
Pediatrician Hulda Thelander establishes the Child Development Center at Children’s Hospital for children with cerebral palsy, developmental delays, and congenital defects.

1960
Internist Roberta Fenlon, MD, becomes the first female president of the San Francisco Medical Society.

1971
Dr. Roberta Fenlon becomes the first female president of the California Medical Association.

1977
Linda Hawes Clever, MD, MPH, founds (and chairs) the Department of Occupational Health at California Pacific Medical Center. She is also the first female editor of the Western Journal of
Medicine and is the founder of RENEW, an organization to help fight professional exhaustion and dissatisfaction.

1980
Children’s Hospital acquires St. Joseph’s Hospital.

1988
Marshall Hale Hospital, formerly Hahnemann Homeopathic Hospital, merges with Children’s Hospital.

1991
Children’s Hospital and Pacific-Presbyterian Medical Center merge to create California Pacific Medical Center (CPMC). CPMC joins the Sutter Health chain.

1995
Judith M. Mates, MD (ob-gyn), becomes the second female president of the San Francisco Medical Society.

1996
Toni J. Brayer, MD (internist), becomes third female president of SFMS and, in 1990, the first female chief of staff at California Pacific Medical Center.

2003
Rita Melkonian, MD, FACOG (obgyn), becomes the fourth female president of the San Francisco Medical Society, with E. Ann Myers, MD (endocrinology), as the president-elect.

In closing, it’s interesting to note that in 1868, while debating the admission of women, the American Medical Association recorded this statement by Dr. Alfred Stille, prominent teacher of pathology:

“Another disease has become epidemic. The woman question in relation to medicine is only one of the forms in which the pestis mulieribus vexes the world. In other shapes it attacks the bar, wriggles in the jury box, and clearly means to mount upon the bench; it strives thus far in vain to serve at the altar and thunder from the pulpit; it raves at political meetings, harangues in the lecture room, infects the masses with its poison, and even pierces the triple brass that surrounds the politician.”

If only Dr. Stille could see us today. We’ve sure come a long way.

Nancy Thomson, MD, was a practicing anesthesiologist at Children’s Hospital from 1963 to 1985. In 1988 she received her master’s in public health from the University of California at Berkeley. From 1991 to 2000 she worked as the infectious disease officer and staff physician at San Quentin State Prison. Dr. Thomson currently serves on the editorial board for San Francisco Medicine and is the magazine’s obituarist.

All About Labiaplasty - Labia Minora Reduction

2009-11-06T15:10:00.000-08:00

WHAT IS LABIAPLASTY?

Labiaplasty is a surgical procedure which corrects excessively long, enlarged or redundant labia minora. Women who seek this surgical procedure may be self-conscious about hanging labial tissue, they may have asymmetric labias, or they may have pain or discomfort during sex, with exercise or sometimes just walking!

The purpose of labiaplasty is to surgically reduce excessive large labia minorae, 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.

Labiaplasty only addresses the labia minora (inner lips of the external genitalia of women). It does not generally affect the labia majora (outer lips), nor does it alter the vagina.

HOW IS LABIAPLASTY PERFORMED?

In order to ensure complete comfort and relaxation, we perform labiaplasty in the operating room, under a short and safe general anesthesia. Surgical loupes (microscope glasses) are always used to ensure the most meticulous possible repair.

The area to be trimmed is marked, and local anesthetic containing epinephrine (adrenaline) is injected to prevent bleeding and bruising during surgery, and to keep the area numb for many hours after surgery. Next, excess tissue is trimmed. A multiple-layer closure is then done (usually 2-3 layers of stitches) using all dissolving (absorbable) sutures. Antibiotic ointment is applied, and mesh panties with an absorbable pad are placed.

On average, surgery takes around an hour and a half to two hours. It is outpatient surgery - women can go home in a couple of hours, when they are awake and alert, without nausea and when they are eating and drinking well.

WHAT IS THE RECOVERY FOLLOWING LABIAPLASTY?

You can expect some mild discomfort requiring oral pain medication such as Tylenol or occasionally something stronger (Vicodin or Percocet) for a few days. Aspirin or Ibuprofen (Advil, Motrin) should be avoided as these can increase bruising or bleeding.

There will be some swelling and possibly bruising of the genital region. You can shower the next day, and will be advised to apply antibiotic ointment daily and wear a thin pad in your underwear in case of any spotting or bleeding.

