Plastic Surgery Risks & Realities

Plastic Surgery Risks and Realities
Plastic Surgery Risks and Realities


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Hi everybody, I’m Heidi Godman,  in this episode we’re gonna be talking about cosmetic plastic surgery.
In particular, we’re going to find out about:

  • Body sculpting, and the various procedures associated with that term.
  • The risk and realities of plastic surgery.
  • What you should look for in a surgeon.

Our guest is Doctor Alissa Shulman, a board certified plastic surgeon and Chief of Staff at Sarasota Memorial Hospital,  a board-certified plastic surgeon at Sarasota Memorial Hospital who specializes in breast cancer reconstruction, discusses the risks and realities and what to expect from your surgeon in this post.

Doctor Alissa Shulman
Doctor Alissa Shulman / SMH Chief of Staff

– [Heidi] Welcome to the program.
– [Dr. Alissa Shulman] Thank you, Heidi.

Body sculpting, and the various procedures associated with that term

– [Heidi] So let’s start out talking about body sculpting, because this is a term that I think we hear a lot now, but it’s really more of an umbrella term that covers a lot of procedures right?

– [Dr. Alissa Shulman] It is, I think people consider us as sculpting, as if we’re sculpting clay, and of course plastic surgery comes from the Greek word plastikos, which means to form or sculpt. So very similar, but mostly it involves any way to improve the body shape, usually involving liposuction, because that’s probably part of the most common way to resculpt but we’re taking away extra skin, we’re altering where the skin is, really trying to enhance your natural shape.

You really can’t carve out a six pack ab, but you’re trying to reduce the fat over your own muscles, so that your muscles show through and we make the most of your natural shape.

– [Heidi] So this could include, what types of surgery?
– [Dr. Alissa Shulman] It could include tummy tucks, abdominoplasty, breast lifts, breast reduction, liposuction of all type.

There is large volume, small volume.
Fat grafting is my very favorite because that really enables me to truly sculpt.
Where I’m adding fat and reducing fat.

– [Heidi] Fat grafting, we hear that one too, but what exactly is it?
It’s using our own fat right?

– [Dr. Alissa Shulman] I think it finally came really to it’s own in the past 5-10 years when we realized the science behind it.

We’ve been actually doing fat grafting for, I would say, hundreds of years unofficially and it maybe not working as well as we’d like, but fat is a live piece of tissue, just like we transfer skin grafts in burn patients, we can transfer bits of fat, as long as it’s a live cell and it goes, and it’s your fat, not someone else’s, and it is able to get a blood supply, so in small amounts, many small amounts, a droplet of fat can get some blood supply.

I tell my patients, “Picture a sponge with all those little holes in them. If you put a drop of fat in every little hole and the tissue is the sponge, then that drop of fat will get a blood supply over the next few weeks and turn into still live fat.”

It’s your fat transferred from any area that you have extra fat in.

I would hate to rob Peter to pay Paul, but if there’s fat that you can afford to get rid of in certain areas, and fat that you need some form in, say breast or any sort of divot.

I also use a lot for reconstructive surgery, again for divots and indentations, and of course that also brings us to the Brazilian butt lift, which is really in the news in Florida all the time, where we’re putting that same fat into the bottom.

However, that is an area that, because of the physiology and anatomy, very large blood vessels, right now that’s under a lot of scrutiny.

There have been a lot of deaths with that specific surgery, just to the buttocks, not to the breasts and other parts of the body, but to the buttock, specifically because of the large blood vessels there and the muscle volume, and we’re still evaluating that.

I am also just about to become president of our Florida Society of Plastic Surgery, and because all this seems to start and come out of Florida, that is what we’re looking at.

So I haven’t done a Brazilian butt lift in two years, because I’m a little concerned about the risks, and until we fully understand it, I’d rather sculpt the bottom by removing fat above and below the butt, and then making the butt look rounder, but not actually adding fat in any large volume to the butt.

– [Heidi] So that particular procedure is something that you’re not doing right now, but so many other things that you can do from it.
So what if someone comes to you and wants a little body sculpting, a little change, where are you typically going to harvest the fat?
Will it come from, can you say, “Hey, I want it out of my legs or my gut or whatever.” Can you make that decision?

– [Dr. Alissa Shulman] For the most part, absolutely, wherever you have extra fat.
But when you’re looking at where the extra fat is, you have to consider also how is the skin going to be when you remove the fat.

