(upbeat music)
- [Narrator] From Sarasota
Memorial, this is HealthCasts.
A healthy dose of information
from experts you can trust.
- Hi everybody, I'm Heidi
Godman, welcome to HealthCast.
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,
and 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.
Welcome to the program.
- Thank you, Heidi.
- [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?
- 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.
- So this could include,
what types of surgery?
- 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
'cause that really enables
me to truly sculpt.
Where I'm adding fat and reducing fat.
I know we're gonna talk about that later.
- Yeah, well let's start
talking about it right now.
Fat grafting, we hear that one
too, but what exactly is it?
It's using our own fat right?
- It is, 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.
- 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?
- 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.
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, say,
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.
- 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?
- 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.
- But does it last?
- [Alissa] It should.
It's going to be there
for 10, 20, 30 years.
- 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.
- 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?
- 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.
- 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?
- 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.
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.
- And some people are
having the implants removed,
the texture implants,
because there've been
problems with those, right?
- 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 microtrauma.
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."
- Or get a check up at least.
- [Alissa] You get a check up, but--
- Tell it to your doctor about it.
- 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.
- 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.
- 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.
- 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?
- 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.
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.
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.
- Yes, and so you want board
certification in your surgeon,
but what else should you look for?
- 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.
- 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--
- You really need a rapport.
- Yes, you would need to.
How does that make a difference?
- 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.
- And the different it makes,
when you have that rapport?
- 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.
- But the difference that
the surgery can make,
cosmetic plastic surgery, tell
us a little bit about that.
- 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.
- And then the difference that it makes
overall in the person's life?
- 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.
- Just the big picture.
- [Alissa] The big picture, absolutely.
- [Heidi] And you're leading the way.
- Oh, well, I'm trying.
I'm trying.
- Doctor Alissa Shulman,
thank you so much.
- You're welcome.
- 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.
If you'd like more information
about Sarasota Memorial
Hospital, call 941-917-7777.
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for joining us today.
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