Smoking and its Effects on Plastic Surgery Results

Dr. Nichter explains the risks and effects of smoking prior to and during recovery after plastic surgery. Smoking — specifically nicotine and carbon monoxide — impedes the body’s ability to deliver oxygen to tissues. As a result, the healing process after plastic surgery is negatively affected. Healing after plastic surgery has a significant effect on the quality of your result.

Dr. Nichter Named in Top Doctors® for 7th Year

America's Top DoctorsSince the origin of its peer review survey of Best Plastic Surgeons, Orange County California plastic surgeon Dr. Larry Nichter has been named in the America’s Top Doctors publication, a listing of the top 1% of physicians in the United Statesfor seven years in a row.

The screening process for this highly exclusive honor is conducted by Castle Connolly Top Doctors®. The process first involves a peer nomination stage in which tens of thousands of physicians are recommended by their fellow doctors. Then, a physician-led research team at Castle Connolly conduct a review of candidates’ medical educations, honors, awards, board certifications, and disciplinary history. The result of their work is a listing of the best qualified doctors in the United States.

From Castle Connolly’s CEO, Dr. John Connolly:

Being selected for inclusion in America’s Top Doctors is a very significant achievement given to only 1% of American physicians. The world of American doctors includes incredibly high quality medical professionals, yet some stand out. Each year we evaluate tens of thousands of peer nominations from throughout the medical community. Then our experts go even deeper to evaluate and select Top Doctors based on referred doctors’ exceptional work and outstanding conduct. My congratulations to Dr. Nichter.

Dr Nichter has also been honored  in peer selected awards such as Best Doctors, Top Doctors, and Super Doctors continuously since their start as well as patient selected awards like Compassionate Doctor  and Patient Choice Awards , Dr. Larry Nichter continues to be recognized as an exceptional physician and one of the best plastic surgeons working in Orange County, Southern California today.

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 »

Larry Nichter, MD receives Boston University Award

Larry Nichter, MD was honored by receiving the Boston University CGS 60th Anniversary Alumni Achievement Award on September 29, 2012.

Only two such awards were given. Dr. Nichter also was inducted to the Boston University Collegium of Distinguished Alumni for the College and Graduate School of Liberal Arts. This is the highest university alumni accolade and was presented to Dr. Nichter by the American Ambassador to China, also a BU graduate.

From the Boston University website:

Dr. Lawrence Nichter (CGS ’71, CAS ’73, MED ’78) is from a BU family.  Besides his mother receiving her Doctorate of Education, his sister, Susan, received degrees from the College of Fine Arts. Larry attended CGS, CLA and BUSM. Currently he is a Clinical Professor of Plastic Surgery at USC and UCI, Chairman, Department of Plastic Surgery at one of the largest hospital departments in the world, and President and Founder of Plasticos Foundation. The latter is a Non-profit institution that trains surgeons while repairing children’s deformities worldwide. He has been on 60 oversees missions thus far and a documentary about one of his trips won an Academy Award. Every institution that Lawrence Nichter has received a degree from has distinguished him with special honors including University of Virginia presenting an annual research award in his name, UCLA giving him an outstanding resident award, and BU College and Graduate School of Liberal Arts presenting him with an outstanding alumni award in 2009.

How to Use Clonidine Patches

Use Clonidine Patches as directed by your doctor. Check the label on the medicine for exact dosing instructions.

You will apply the patch to a hairless area on the upper outer arm as directed by our office.

If your blood pressure is normal, it is usually applied two days prior to surgery and left on for one week. If directed to use one prior to that, it should be changed in 7 days if applicable. The area chosen should be free of cuts, scrapes, irritation, scars, and calluses. Do not place the patch on skin folds or under tight undergarments because it may come loose. If more than one patch is prescribed then the new patch should be placed on a different skin site from the previous site.

  • Wash your hands with soap and water and dry them completely before applying Clonidine Patches.
  • Clean the chosen application area with soap and water. Rinse the area and wipe it with a clean, dry tissue.
  • Remove the patch from the pouch. Remove the clear plastic protective backing from the pouch by gently peeling off one half of the backing at a time. Avoid touching the sticky side of the patch.
  • Place the patch on the skin site (sticky side down) by applying firm pressure on top of the patch. The adhesive overlay does not contain any medicine and should not be used alone.
  • Wash your hands with soap and water to remove any medication that may be on your hands.