If you have your period, use a pad instead of a tampon for your first 1-2 menstrual cycles to avoid irritation of the incisions while they are healing.

Most women take at least a few days off of work, or work from home during the first few days after surgery, when they are swollen and tender.

Sexual intercourse should be avoided for 3-6 weeks, or until the area is no longer swollen and tender. Aggressive physical activity should also be avoided for at least a week, as increasing your heart rate and blood pressure will bring more blood flow to the area and create more discomfort or swelling.

Some women describe intense itching (due to histamine release during healing), while others have very little discomfort at all after surgery. Keeping a small pillow in your purse can cushion the area if you are sitting on a hard surface during healing.

Like any incision, it takes at least 3-4 weeks for initial healing, and 6 months up to a year for the results to be absolutely final. Incisions are hidden in the natural crease. The area of surgery will eventually be very difficult to see, and there is usually very little scarring, as it involves a mucosal membrane (think about cuts to the inside of your mouth or gums, and how they have healed).

You will be seen back at your surgeon's office within a few days of surgery for an initial checkup, and then usually at 2-3 weeks, 6 weeks, 6 months and one year. All follow-up visits are covered by your surgery fees.

Most women find this operation liberating and are very satisfied with the results.

POTENTIAL RISKS AND COMPLICATIONS OF LABIAPLASTY:

Any surgical procedure carries with it potential risks of anesthesia (nausea, headache, etc), the potential for bleeding, infection and wound healing problems. There will be temporary pain or tenderness, swelling, bruising, and numbness of the area.

Bleeding is controlled during surgery by a cautery pen that coagulates any blood vessels that are encountered. You likely be given a few days of prophylactic (preventative) antibiotics to help prevent infection. You should shower daily and ensure the area is kept clean after surgery.

Your labia may not be completely symmetric - this is the norm for most women. You can have temporary change in pigmentation (lighter or darker) while you are healing.

WHO SEEKS LABIAPLASTY SURGERY?

Women of all backgrounds, shapes and sizes, professions (including stay-at-home moms) and cultures seek labiaplasty! Many women are born with asymmetric or redundant labial tissue, which is normal for them! Sometimes after childbearing, labial tissue can become stretched, and following menopause, the area can droop more.

Labiaplasty is a private procedure that should not be viewed with embarrassment or shame! It is often an empowering experience that can improve a woman's body image and self-esteem.

WHAT IS THE COST OF LABIAPLASTY?

Any surgical procedure includes a surgical fee, operating room or facility fee, and anesthesia-related fees. On average, the total cost can range between $4000 and $8000, depending on the complexity of the surgery, time needed for surgery, and other details specific to your unique anatomy.

Insurance does not usually cover labiaplasty. You can inquire with your insurance carrier about this benefit, but labiaplasty is usually viewed as cosmetic.

HOW SHOULD I PREPARE FOR MY LABIAPLASTY PROCEDURE?

Smoking should be stopped for at least 6 weeks before any operation. Other health problems such as diabetes, heart disease, high blood pressure, or autoimmune disorders should be well-controlled before considering any surgery.

You should be cleared by your primary care physician for surgery, and have had routine preoperative tests (bloodwork, EKG), as appropriate based on your age and medical history. You should not be pregnant, and should not undergo surgery immediately before a major life event (give yourself at least 4-6 weeks to heal before a vacation, etc).

Avoid medications and herbs or nutritional supplements that can increase the risk of bleeding or bruising with surgery (aspirin, anti-inflammatories, vitamin E, fish oil, etc) - your surgeon will give you a comprehensive list of what types of things to avoid and for how long before and after surgery.

Research pays off when choosing a breast implant surgeon

2009-11-01T15:57:00.000-08:00

When you are considering breast augmentation, be sure to research both the procedure and your surgeon extensively.

Learn as much as you can about the procedure using online sources (visit reputable websites such as the American Society of Plastic Surgeons (ASPS) or the ASAPS website) that do not feature only one surgeon, and that provide data on national statistics and safety issues.

Visit a surgeon who is experienced with breast augmentation, and is Board-Certified by either the American Board of Medical Specialties or the Royal College of Physicians and Surgeons of Canada (these are the only two Boards recognized by the American Societies for Plastic Surgery and Aesthetic Plastic Surgery).

