OC Register: Best Plastic Surgeons of Orange County 2013

Best Plastic Surgeon 2013Dr. Nichter has been named as among the top plastic surgeons in Orange County by the OC Register for 2013.

Orange County Plastic Surgeons, Dr. Jed Horowitz and Dr. Larry Nichter are honored to be voted into the categories of Best Doctors in America, Top Doctors and America’s Top Surgeons for over a decade. The success of their practice, Pacific Center for Plastic Surgery, can be attributed to providing the highest level of patient care while striving to provide an intimate family atmosphere. In addition, they have been at the forefront of pioneering the minimally invasive lower face lift, branded the LiteLift™. Recognizing the demand for facial rejuvenation which is less invasive, safer, and requires less recovery time, the LiteLift™ has proven to be extremely effective. Dr. Horowitz and Dr. Nichter also provide outreach work through their humanitarian foundation Plasticos Foundation.  Through volunteer contributions, medical teams are sent across the globe providing reconstructive surgery to those in need. Plasticos Foundation continues to be their passion and opportunity to give back.

Via the Orange County Register »

Dr. Nichter receives Patients’ Choice Award 2012

Patients Choice Award NichterDr. Nichter has been awarded the Patients’ Choice Award for 2012 in recognition of his consistently positive throughout 2012. From patientschoice.org, which issued the award:

While doctors generally receive positive reviews from their patients, only a select few receive uniformly rave reviews worthy of a Patients’ Choice acknowledgement. In fact, of the nation’s 830,000 active doctors, only 5% were accorded this honor by their patients in 2012.

IDEAL Structured Breast IMPLANT® feels more natural, new study finds

Women wanting breast augmentation have until now faced a dilemma: a choice between safer but less natural-feeling saline implants, and more natural-feeling silicone implants which are perceived to come with health risks.

The Ideal Implant®, a new breast implant soon to be made available to the public, promises to change all of this. The Ideal Breast Implant is a saline implant with the natural feel of a silicone implant made possible by its innovative double-lumen design. This design consists of a series of nested shells which control the flow of liquid inside the implants, giving them a more realistic feel than standard saline implants.

The Ideal Implant has completed its two-year trials with stunning results. Of the 472 women who came in for two-year follow-up examinations, patient satisfaction for those who received the Ideal Implant as their first implants was 94.3%. Satisfaction among women who received Ideal Implants as replacements for their previous ones was 92.3%. Surgeon satisfaction with the results was also high (96.5% for primary implants and 93.4% for replacements).

Dr. Larry Nichter, one of the surgeons assessing the new implants for the FDA, comments very favorably on the new breast implants in a press release by the American Society for Aesthetic Plastic Surgery:

“The two-year clinical data from this study show that the Ideal Implant may provide a good alternative to current saline- or even silicone gel-filled implants. One of our most significant and unexpected findings was the low rate of capsular contracture for the investigational, double-lumen implant compared to current single-lumen saline implants.”

The Ideal Implant’s two-year statistics for capsular contracture were better than those for regular saline implants at one year, and none of the small number of deflations were caused by shell fold flaws.

As a further guarantee of quality and safety, the Ideal Implant will only be available through plastic surgeons who are certified by the American Board of Plastic Surgery, which is the only plastic surgery board recognized by the American Board of Medical Specialties. This means that women who choose the Ideal Implant will automatically be choosing from among the best plastic surgeons in the United States.

To receive updates about the ideal implant or to be placed on Dr. Nichter’s waiting list for the procedure, please contact our office using the form below.

[si-contact-form form=’2′]

IDEAL Structured Breast IMPLANT®: 2-year Follow-up Study Results

Larry S. Nichter, MD; and Robert S. Hamas, MD

“Two-Year Outcomes With a Novel, Double-Lumen, Saline-Filled Breast Implant”
Originally published by the American Society for Aesthetic Plastic Surgery, Inc.

Click on the thumbnail to download this article as a PDF.

Abstract

Background: A double-lumen, saline-filled breast implant with a baffle structure (IDEAL IMPLANT Saline-Filled Breast Implant; Ideal Implant Incorporated, Irving, Texas) was developed to overcome the limitations of single-lumen saline implants by controlling saline movement and providing internal support to the implant edge and upper pole.