If the patch does not stick firmly or begins to come loose, apply the adhesive overlay on top of the patch. The adhesive overlay does not contain any medicine and should not be used alone.

After removing the used patch, fold it in half with the sticky sides together. Discard the patch out of the reach of children and away from pets. Even after it has been used, the patch contains active medicine, which may be harmful if accidentally applied or ingested.

Continue to use Clonidine Patches even if you feel well.

Best Scar Management Practices

Dr. Larry Nichter

Best Scar Management is important to minimize or completely hide from view, the telltale signs of your surgery—namely, scars. Both you and your surgeon want you to have the most minimal scarring possible. There are many possible causes for scars that are enlarged or not healing well. Unsightly scars are most commonly due to genetics, underlying medical conditions, or improper scar/wound care. The last part is very important and patients can make a noticeable difference in their scars’ appearance by following best scar management practices. Here are some simple tips.

Scar Management tips:

  1. Minimize tension on the scar. Steri-Strips and/or surgical tape are often placed in non-hair bearing areas at the time of surgery to minimize tension and keep pressure over the scar.  This minimizes the  stress that  can pull the scar apart (dehiscence) creating a wound and  delaying healing time, and can make the scar wider, or more “ropy”. In the first few weeks after surgery, I recommend the use of Embrace Scar Therapy which is an adherent silicone sheeting pre-stretched when applied so as to offload tension on the scar.
  2. Keep your incision site/scar clean to prevent infection. Follow your surgeon’s wound care instructions to the letter with out modification. Never apply different products then recommended without first discussing them with your surgeon. This is especially important during the first few weeks. If there are any signs of infection, contact your surgeon’s office right away and/or see your doctor or his nurse immediately. Typical signs of infection may include redness outside the immediate incision site, asymmetric swelling, and drainage, of pus, fever, chills, and “feeling sick”.
  3. Protect your scars from the sun. Staying out of the sun is the best advice. Minimal exposure to sunlight is prevents hyperpigmentation (permanently turning brown) and other problems that can make the scar more noticeable. Sunscreen, at least 30 SPF and an overlying make camouflage make up additionally protects the scar from the suns harmful rays. This advice is especially important the first year following your surgery.
  4. Use specific scar maturation products recommended by your surgeon. Patients seem to have their own opinions on this touting everything from Pure Vit E, Coco butter, to Aloe Vera, etc but most have minimal benefit other than keeping the scar hydrated. Although hydration is important there are better, scientifically studied products with greater efficacy. Most of the scientific articles written about this subject indicate that topical silicone gel or silicone sheets work the best. The best product available in my opinion is the Embrace Scar Therapy System by Neodyne BioSciences, Inc. available in many surgeons’ offices. Essentially this is an adherent silicone sheeting pre-stretched when applied so as to offload tension on the scar. For areas that are not applicable for this product (e.g. smaller areas or on the face), I prefer BioCorneum or Kelo-Cote products There are a lot of products to choose from, but silicone should be one of the key ingredients. Although Mederma, an onion extract derivative active ingredient rather than mainly silicone based may help, primarily silicone based products are better and many also contain other ingredients that may be synergistic (hydrocortisone or other steroid, Vitamin E, Sunscreen, etc).. If the reader has problems obtaining these they can call my office. Patient compliance is also critical – use often and according to directions or it will not work optimally. NEVER apply products without first discussing them with your surgeon.
  5. Monitor to make sure your scar is progressing optimally. Keep your scheduled follow-up appointments with your surgeon to verify that your scars are maturing as expected.  Occasionally if indicated you may need a topical steroid preparation or even a series of  injections (5-FU and/or Steroids) or laser treatments  to treat or  prevent scar hypertrophy or keloid formation (red raised scars), or other topical medicines to treat post inflammatory hyperpigmentation (brown scars) with prescription creams and possible laser treatments.