Write your questions down for your surgeon, and ask to see before-and-after photographs of typical (not just the best) patient results. Ask to speak to patients who have had the procedure before.

Do your homework! Ensure you have found a good fit with the surgeon in terms of personality, office environment, and aesthetic goals for the procedure.

Why Postoperative Breast Implant Massage is Important!

2009-10-27T10:17:00.001-07:00

QUESTION:

about massage for breast implant
October 27, 2009 9:46 AM | Breast Augmentation

I am 5 weeks postop and I had a lift with silcone gel implants and was told I did not need to massage them . Is there a reason I was told this?

ANSWER:

Doctor/Professional Answers (1)

drkarenhorton

Plastic surgeon
San Francisco, CA
United States

Why Postoperative Breast Implant Massage is Important!
October 27, 2009 10:16 AM

After a breast augmentation, we teach our patients to massage their implants each day in order to ensure that they stay soft and mobile, with the most natural results.

Implants can be placed under the pectoralis major muscle ("submuscular" or "subpectoral"), or on top of the muscle and under the breast tissue alone ("subglandular").

Sometimes, surgeons feel that having the implant under the muscle will do some of the massaging motion just by normal muscle movement and that massage of the implants by hand is not necessary.

In Plastic Surgery, there are few absolutely right or wrong answers. What I teach my patients is that implant massage helps to create a "pocket" that is larger than the implant itself. This will facilitate the implant to move around naturally inside its pocket and have a natural shape and motion, like a normal breast.

Implant massage also functions to some extent as a breast self-exam. Two studies of women with breast implants found that in those women who developed a breast lump, it was found earlier if they regularly massaged and felt their implants - which could be life-saving!

I recommend women massage their implants for a few minutes each day, for the rest of their life! After the scar tissue has completely healed and softened (by one year), massage could simply consist of lying on your tummy or rolling with your breasts against an exercise ball.

The purpose is to ensure the implants move around within their space and that the scar tissue does not contract around the implant ("capsular contacture").

There are videos on implant massage on my website you could refer to for reference: CLICK HERE TO VIEW THE VIDEO.

Ask your Plastic Surgeon what their normal postoperative routine is and to demonstrate what you should be doing.

Karen M. Horton, MD, MSc, FRCSC

What to expect after routine liposuction: What is normal?

2009-10-25T17:03:00.000-07:00

Question:

i had lipo to my hips and back area 4 days ago. i was really surprised that i had no drainage from the lipo. i went home an hour after surgery.

Details:

i was expecting drainage from the lipo. i had nothing! not one drop. is that normal? i do have severe bruising. i also weighed myself, i now weigh more than before my surgery. is all this normal?

ANSWER:

After routine liposuction, it is normal to expect the following signs and symptoms:

1. Bruising - despite the use of "tumescent" solution, some bruising is normal. This will take 2-3 weeks to resolve.

2. Swelling - most MDs recommend the use of compression garments that help keep the swelling under control and feel protective while you are swollen. You can expect to wear your garment for up to 6 weeks.

3. Water retention - seen as weight gain. Stop weighing yourself! Give yourself at least 6 weeks for the majority of the initial surgical swelling and water retention to be processed by your kidneys, and to be eliminated.

4. Fatigue - you will not feel like yourself for at least a few weeks after liposuction. Your body is busy recovering from surgery; you will not have the usual energy to perform all your usual activities during the daytime. Ensure you have some helpers to assist with your activities of daily living, child care, house work, tasks around the home, etc. Be sure to take as much time as you realistically need off work!

In addition, as long as the amount of tumescent solution injected was approximately at a 1:1 ratio to the fat removed (known as the "superwet" technique), you will not likely drain from the incisions. Most Plastic Surgeons perform this technique, as it enables accurate evaluation of how much was is being removed during surgery, enables a smooth contour, and avoids blood loss during the procedure.

Get some rest and remember that any surgery is an "injury". You need to allow your body to heal, and to deliver the building blocks needed for healing in the form of healthy nutrition, lots of restful sleep, and a positive attitude.

Happy healing!
Karen M. Horton, MD, MSc, FRCSC
womensplasticsurgery.com

2009-10-18T21:21:00.000-07:00

Karen M. Horton, MD answers: Sacramento Tummy Tuck doctor recommendations

I live in Oregon but I am spending 3 months with a friend in Sacramento. I have been searching the internet for a quality doctor in Sacramento, CA to perform a tummy tuck. This will be the biggest surgery of my life and I want quality work. Any success stories out there?