Objective: The authors report 2-year data from a 10-year US clinical trial evaluating the safety and effectiveness of this investigational implant.

Methods: Women seeking primary breast augmentation or replacement of existing augmentation implants were enrolled between February 2009 and February 2010 at 35 private practice sites, where the women underwent surgery to receive the new technology implant. Data collection included incidence and grade of capsular contracture (CC) and wrinkling as well as patient- and surgeon-reported satisfaction measures. All clinical data were reported as Kaplan-Meier risk rates of first occurrence, per patient, in each cohort.

Results: Two-year follow-up visits were completed by 472 of 502 enrolled women (94.0%), 378 of whom had undergone primary breast augmentation and 94 of whom had received replacement augmentation. Patient-reported satisfaction with the outcome was 94.3% for primary augmentations and 92.3% for replacement augmentations; surgeon-reported satisfaction was also high (96.5% and 93.4%, respectively). Baker Grade III and IV CC rates were 3.8% (primary) and 8.2% (replacement), whereas moderate-to-severe wrinkling was 3.8% (primary) and 12.0% (replacement). Deflations occurred in
4.8% of primary augmentations and 3.3% of replacement augmentations. No deflations were caused by a shell fold flaw.

Conclusions: Two-year data from 472 women indicate that this double-lumen saline implant containing a baffle structure has a low rate of wrinkling and a lower rate of CC at 2 years than was reported for current single-lumen saline implants at 1 year.


Although saline-filled implants are a safe, effective alternative to silicone gel-filled implants,1 the currently available saline-filled implants are essentially balloons filled with freely-moving fluid, which may result in an unnatural feel or suboptimal aesthetic result.2-5 These implants, which have only a single lumen, tend to be less forgiving than silicone gel implants in terms of palpability, visibility, and rippling.5,6 Scalloping or wrinkling, for example, is a well known problem.5-7 This may be a significant part of the reason that 31% of women in the United States chose saline-filled implants for breast augmentation in 2011.8 For a more natural result, the only currently available alternatives to saline-filled implants are silicone gel-filled implants, which some women will not accept. Clearly, there is a need for a saline-filled implant that offers a more natural result, without the wrinkling, bouncing, or globular shape commonly attributed to current saline implants.2-5 Continue reading “IDEAL Structured Breast IMPLANT®: 2-year Follow-up Study Results”

Are Silicone Implants Toxic?

Image: FDA

I think you have to answer this question in two ways:

  1. First, to address the perceived silicone toxicity by the public/patients which has not been substantiated by scientific studies and would be rare if it occurred at all.
  2. Secondly you have to address if they have ever been proven to be toxic.

The first question is easy to answer: there is no known toxicity from silicone gel breast implants. It has been studied by the FDA for more than three decades to establish its safety. Silicone is the most common material used in medical devices/implants. Examples include shunts that go from the brain to the abdomen (for hydrocephalus) which are left in for a lifetime, artificial finger joints, syringes, IVs, catheters (including ones that go next to the heart), surrounding pacemakers, and even oral anti-gas tablets.

The one possible exception may by the PIP implant made in France (generally not available in the USA). Most of the concerns about the PIP implant were about the use of non-medical silicone and manufacturing problems, and do not relate to implants used in the United States by board-certified plastic surgeons. This is not to say that breast implants, like any implant, can have problems; they may have to be removed and are not meant to last a life time. Common reasons for replacement include: capsular contracture, rupture, infection, change in breast size, and pain—but not for toxicity.

To answer the perceived toxicity of Silicone by the general public—this is quite a different matter.

Breast implants have been around since the 1960s. About 15 years ago Connie Chung ran an exposé, Face to Face with Connie Chung, claiming silicone implants were responsible for different health problems. This led to lawsuits, a huge windfall for lawyers, and the subsequent ban on silicone implants for first-time breast augmentation patients went into effect. They were always available for breast reconstruction (e.g. after mastectomy) and replacement of existing silicone breasts. Also, please note that saline implants are still covered by a silicone envelope.