Body sculpting
Body sculpting

Some parts of the body have very good thick skin that’s going to tighten after we remove the fat a little better than others, so the middle thigh, that whole thigh gap thing everyone’s looking for, is a very tough area to work on, because it’s really thin skin, and even in young patients, it’s unlikely to retract very well and you’ll just be left with extra skin there, so sometimes fullness is better than lack of fullness, but outer thigh and hips and belly very often has good skin.

Now if you’ve been stretched out from, pregnancies or weight change, then that skin might also not retract as well.
So then we start looking at skin tightening at the same time as fat reduction.

So I try a look that’s going to be a benefit to your shape.

Sometimes I really need the fat to put it somewhere, either in reconstruction or say an autologous breast augmentation.

Instead of using implants, we’re using fat, and I love doing that because the fat stays where I put it.

If you treat the fat well, filter out all the impurities and put lots of tiny droplets, not any big amount of fat, it will stay where you put it.

So if you need some fullness in your upper breast, which is very common after 40, you tend to get a very hollow upper breast, especially after breast feeding, things like that, it will stay where you put it, but you have to be very judicious where you put it.

You can’t put a big amount. You can put lots of little layers in and tiny droplets and then it gets a blood supply because you’ve given it a chance to be surrounded by healthy tissue.

– [Heidi] Yeah, I was gonna say. Is it the resorption of this fat that’s helping it stay where it is?
Or what is it making, what’s keeping it in that place?

– [Dr. Alissa Shulman] Well I’m putting tiny droplets in a solid area already. So I’m not making a pocket like you would for an implant.
So for an implant, you make a pocket, either over or under the muscle and then you put the implant in and then that surrounding tissue holds it in.

Now for fat grafting, I’m literally almost like, as they fill eclairs, you don’t make a hole in an eclair, you stick a tube in and pump the filling in, so that’s where the fat droplets go.

I have a tiny little blunt needle and I’m putting thousands of droplets in multiple layers and, assuming that there’s a blood supply around, of course, you wouldn’t put it in unhealthy tissue, that blood supply gets to the fat and the fat lives.

Now does it all live?

No, not quite. You’ll read about maybe take or the survival of fat, anywhere from 50 to 80%, depends how well you treat the fat.

That is a varied thing that people do because there’s no consistent way to do fat grafting.
In plastic surgery, there’s about a dozen ways to do everything that we do, so every surgeon has their preference.

I prefer to filter my fat and treat it really carefully.
I don’t let it look at air.
I don’t let it get exposed to the elements.
I keep it contained.
I keep it body temperature and I lightly centrifuge it, so that I don’t get rid of the good things.

There are actually stem cells associated with fat as well and those stem cells help heal damage, so I like to keep those stem cells around
by not over-filtering.

But I also, again, treat it very carefully.
You don’t want to treat it with laser or ultrasound.
There’s different ways to harvest fat and I want to harvest it carefully, so that you treat the fat cells as the liquid gold I consider it.

And so you treat the fat well and you surround it with healthy tissue, it lives, and it actually stays wherever you put it.

So you’re putting it in a tiny little spot and multiple directions, multiple layers, and it stays there.

I’d say my take is about 80% and mostly because some of my reconstructive patients are very challenging.

They’re either very slender or have radiated tissue, so I know that by treating the fat well, it does stay.

– [Heidi] But does it last?
It’s going to be there for 10, 20, 30 years.

– [Dr. Alissa Shulman] If your weight stays pretty much the same or if you gain a little, it will get larger.
Now I’ve had patients who then very quickly went on some sort of diet and lost weight, and they’re like, “Oh my gosh, my fat disappeared.”

Well, it shrunk, because they’re fat storage cells, that’s what they do, but it also then, a few months later, they gain some of the weight back.
“Oh, look, it’s back again.”
So it is a live cell.

The risk and realities of plastic surgery

– [Heidi] What about the risks of doing this?
Sometimes we hear about lipo and risks involved with that. Is that same risk here for fat grafting?

– [Dr. Alissa Shulman] Yes, so the harvest is the liposuction and this is more traditional liposuction.
So not using any extra energy. You don’t wanna hurt the fat.
So the risk for liposuction tends to be lumps and bumps and ripples.
The harvest site should be in a very hidden spot, very tiny cuts there, so you really wanna make sure that you’re not taking big chunks of fat.

I don’t want big chunks of fat to be injected either, so I’m using a very small tube or cannula, about four millimeters, and I’ve got a very predictable size that I’m injecting it through.