2 seconds ago

By Karen M. Horton, MD - San Francisco Plastic Surgeon

A tummy tuck is a wonderful procedure and one of my very favorite operations to do!

For women who have completed childbearing, an abdominoplasty makes up the abdominal portion of a "mommy makeover".

For anyone considering surgery, my advice is always this:

Do your research and homework before deciding on a Plastic Surgeon!

The internet is often a good start, but word of mouth and referrals from other doctors is also a good source of information. Think about how you found your dentist, a realtor, your childcare giver, a plumber... You will be trusting your body to this person! Do your 'due diligence'.

Following your online research, visit a number of surgeons in person - bring a list of questions with you, and bring a friend to act as another listener and objective observer. Ask to see before and after photos - both of the best results, but average results. Ask to speak to former patients about their experience with the doctor.

There should be a "good fit" between you and the physician - in terms of personality, aesthetic goals for the procedure, office staff atmosphere, etc.

Often, making the trip outside your immediate area is worth it. If you don't find someone directly in your town, consider going to a larger cosmopolitan area for treatment. You will probably stay overnight in the hospital or surgery center after a tummy tuck, and you are usually seen 3-5 days after surgery in the surgeon's office for your first follow up visit.

I see many out of state patients for surgery. I recommend my out-of-town patients stay in the near vicinity (within a 3 hour drive) for at least 2 weeks before traveling home.

Best of luck to you!

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

Wait to have breast augmentation surgery until your health is stable

2009-10-18T21:02:00.000-07:00

http://www.realself.com/question/Breast-augmentation-safety-thyroid-ablation

Breast implants safe after thyroid ablation?

I'm 31 years old and a mother of 3 children. After the birth of my last child, I got Graves Disease. I tried for remission on an anti-thyroid drug, but I did not obtain it.

I'm scheduled to have my thyroid ablation on Nov. 6th. I'm also scheduled for breast augmentation on Nov. 23rd. I'm very excited about both procedures. Is it safe for me to have surgery after the ablation? And, I will be using the IV sedation with the augmentation which is only about 45mins. Will my hormones react to anesthesia?

Enough3 in North Myrtle Beach

A: Wait to have breast augmentation surgery until your health is stable

By Karen M. Horton, MD - San Francisco Plastic Surgeon

Congratulations on your decision to have breast augmentation! As long as it is done for the right reasons, in an appropriate candidate, and by a Board-Certified Plastic Surgeon, and at the appropriate time, breast augmentation is a wonderful procedure with fabulous results!

However, when you are actively treating any complex medical condition such as Graves Disease (overactive thyroid), you should postpone elective surgery until your medical situation has stabilized.

Radioactive ablation of the thyroid can have a short-term surge of thyroid hormone release, followed by a longer period of hypothyroidism (low thyroid) when your natural thyroid hormone decreases.

I speak from personal experience: it can take up to a year or longer for the full effect of the thyroid ablation to be complete. During this time, you will need to take increasing doses of thyroid replacement until your own thyroid has completely stopped working or its production of hormone is stable. Your mood, energy level, metabolism and other body systems can undergo major swings.

The thyroid gland controls your metabolism and nearly all your organ systems. I would strongly advise against having a surgical procedure while you are being treated for this condition.

Ask your Endocrinologist about how long you should wait before undergoing elective surgery.

Best of luck to you, and take care of your health first!

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

Breast Cancer In Young Women May Be Hereditary

2009-10-18T19:47:00.000-07:00

Many women presenting to my office for breast reconstruction do not actually have breast cancer.

Many of them have a strongly positive family history for breast and/or ovarian cancer, and upon testing, they may learn they carry the BRCA gene. They may wish to have prophylactic (preventative) mastectomy and reconstruction to lower their risk of developing breast cancer.

Read the article below on hereditary breast cancer from the latest FORCE publication:

WHAT is hereditary cancer?

Breast cancer can result from changes in genes called "hereditary mutations." These gene changes can be passed down from the mother or the father to daughters or sons and cause cancer to run in some families.

The genes most often associated with hereditary breast cancer are called BRCA1 and BRCA2.
Changes in these genes can increase the risk for breast, ovarian, and other types of cancer.