Soon after, a ban on silicone implant use became worldwide. This lasted for years until more than 100 clinical studies showed that breast implants aren’t related to cancer, lupus, scleroderma, other connective tissue diseases, or the host of other problems they were accused of causing.

June 1999, The Institute of Medicine released a 400-page report prepared by an independent committee of 13 scientists. They concluded that although silicone breast implants may be responsible for localized problems such as hardening or scarring of breast tissue, implants do not cause any major diseases such as depression, chronic fatigue syndrome, lupus or rheumatoid arthritis, etc.

The Institute of Medicine is part of the National Academy of Sciences, the nation’s most prestigious scientific organization.

Eventually, a federal judge dismissed/rejected the lawsuits, declaring them junk science and ended for the most part the barrage of lawsuits. This led to the present reintroduction of silicone implants years ago and their approval by the FDA. Interestingly enough, most of the rest of the world reintroduced them many years prior to the United States.

Dr. Larry Nichter

I happened to be in private practice in Orange County, California during this time of confusion by the public and media. My office was deluged with patients, mostly new ones having had surgery elsewhere, believing they were being poisoned by their breast implants. Most of my consults lasted about an hour and were spent trying to convince patients that they did not need surgery. In fact, I told them that they would not even have to pay for the consultation if they decided to not have surgery. Most of the patients had no problems but were simply gripped with general panic, mass hysteria, and fear from all the media hype and false information. Despite my strong advice to not remove their implants, many insisted upon that action. As a footnote, the vast majority of these patients that I removed implants eventually returned to my office for silicone gel replacement.

—Larry S. Nichter, MD FACS

Picking the Best Plastic Surgeon: Finding Dr. Right

The most critical decision to be made in achieving the best plastic surgical result is picking the most experienced and talented, that is the best, plastic surgeon possible. Too often, patients choose a physician based on a catchy ad, the brand name of a technique, the basis of one or two before and after photos, or their web site’s search engine ranking. These criteria will not find the most experienced and talented plastic surgeon.

My Background

Dr. Larry Nichter

I have been a practicing plastic surgeon for more than 25 years, having trained scores of plastic surgeons as a tenured professor of plastic surgery at USC, and I have had a private practice in Orange County since 1993. Speaking from all this experience, here is my advice and the criteria I would use to find the best plastic surgeon in Orange County, Los Angeles, California, or anywhere in the United States. These are the criteria I would use to select a plastic surgeon for my friends, my family, or myself.

First, I want to stress some general observations I have found to be true over the years.

Caveat Emptor: Buyer Beware

The longer a surgeon trains at his craft, the finer his skills and the better his judgment become. Board certification in Plastic Surgery (see below) is a bare minimum. Board certification in an additional surgical field recognized by the American Board of Medical Specialties, or for that matter “triple-board certified,” attests to a doctor’s advanced training and skill and judgment. It also means that they have attained Chief Resident Status in more than one field during their training which means they essentially ran a large departmental service and had senior decision-making and independent operating responsibilities. It is this step that is most maturing for a surgeon.

The institution where the surgeon trained is also important. More renowned schools usually attract the best faculty.

You can use the internet to research the background of a prospective plastic surgeon quickly. Please do this prior to making an appointment. “Just because you wear a baseball cap it doesn’t mean you are a good ball player.” The same applies to anyone wearing a white coat—it doesn’t make you a plastic surgeon, much less a great one.

Caveat Emptor in Latin means “Buyer Beware.” In most states, including California, any physician with a medical school diploma and state license is viewed as a doctor and a surgeon—even without any formal surgical training. In some cases even doctors who have completed only the minimal requirements (medical school, licensing examination, and a one-year internship that need not include surgical training) are touting themselves as “cosmetic surgical experts.” They make these claims of expertise despite the fact that they are only formally trained as family practitioners, OB/Gyns, emergency physicians, dermatologists, or ear-nose-throat specialists. Even physician assistants and nurses have made such claims.

7-Step Process for Finding the Best Plastic Surgeon

The following are my screening guidelines and criteria for picking the best plastic/cosmetic surgeon.