So a small one millimeter blunt needle to inject it with.
And I’m harvesting with a four millimeter, that’s probably most common, ’cause you want a perfect little fat globule, so to speak,
that’s a live cell. So a very large fat cell.

For someone who has very large fat cells, you can have that.
Sometimes those will explode and they should hopefully go through my filter once they’ve exploded.

Exploded fat cell is oil. That won’t live. So plasma, that’s not what I’m looking for. I’m looking for fats so I try to filter all that out.
But if you keep and maintain a nice weight, your fat should stay.

– [Heidi] What about the estrogen that lives in fat cells or is produced by fat cells?
Does that increase cancer risk in any way, for women who’ve had a mastectomy or a lumpectomy, and want some fat placed there in the breast?

– [Dr. Alissa Shulman] It shouldn’t, because really the whole concept of estrogen production in exogenous fat or in extra fat, it’s a circulating chemical.

It’s not just staying right there. So you normally produce estrogen in your fat and wherever your fat is, you would still normally produce it.

But it doesn’t really change by the fact that its now gone from your hips to your breasts, and they’ve actually been studying that, fortunately, because honestly before that we didn’t really have an answer, but they have been studying.

It does not increase your risk of breast cancer, and certainly when we’re fat grafting to the breast, you still want to obey certain anatomy.

So the fat in the breast should be just under the skin or between the breast and the muscle.
You don’t really wanna put fat in the middle of the breast.
It’s going to distort your mammogram. Now, it is translucent, unlike an implant.

So an implant, even if it’s salt water, like a saline implant, it’s still going to look solid white on a mammogram.
So fat is translucent. You see right through fat.

Fat grafting
Fat grafting

So if you put fat in a nice careful way around the breast, under it, above it, it should not, in any way, interfere with a mammogram and I’ve had patients where. The most common thing I am doing right now is removing old implants, lifting the breast and plumping them up a little bit with their own fat.

So they’re not quite going through the transition they were afraid of, of losing the volume of their implant.
But most of the time, they don’t wanna be as large as they were with the implant.

So somewhere in the middle and we’ve had a couple of patients in the past few years, because now they’re able to get a mammogram, I call it their first mammogram really, in a very long time, where you can see everything and they found tiny little breast cancers.

They were not caused by the fat cells that were nearby, but now that that implant’s gone, you can actually see on a mammogram much better everything.

– [Heidi] And some people are having the implants removed, the texture implants, because there’ve been problems with those, right?

– [Dr. Alissa Shulman] Yes, we’ve been associating this very rare large cell lymphoma with a textured implant, and more specifically, one type of brand, because the texturing’s so deep.

There are a lot of different theories on that.
I think the most common one’s going to be that it’s like micro trauma.
This texturing’s like Velcro, basically.
It was put on these implants so they would stay in place, and if you can imagine, they’re on your chest.

Every time you take a breath, you’re probably tearing that Velcro-type substance a little bit, every time breathe or stretch, and then your body heals over and over.

I’ve now been replacing my patient’s for reconstruction.
Now when I’ve fitted cosmetic implants, I’ve actually not used the textured ones.
I didn’t think there was a need for it.
I think the round implants were lovely.
But for the textured ones, for those tear-drop shape, every time I’ve gone back in, I have found a double capsule or their body makes some scar tissue under anything artificial, and we’re used to that for an implant.

But for the textured implants, everyone I’ve now exchanged has a double capsule.
So your body’s making extra tissue, probably in response to that trauma.
So you do that for eight to 10 years, your body will eventually not correct itself very easily.

I think that’s where they’re eventually going to find that chronic trauma, is going to be found to be some of the source of that lymphoma, and it’s really just staying around the breast.

There still have been very few deaths, thank goodness.
But I’m telling patients, “Don’t wait for a sign or symptom. If you have a textured implant, either get rid of it or exchange it for a smooth one.”

– [Heidi] Or get a check up at least. Tell it to your doctor about it.
– [Dr. Alissa Shulman] You get a check up, but It’s just not worth waiting for when you might be too old for an exchange, or might be too ill for an exchange, and if there’s a way to fix that now, I wouldn’t wait, cause there really is a time frame.
They’re looking at eight to 10 years, when this change could happen, and, if you’re early, then you can get rid of that worry.

– [Heidi] All right, and so we could consider that may be an unfortunately reality of this type of surgery, and that really can apply to a lot of different aspects of plastic surgery.
It’s not always what you think it’s going to be, right?
There are misconceptions.