If you have had breast cancer at age 50 or younger, you are more likely to have a BRCA mutation if you have:

had ovarian cancer
breast cancer in both breasts
a relative with ovarian cancer at any age
a relative with breast cancer at any age
a relative with male breast cancer
a relative with pancreatic cancer
a relative with prostate cancer
Eastern European Jewish (Ashkenazi Jewish) heritage

Women with “triple negative” breast cancer (one that is negative for estrogen receptors, progesterone receptors, and Her-2/neu status) may be more likely to have a BRCA1 mutation.

WHAT is gene testing and how would it affect me?

If you are a young woman who has been diagnosed with breast cancer, you can take a blood test (or a genetic test using cells swabbed from the inside of your cheek) to find out if you carry a BRCA gene mutation.

Cancer genetics experts include genetic counselors, risk assessment counselors, geneticists and other physicians with advanced training in genetics and hereditary disease. Before gene testing, you should talk with a genetics expert to learn if your cancer may have been caused by a BRCA mutation, and to help you and your family members decide if gene testing is right for you.

(I usually refer my patients to their breast surgeon or an oncologist to determine whether genetic testing is appropriate for them).

Learning that your breast cancer is hereditary may change treatment or follow-up recommendations. If you test positive for a mutation, each of your children and siblings has a 50% chance of carrying the mutation. Aunts, uncles, nieces, nephews, and cousins may carry the mutation, too.

If you test positive for a mutation, your risk for a second breast cancer and other cancers may be
increased. If you test negative for these mutations, your risk for additional cancers depends on other factors. A genetics expert can help you better understand your risks for additional cancers.

The cost for gene testing can vary depending on which test is ordered. The cost is usually covered for young women diagnosed with breast cancer, either in part or in full, by insurance carriers.

WHERE can I learn more about hereditary cancer?

Experts in cancer genetics can help you understand hereditary cancer and provide you and your family with information about your cancer risk. They will:

review your family medical history to assess and explain your risk for cancer
describe the benefits and drawbacks of gene testing and discuss whether you are a candidate for testing
order the appropriate test if you choose to proceed with gene testing
assist with insurance coverage of testing
interpret gene test results and explain what they mean for you and your family
discuss how to manage your cancer risk and refer you to experts for follow-up care

If you are a young woman with breast cancer, please talk with a genetics expert and your doctor about gene testing for a hereditary mutation!

To find an expert in your area, or to receive support and information visit www.facingourrisk.org or call the helpline at (866) 288-RISK (7475)

Women who develop breast cancer before age 50 are more likely to have one of these gene changes than women who develop breast cancer after age 50. There are options available for you and your family members to lower cancer risk and to detect cancer at an earlier, more curable stage.

Busted! Fifteen Bodacious Facts About Boobs - DivineCaroline

2009-10-16T16:01:00.001-07:00

Busted! Fifteen Bodacious Facts About Boobs - DivineCaroline

Although breast cancer is a serious health threat to women, boobs shouldn’t only conjure up thoughts of mammograms, mastectomies, and medical issues. Breasts as we know them are unique to the human female body, and there are many things that most people don’t even know about them. In honor of National Breast Cancer Awareness Month, check out these crazy, fascinating, and downright weird things you may not have realized about boobs.

Human females are the only mammals whose breasts are visible at all times throughout maturity. Most animals, such as dogs, cats, and lesser primates, display swollen or enlarged mammaries only when they are pregnant or nursing their young; their breasts recede when the offspring are weaned. Evolutionary biologists think that humans’ permanently displayed breasts are intended to confuse potential mates about women’s reproductive status.

In Greek mythology, the universe was created when the god Zeus tricked his wife, Hera, into breastfeeding his half-human son Heracles. According to the legend, when Hera realized that the suckling infant was not her own, she pushed him away and the drops of spilled milk became the Milky Way galaxy.

There’s no such thing as a perfectly symmetrical set of breasts. All breasts have differences, but most discrepancies are simply too tiny to be noticed. For reasons unknown, the left breast tends to be larger than the right.

Two million women in the United States have breast implants. The average age at which a woman gets implants is thirty-four.

In early 2009, Sheyla Hershey of Brazil was awarded the Guinness World Record for having the largest set of breasts. After nine surgeries and more than a gallon of silicone, her breasts are a size 38KKK.