1. Board Certified Plastic Surgeon by the American Board of Plastic Surgery

The American Board of Plastic Surgery is the only certifying board in Plastic Surgery that is a member of the American Board of Medical Specialties. Use these links to look up a prospective surgeon’s status.

To become a plastic surgeon certified by the American Board of Plastic Surgery requires a minimum of five years of surgical training with a minimum of two years of training specifically in plastic surgery. Then the applicant must also pass a comprehensive written board exam. If successful, the candidate must present his/her clinical cases for critical review by board examiners (I was one such board examiner) and if accepted will take a series of oral examinations.

Since the 1990s, the American Board of Plastic Surgery Certification is only valid for ten years. To retain your board certified status, a plastic surgeon must complete a Maintenance of Certification including written testing and case review. This means that all who pass are trained and experienced in all plastic surgery procedures including facial procedures, breast, and body; essentially all cosmetic and reconstructive procedures.

If a Plastic Surgeon is additionally board certified by another surgical specialty recognized the American Board of Medical Specialties, then this also marks additional expertise and training at the highest level. The American Board of Facial Plastic Surgery (ABFRS) is not a licensing body nor an educational institution and the certificates it issues are not legal licenses to practice facial plastic and reconstructive surgery. The ABFRS is not recognized by the American Board of Medical Specialties (although it does note additional specialty training/interest in facial aesthetic surgery).

Likewise, beware of physicians armed only with certification from other non-ABMS recognized boards or special society memberships other than those I have recommended (eg. “Cosmetic Surgery Board,” “Lipoplasty Society of North America,” etc.).

2. Fellow of the American College of Surgeons: FACS

The American College of Surgeons is dedicated to improving the care of the patient and to safeguarding standards of care in an optimal and ethical practice environment. Members of the American College of Surgeons are referred to as “Fellows.” The letters FACS (Fellow, American College of Surgeons) after a surgeon’s name mean that the surgeon’s education and training, professional qualifications, surgical competence, and ethical conduct have passed a rigorous evaluation, and have been found to be consistent with the high standards established and demanded by the College.

To be a member you have to:

  • be board certified in a surgical specialty recognized by the American Board of Medical Specialties
  • be in practice in one location for a number of years, with a background check, nomination, and interviews which verify that you are an ethical and safe surgeon among other criteria.

Hint: Look for the “FACS” (or “FRCS,” see below) after the “MD” in a doctor’s title or in his/her Curriculum Vitae to see if he/she is a “real surgeon.”

Note for patients in Canada: The equivalent of FACS in Canada is the Royal College of Physicians and Surgeons of Canada, FRCS.

3. Member of the American Society of Plastic Surgeons (ASPS)

The American Society of Plastic Surgeons is the largest organization of plastic surgeons in the United States and one of the largest in the world. ASPS members are uniquely qualified because of the society’s membership requirements:

Beware of physicians without this membership but belonging only to similar-sounding societies as their claim to excellence eg. “American Society of Cosmetic Surgery,” “Lipoplasty Society of North America,” etc.

4. Member of the American Society for Aesthetic Plastic Surgery (ASAPS)

This is the most elite society in the United States and perhaps the world for Aesthetic Plastic Surgery. To be a member means that your career is focused in cosmetic surgery at the highest level. Among the requirements for invitation and election to ASAPS membership, a plastic surgeon must:

  • Be certified by the American Board of Plastic Surgery (or in plastic surgery by the Royal College of Physicians and Surgeons of Canada);
  • Be in at least the third year of active practice following board certification;
  • Participate in accredited Continuing Medical Education (CME) to stay current with developments in the field of cosmetic plastic surgery and patient safety;
  • Document the performance of a significant number and variety of cosmetic surgical cases to demonstrate wide experience;
  • Be sponsored by two ASAPS-member plastic surgeons to help ensure that the applicant’s professional reputation meets the high standards required by ASAPS;
  • Adhere to current ethical standards for professional conduct as outlined in the Code of Ethics observed by all ASAPS-member surgeons;
  • Operate in accredited surgical facilities; and
  • Be elected by at least 80% of the Active Membership.

Find an ASPS member online.