– [Dr. Alissa Shulman] It’s tough because plastic surgery’s probably the only area where we take perfectly healthy people and do things to them that could make them sick.

They were perfectly fine before we operated on them.
There’s pretty much nothing that I do that can’t have a complication and that’s what the reality of any sort of cosmetic surgery, even as easy as an injection or Botox, something like that, there’s potential complications with all of them.

So patients need to understand that’s what we’re looking at.
When we’re weighing risk and benefit, and are you a good candidate, it’s not that I can’t do the surgery but it might not be worth the risks for you.

You have medical conditions or the reality of their anatomy.
They might not get the results they’re looking for, and is it worth going through the scar, the risk of infection, the fact that you might not look
like you think you’re going to look like.

And so that’s why, when we talk about, when you’re interviewing with your plastic surgeon, it’s a two way interview.

We’re interviewing you to see if you have tissue I think we can work with and they should be interviewing us to see,
“Is this someone I can trust?
Is it someone I can understand?
Are they making sense?
Will I believe what they’re talking about?
Are they just trying to make money?”
That’s the reality of the business.

– [Heidi] Right, a business, but also something that the patient has to take seriously, as a consumer, as you’re saying.
So you shouldn’t only be looking for particular aspects in a surgeon, which we’ll talk about in a second, but also in the place that it’s going to happen, right?
At a hospital or an outpatient center. What do you look for?

– [Dr. Alissa Shulman] Well, there’s a lot of different things.
People will have their own surgery centers and I’m not against it.
Just that here, we’re in Florida. Our average population might be a little bit older.

So I think whatever we’re doing has a little bit of added risk to it.
My personal bias is I like to do all of my surgeries from an outpatient surgery center, that’s partially attached to a hospital.

Sarasota Memorial Hospital
Sarasota Memorial Hospital

In my case, I’m with Sarasota Memorial Hospital, just because of geography.
I want my office close. I can run over to the hospital.
I can run over to their outpatient surgery center and that’s where I spend all of my time.
Now you can also have your own surgery center, and if you’re in a multi-physician group, it makes more sense.

You can use that surgery center every day.
If you’re using it every day, then financially it makes sense, and you can have every bit of control over the safety.

What you should look for in a surgeon?

You’re looking for things that are accredited.
What they call AAAASF.

The American Association for Accreditation of Ambulatory Surgery Facilities.
That’s what it stands for. But that would probably be the gold medal
of outpatient surgery centers that are not part of a hospital and that’s what you’re looking for.

It’s almost like looking for the board certification of your physician.

– [Heidi] Yes, and so you want board certification in your surgeon, but what else should you look for?

– [Dr. Alissa Shulman] You wanna look for someone who has privileges in a hospital.
Even if they’re not doing their surgeries in a hospital, they’re doing it in their own surgery center, they should have privileges at a nearby hospital for those procedures.

Because if there is a complication, it’s unlikely they’re going to be able
to open up their own surgery center in the middle of the night for an emergency.

So if they can take care of you in a hospital, then you should be feeling a little safer about it.

If a physician does not have privileges for that procedure in a hospital, then who’s going to take care of you?
A complete stranger, if you have a complication.

Some of the surgeries we do, yes, are fairly routine and you can probably train anyone to do them, any surgeon to do them.

However, can they take care of the complication?
Are they going to be able to be there for you, if something unpredictable happens?
And it happens, this is surgery.
People are human, we’re human.
And hematomas happen, bleeding happens, infection happens.
You can fall right on your breast and it rips open.
That’s not something that can wait till the next morning.
Or a car accident, I had a patient who was a week out of her breast reduction, had a car accident.
Luckily I could take care of that emergently in the hospital.

– [Heidi] So you want to make sure that there’s a board certified surgeon, hospital privileges, but also, how important is the rapport you have  with the surgeon?
Sometimes you hear, “Oh, there’s a doctor.
“No bed-side manner, but a great doctor.”
In this case–
-[Dr. Alissa Shulman] You really need a rapport.
– Yes, you would need to.
How does that make a difference?

– [Dr. Alissa Shulman] Because you can believe you feel like
they’ll tell you the truth.
I tell my patients, if it’s good or bad, I tell them absolutely the truth.
I would advise this to my best friend, my mother, my sister, anyone.
And so, you’re not in a rush.
The nice thing about plastic surgery, other than in the emergency room when we’re repairing an actual emergency, rarely is any of this life threatening tomorrow.