Women who get breast implants are at least three times more likely to commit suicide, a risk that increases with time. As the August 2007 Annals of Plastic Surgery reported, it’s unlikely that silicone toxicity causes the correlation. It’s more probable that women who undergo breast augmentation are more apt to have an underlying psychiatric problem that predisposes them to suicide. (Most women seeking breast augmentation are good candidates. The best candidate for surgery is a woman who is mature, with realistic expectations, a supportive support network and who has done all of her homework! See a Board-Certified Plastic Surgeon for more information).

Contrary to popular legend, the brassiere was not invented by a man named Otto Titzling. Although women have worn chest-binding garments for exercise at least since the time of the ancient Greeks, the modern bra was invented by a French woman named Herminie Cadolle in 1889. The word brassiere—denoting an upper-body harness with straps—has been in use since at least the seventeenth century. It wasn’t until the 1920s that the term referred to a garment that supports the breasts.

At Hong Kong’s Polytechnic University, students can major and get a degree in bra studies.

Sleeping on one’s chest can change the shape of breasts over time, stretching the skin and leading to sagging. Experts recommend that women sleep on their side with their breasts supported by a pillow. (This is debatable)

Wearing a bra to sleep does not lead to breast cancer. (The main risk factor for any woman is family history.)

Breasts contain no muscle tissue, so there’s no exercise that can change their shape. The only way to make breasts look firmer or perkier is to exercise the pectoral muscles underneath the breast tissue.

Men can lactate, too. It’s exceptionally rare, but since men possess mammary glands just like women do, they have the capacity to produce milk. When male lactation happens, it’s usually because of hormonal treatments for diseases like cancer.

According to the American Surgeon, up to 6 percent of the population has extra breast tissue, a condition called polymastia. The excess tissue usually exists in the armpit, although in rare cases, extra breasts may also appear on the neck, face, back, buttocks, vulva, thigh, or even foot and may be fully functional for nursing. The development of extra nipples without breasts is a condition called polythelia.

“Breast ironing” is a practice in Cameroon in which young girls’ developing breasts are beaten and flattened with heavy objects to prevent their emergence. Usually performed by mothers and older female relatives, the procedure is intended to ward off men’s unwanted sexual advances, as well as to prevent early marriage.

According to lingerie manufacturers, the average American woman’s bra size has increased in the past ten years, from a 34B to a 36C.

A woman’s lifetime risk of developing breast cancer is about one in eight, and the likelihood is higher for women who smoke, are obese or inactive, or have a family history of the disease.

It’s no secret that people—both men and women—are obsessed with breasts. But far from being simple lust objects, they’re actually surprising, versatile, and highly individual parts of a woman’s body. This October, do yours a favor and do a breast self-exam to make sure they stay healthy and beautiful for years to come.

First published October 2009

Find this article at:

http://www.divinecaroline.com/22180/85367-busted--fifteen-bodacious-facts-boobs

Shared via AddThis

Breast Cancer Picture Book - A Year of Treatment

2009-10-05T17:39:00.000-07:00

See the video link in this blog post for for a very special photo album created by one of my patients.

She shares with each of us her personal journey through bilateral (double) nipple-sparing mastectomies, implant reconstruction, with later chemotherapy and radiation.

She shows the transition through the various stages of her treatment, to the final few shots of her being active on vacation and living with lymphedema.

Thank you for sharing these intimate and very special memories with us!


Schedule your appointment now. Ask your doctor if LATISSE® (bimatoprost opthalmic solution) 0.03% is right for you. Prescription only. Get free trials of VIVITÉ® Vibrance Therapy and LATISSE® *Offer expires 6/30/10 or while supplies last. Good for augmentation patients only.

WOMEN'S PLASTIC SURGERY

Rebirth of the Women's Plastic Surgery blog

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

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

Links on this page:

Report: Possible RARE Association Between Breast Implant Capsules and Lymphoma

Repost of a wonderful article by a Mommy Makeover patient!

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

Nipple-Sparing Mastectomy: The Ultimate Aesthetic in Breast Reconstruction

Upcoming Presentation: RECONSTRUCTION OPTIONS FOR YOUNG WOMEN AFFECTED BY BREAST CANCER

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.

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

Educational Programs

Breast Reconstruction: Understanding Your Options

"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?

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?