5. Hospital privileges to perform the same type of surgery

Hospitals often examine qualifications of doctors applying for hospital staff privileges and restrict privileges to only surgeons best trained and qualified to do certain procedures. For example, in order for surgeons to be granted plastic surgery privileges in most hospitals in Orange County, California, that surgeon must have completed plastic surgery residency training and must be board-eligible or -certified in plastic surgery to be allowed to perform plastic surgical operations in that hospital.

Non-surgeons and other physicians that are not plastic surgeons circumvent this process by performing surgery in their offices or in outpatient surgery centers where the credentialing process is less rigorous or nonexistent. In these settings non-plastic surgeons perform procedures in which they have no formal residency training.

I am not warning against use of outpatient surgery centers or in-office procedures. I am only recommending that you check that your physician has hospital privileges for these same procedures.

6. Surgical Experience in the procedure you are having

Few patients ask how long doctors have been doing a certain procedure or how many they have performed. When you consult with a plastic surgeon:

  • Ask to see typical “before and after” photos;
  • discuss the details of the procedure in a manner that is clear to you;
  • review benefits and potential complications;
  • get full answers to your questions.

7. Evidence of Excellence, Experience and Commitment to the field of Plastic Surgery

Here are some additional criteria to look for in your plastic surgeon.

  • Surgical Board Certification in more than one field
  • Plastic Surgical Fellowships in addition to Plastic Surgical Residency.
  • Number of years practicing.
  • Peer Review Honors in their own board certification from groups such as Best Doctors, Top Doctors, Super Doctors.
  • Current or Prior position denoting excellence in the field or high regard by their peers such as:
    • Prior or present Professor or Faculty affiliation with a University Plastic surgical program (the higher the rank the better)
    • Chairman of a Department of plastic surgery at a regional hospital
    • Honors from surgical societies of which they are members such as Board Examiner, etc.
  • Published Plastic Surgical papers in peer review journals are also a good sign that they are committed to being on top of their field.

Feel Comfortable with your choice

It is very important that after you have done this screening and met with your potential surgeon that you feel confident in your choice.

Complications are not common in cosmetic surgery, but if one did occur are you confident that this surgeon would take charge and handle just about any problem?

Do you feel that he listens to you and communicates well by answering your questions completely, doesn’t rush you in to a decision but rather makes you part of the decision-making process? You should truly feel that it is a combined effort.

Does the surgeon’s office run smoothly? Do the staff take good care of you? If you answered in the affirmative and have gotten this far in your screening guidelines then I think you have found your “Dr. Right.”

—Larry S. Nichter, MD, FACS

Compression Garments are Important after Liposuction

Dr. Larry Nichter

A compression garment is required and beneficial after liposuction because:

  1. It restricts the amount of edema that forms and hastens its resolution by mechanical pressure.
  2. It decreases the amount of bruising.
  3. It assists the loose skin in retracting or shrinking.

It is common to have weight gain due to edema, serum that collects in the area, and the tumescent fluid that was injected. This will resolve over time. The more you wear the garment initially, the quicker this fluid resolves.

Edema: a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body.

The length of time that the garment should be worn varies depending on the amount of fat removed, the elastic nature of your skin, how much loose skin remains, and other factors. Your surgeon would give you the best advice, however this is the general routine for my patients.

The first garment should be fitted for you in the office prior to surgery and applied in the operating room. Often it will become loose as the edema is mobilized, and then it will need to be replaced. Spanx is a reasonable compression  garment if it gives enough support and is the right size. I have my patents bring them in so I can confirm that it fits well.

Most important advice is to listen to your surgeon, as he or she knows how much fat was removed, the elasticity that remains in your skin, and amount of skin redundancy.

I recommend that my patients wear their garments for a minimum of three weeks full time then for twelve hours at a time (day or night). If there is not a lot of redundant skin, this continues to a maximum of six weeks.

To be effective, the garment needs to fit snugly—but not too tight as that can make it difficult to sleep or cause pressure problems (inspect your skin when it is exposed if you are uncomfortable). As the edema resolves it is common for patients to switch to a smaller garment that fits. A Spanx-type garment would work fine, rather than ordering one or paying more at your doctor’s office.

—Dr. Larry Nichter, MD, FACS