So even if it’s something like breast cancer, where there’s an urgency,
you have a little bit of time to talk to a few surgeons.

You really need to have a rapport with your surgeon.
You need to feel like your surgeon’s listening to you, understands you, and you’re comfortable with them.

If there’s something that is off-putting about your surgeon, you probably should go to a different surgeon.

– [Heidi] And the different it makes, when you have that rapport?

– [Dr. Alissa Shulman] They’ll tell you everything.
They’ll tell you everything you need to know, and if you talk to ’em often enough, you’ll figure out what they really want.

I’m not the surgeon who draws little images on a computer and does a mock-up.
“This is what you’re going to look like.” Because it’s not really that predictable. Everyone’s different.
I prefer to spend time with the patient.
Try to get an idea of what they’re looking for.
What they’re expecting.

And sometimes, even at the last minute, we can get an uh-huh moment, like, “Hm, this might not be the right surgery.”

I have changed surgeries at the last minute because you tend to take the patient home with you in your head, and you go over and over and over and over, and you want a physician who’s going to do that.

I’ve called my patients up the night before surgery, saying, “Look, I’ve thought about this a few more times.
“We might wanna change our options.”
And if at the last minute, they’re not ready for that?
We’ll cancel surgery.
That’s fine, we can always do that.
We refund the money.

We really want to make sure that you’re comfortable with the surgery
because something bad might happen, because of the surgery, and I can’t always prevent that.
As many times as I’ll go over it in my head, and try to do the right thing and prevent a disaster, it can still happen.

– [Heidi] But the difference that the surgery can make, cosmetic plastic surgery, tell us a little bit about that.

– [Dr. Alissa Shulman] I don’t wanna say it’s life altering, but for the most part, it should make people feel as good on the outside as they feel on the inside.

This is a very healthy town, where people are staying healthy for many years.
I don’t consider 70 or 80 that old anymore.
I think when I was younger, I’m sure I did.
70 is not old, and at 70, if you feel like you feel 40 on the inside and don’t want to look 70 on the outside, and you’re otherwise healthy, there’s no reason why you can’t try to look as young as you feel.

Within reason, of course.
And most people would gladly say, “I don’t want to be 15 again.”
“I’d like to be 30 again.”
“I don’t wanna be 15 again.”
And so that’s pretty realistic.
You don’t want your breasts hanging down past your bellybutton, or you’ve lost some weight and you’ve been working out, but your skin is still a little bit loose.

Well, that is a very natural progress for aging.
But that doesn’t mean you have to put up with it.

And if it’s safe to have a tummy tuck or an arm lift, or any sort of tightening procedures, and your other other doctors also agree, because I always ask the blessing of your primary doctor, someone who knows you long before I did, then I think that’s absolutely fine.

But you also wanna listen, is it going to change their life?
No, I don’t expect plastic surgery to change someone’s life, and if they start acting like it is, I consider that a little bit of a red flag.

Let’s talk a little bit more.
Are you just out of a bad relationship?
Was there a spousal death or a divorce?
I’d bring them back a few times and let’s talk about it.

– [Heidi] And then the difference that it makes overall in the person’s life?

– [Dr. Alissa Shulman] I don’t wanna say it should be earth-shaking.
It really should be moderate.
It should be the part of the progress that they’ve done to get healthy.

So they’re working out, they’re eating healthy, and now they’d like their body to look like the results that they’ve asked for.

I feel better when those are the expectations.
When they really think they’re suddenly going to have the perfect life because of that breast lift or liposuction, I get a little worried.\

We really wanna talk.
I think breast reconstruction might fall in that level of life altering because really you’re having a body part removed and you’d like to just look normal again.
But everything else should be part of a process.
– [Heidi] Just the big picture.
– [Dr. Alissa Shulman] The big picture, absolutely.
– [Heidi] And you’re leading the way.
– [Dr. Alissa Shulman] Oh, well, I’m trying. I’m trying.

– [Heidi] Doctor Alissa Shulman, thank you so much.
– [Dr. Alissa Shulman] You’re welcome.

– [Heidi] Okay, everybody, time now for today’s take-aways.

  •  One is that when you hear the term body sculpting, it can refer to breast, hip, or even buttock augmentation.
  • Two is that it’s important to have realistic expectations  about plastic surgery results.
    Talk to your doctor about what you can really expect and work with your physician.
  • And three, make sure your doctor is board-certified plastic surgeon, and find out where your surgery will be performed.

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