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

Plastic Surgery After TwinsGetting Your Body Back

WHAT TYPE OF DOCTOR ARE YOU AND WHAT DO YOU SPECIALIZE IN?

CAN YOU TELL US A BIT ABOUT WHAT HAPPENS TO OUR BODIES. ABDOMENS, BREASTS AFTER PREGNANCY(especially a twin pregnancy)?

WHEN DIET AND EXERCISE HAVE DONE ALL THEY CAN FOR A WOMAN WHO HAS TRIED TO LOSE THE POST-PREGNANCY WEIGHT, WHAT TYPES OF PROCEDURES SHOULD SHE CONSIDER?

WHAT TYPES OF PROCEDURES ARE AVAILABLE FOR WOMEN WHO WANT TO ADDRESS THE EXTRA SKIN, STRETCH MARKS, AND BELLY BULGE LEFT AFTER HAVING TWINS?

LET'S TALK ABOUT BREASTS. FOR THOSE OF US WHO HAVE BREASTFED OUR TWINS, WHAT CAN WE DO ABOUT THE INEVATABLE SAGGING?

ARE THERE ANY OTHER PROCEDURES OR TOPICS YOU WOULD LIKE DISCUSS?

WHAT SHOULD WE BE LOOKING FOR IN CHOOSING A DOCTOR TO PERFORM THE AFOREMENTIONED PROCEDURES?

COST WISE, CAN YOU GIVE US A BALLPARK FIGURE ON WHAT WE SHOULD EXPECT TO PAY FOR SOME OF THE MENTIONED PROCEDURES (plastic surgery after twins)?

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?

Words of Thanks from a Breast Cancer Survivor

The Psychology of Potential Cosmetic Surgery Patients - The Surgeons' Perspective

Liposuction Q & A with Dr. Karen Horton

Medicare Participation Among Surgeons - Current Statistics and Forecast for the Future

Nation’s Surgical Groups Survey Members on Medicare Participation

The New Guidelines for Mammograms and Breast Self-Exams: An Interview with Three Breast Experts

The Art of Breast Reconstruction - 9th Annual Breast Conference Conference, Presidio of San Francisco

What are drains? Why are they used?

Breast implant massage video - Instruction on how to keep your breast implants soft after breast augmentation

Eat-Sleep-Plastic Surgery!

Online Article with Dr. Karen Horton of Women's Plastic Surgery - Neko Cheri and NC Mag Online

Step-by-step animation about breast augmentation surgery!

How are breast implants put in the body?

The SAFETY and science of breast implants and SILICONE!

Free bonus gift (value $225) for my patients who choose silicone breast implants!!!

Power Women Magazine's Blogtalk Radio - Dr. Karen Horton as featured guest!

Online Plastic Surgery consultations: Convenience or Trouble?

How is bra cup size determined???

TUG (Inner Thigh) Flap Microsurgical Breast Reconstruction

How do you reconstruct a nipple and areola after breast cancer?

Constipation is very common after any surgery!

Personal beauty tip from a Plastic Surgeon: Keep it simple

You should be at your ideal weight and fitness level before a "mommy makeover"

Alloderm with the use of implants - is it safe?

Template for a Letter Regarding Cosmetic Surgery Tax ("BoTax")

Federal Health Care Reform - Concerns of the California Medical Association

Research, Stem Cells and Microsurgery - Working toward growing breast tissue in the lab

The Jakarta Post Article - The Brave New World of Plastic Surgery

Local Heroes in Medicine: Women Pioneers that Shaped Medicine in San Francisco

All About Labiaplasty - Labia Minora Reduction

Research pays off when choosing a breast implant surgeon

Why Postoperative Breast Implant Massage is Important!

What to expect after routine liposuction: What is normal?

Karen M. Horton, MD answers: Sacramento Tummy Tuck doctor recommendations

Wait to have breast augmentation surgery until your health is stable

Breast implants safe after thyroid ablation?

A: Wait to have breast augmentation surgery until your health is stable

Breast Cancer In Young Women May Be Hereditary

Busted! Fifteen Bodacious Facts About Boobs - DivineCaroline

Breast Cancer Picture Book - A Year of Treatment

Plastic Surgery After Twins
Getting Your Body Back

CAN YOU TELL US A BIT ABOUT WHAT HAPPENS TO OUR BODIES. ABDOMENS, BREASTS AFTER PREGNANCY
(especially a twin pregnancy)?