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

Bromelain: a pineapple extract may improve post-surgery healing

Many of my patients ask about supplements that can speed the healing process. One such supplement that I feel is efficacious, decreases bruising and speeds healing is Bromelain. Below is a summary that details some of its potential beneficial qualities.

Pineapple plant. Image: Wikimedia Commons

Bromelain is a type of enzyme found in high concentrations in pineapple plants (and other plants of the plant family Bomeliaceae). Animal studies and anecdotal evidence of the medicinal properties of this pineapple plant extract have brought to light its therapeutic value. Bromelain has also been shown to have low toxicity and produces little to no undesirable side effects.

Evidence from decades of research suggests that bromelain is effective at:

  • reducing pain
  • reducing edema
  • reducing inflammation
  • improving the potency of antibiotics.

All of these properties are related to important aspects of post-operative healing.

The FDA in the United States recognizes bromelain as generally safe, and has categorized it as a food additive. It is commercially available in capsule, tablet, powder, and liquid forms for oral consumption. The recommended dosage varies between 500 to 1,500 milligrams per day.

Evidence from early studies indicate that bromelain may be an effective pain reducer. Healthy adults showed a dose-dependent response to the extract, which reduced acute knee pain and appeared to promote their general well-being. Bromelain reduced pain when applied directly to open blisters in another study.

Bromelain may reduce healing time for soft-tissue wounds. Patients in one controlled clinical trial who took Bromelain had bruising and faster reduction of edema than patients who did not. Analysis of the results, however, showed that the effect fell short of statistical significance. Results from another study showed that patients who took vitamin supplements containing Bromelain had shortened wound-healing time than those who did not.

Bromelain enhances the action of antibiotics. An early study suggested that Bromelain makes tissues more permeable to antibiotics but the results were not statistically significant. Another study, in children, found that Bromelain significantly reduced healing time for sepsis by potentiating the antibiotics.

Studies of Bromelain’s toxicity have found it to be very low. Some reports of “gastrointestinal problems, headache, tiredness, dry mouth, skin rash, and unspecified allergic reactions” have been cited as possible side effects of high doses of Bromelain. Then again, some of these symptoms are seen with placebos. Higher doses have been correlated with stronger side effects. Overall, there have been few reports of adverse effects.

Dr. Larry Nichter

More controlled clinical trials will have to return statistically significant results before Bromelain is accepted for therapeutic purposes. The extent of its efficacy and the mechanisms by which it works must be better understood. However, because of its potential, bromelain has caught the attention of the medical community and will be the object of future research.

I hope you have found this helpful and now understand why I recommend Bromelain to my patients.

—Larry S. Nichter, MD

Citations:

  • Orsini, Roger A. “Safety & Efficacy Report: Bromelain.” Plastic and Reconstructive Surgery 118.71 Dec. (2006): 1640-44. Print.

New Breast Implant on U.S. Market

Dr. Larry Nichter of the Pacific Center for Plastic Surgery would like to make prospective breast augmentation patients aware that the FDA has approved a new silicone gel-filled breast implant made by Sientra, Inc. for use in the United States.

The implants will be available for women at least 22 years old seeking augmentation surgery, and women of any age seeking breast reconstruction surgery.

Silicone gel-filled breast implants are medical devices implanted under the breast tissue or under the chest muscle for breast augmentation or reconstruction. These implants have a silicone outer shell that is filled with silicone gel. They come in different sizes and have either smooth or textured shells.

This approval introduces a third company into the U.S. breast implant market, which previously consisted only of Allergan and Mentor.

The deputy director for for science at the FDA’s Center for Devices and Radiological Health, Dr. William Maisel, commented that although silicone gel-filled breast implants have demonstrated consistent safety, “It’s important to remember that breast implants are not lifetime devices. Women should fully understand risks associated with breast implants before considering augmentation or reconstruction surgery, and recognize that long-term monitoring is essential.”

The approval of these new implants follows a 3-year study involving clinical trials of the implants on 1,788 women.

As a condition of the approval, Sientra will carry out five- and ten-year studies into the long-term health effects of their implants.

Source: FDA – FDA approves new silicone gel-filled breast implant