Surgical Healing Times

How long do my breast implants, liposuction, facelift, or other surgeries take to heal?

I’ve just had liposuction in Dr. Yoho’s Los Angeles office, how long do I have to wait to be “normal” again?

The answer: Los Angeles liposuction is no different than anywhere, and while things can look great right away, there’s a rule of thumb that soft tissue takes at LEAST four months to soften, improve and normalize. Darker skin types--which may be stronger incidentally--also have a tendency to complete the healing cycle over a longer period, and possibly scar more. We have treatments for this. TRY to be patient. Despite all the warnings and disclaimers and education we try to provide for our patients in Visalia / Fresno / Los Angeles getting liposuction and other types of procedures, we always have people who think their result should be perfect RIGHT NOW. This is one of my biggest frustrations as a surgeon. Cosmetic surgeries are often a work in progress. Complications happen (see “What’s the worst that can happen” chapter on Dr. Yoho’s book at http://www.dryoho.com/dr-yoho-book/chapter14-1.cfm). We don’t have a magic wand! We promise to work with you until we are satisfied that we have the best result we think is possible. Again, be patient… Don’t panic when things aren’t just right. We do not desert our patients!

I learned about healing the hard way. I broke my ankle trying to climb El Capitan in a day. See ** below for the story about how a 55 year old man (me) was trying to recover his lost youth by climbing things he should leave to the young dudes. That was June 2008, and it still hurts in July 2009. I found out that for bony injuries, it can take TWO YEARS for things to be the best they will be. Soft tissue surgical recovery doesn’t take as long but it can be many months.



**Dr. Yoho Breaks His Ankle Trying to Climb El Capitan in 24 hours
In June 2008, Dr. Yoho tried to climb El Capitan in Yosemite (3300 feet high and nearly vertical) with his friend Chris Gonzalez, MD. About 15 per cent of the way into the climb, he took an unexpected swing into a corner and broke his left talus (ankle) bone. Chris (52 years old at the time; Dr. Yoho was 55) helped Dr. Yoho slide down the ropes to the ground and then assisted as he crawled to the road, a half mile away.
Dr. Yoho and Dr. Gonzalez have climbed El Capitan before in 27 hours in 2007, but they were trying to beat the 24-hour mark. If they do, they would be the oldest climbing team ever to do this. For more information at DrYoho.com, see http://www.dryoho.com/dr-yoho/yogo-method.cfm.

Why Los Angeles Discount Breast Implants Are a Bad Deal

Did you know that implants of different shapes have different costs to the doctor? And did you know that the discount Los Angeles breast implant surgeons generally use only the cheapest breast implants?

Implants made by the two major manufacturers approved for USA use have almost identical shapes. There are three types: flatter (the oldest and cheapest), intermediate, and “high profile.” The high profile implant, for the same volume, has a narrower base diameter and has a bit higher “projection” or distance out from the body when placed under a breast. This is the best implant for most people, but it’s significantly more expensive. In order to visualize this better, the lower or flatter profile implant is shaped more like a Frisbee (not this flat, but you get the idea), while the higher implant looks more like a real breast. The higher profile implants ripple less, a significant consideration especially when saline implants are used.

Now, base diameters must match the patient’s chest. If you have a larger chest, maybe the flatter implant is OK for you to help your cleavage, but for implants over about 350 cc volume, we use almost exclusively the more expensive high profile implants because they look better and the base diameters are usually fine for even a bigger chest. We won’t compromise the result by spending less on the implant. And the wholesale cost of the implant from the manufacturer is a significant part of your breast implant expense.

The Los Angeles breast implant field is an art, because women’s breasts are all different and we have to match your psychological needs for size and shape with both your breast type and the implant choices. We also use different approaches—over versus under the muscle and the different surgical approaches—to try for the best result for you. For example, with relatively large breasts that do not sag, there are many options. Many times, patients like this get the best results with a through-the-armpit approach over the muscle, but under the “fascia” or skin of the muscle. This has many advantages of If you have saggy breasts, many times just an implant will be enough. You may not need a lift, which puts scars on the exterior breast. But some breasts need a lift to get the right result. And if you have very little breast tissue, through the belly button under the muscle may be best. And the “peri-areolar” approach, given careful closure of the incision, gives the best control of the breast pocket and the incision usually almost vanishes. The areolar skin is sort of like lip skin, it hides scars well if the surgeon does his or her job well.

A “one size fits all” approach just won’t give the best results for every person. For example, one surgeon we know only performs his breast implants as over the muscle through the crease at the bottom of the breast. I can’t believe his results are consistently the best. And because his prices are so cheap, I’m sure he’s using only the low profile implants, which aren’t optimal in most cases.
We like silicone implants, but it’s of course your choice if you can’t afford the silicone implants (wholesale cost roughly $2000 to the doctor), or have concerns about silicone. And while we are on the subject, I want to mention the “gummy bear” implant. It’s great marketing, but these implants are hard and unnatural. Too hard for my preference. And they are touted to have a thicker silicone that won’t migrate or run into other tissues if the implant shell ruptures or breaks. I don’t think this is true based on what I have seen when the implants are cut. The silicone in these implants runs and is just as sticky and has characteristics just like the silicone which is used in ordinary implants.

Check out three implants of the same volume, with the three profiles to show the three profiles we use for our Los Angeles / Visalia area patients, http://www.dryoho.com/dr-yoho/consumer/choosing-breast-implants.cfm. Remember the high profile implant, the more expensive one, is usually best for implant sizes above 350 cc. You get what you pay for. And you will have a really hard time making decisions about all this complex stuff by yourself, no matter how much reading you do. Try to keep an open mind when you come in for your consultation(s). Chose a surgeon who’s willing to carefully select a size, style, and surgical approach that has the best chance of working, and who is experienced with all four surgical approaches to breast augmentation. And be patient if you don’t get what you want right away. Implants often need to settle into place, and sometimes months of treatment with oral medicines can help this, rather than insisting on an immediate secondary surgery. Much more information is available at DrYoho.com, in particular see http://www.dryoho.com/dr-yoho/consumer/choosing-breast-implants.cfm.

Michael Jackson’s death and drugs involved

Recent news reports have said Michael Jackson was using a variety of opiate narcotics, including oxycontin, Demerol shots, and was sleeping using an intravenous Propofol drip, just like the patients do in the intensive care unit. Patients who are as wealthy as Jackson can easily find an unscrupulous physician to give them whatever they want, for a price.

The dangerous thing here is the use of the opiate narcotics, and the drug combinations, which lead to unpredictable consequences. The common end point is difficulty breathing, and stopped breathing. If Jackson were in an intensive care unit or under the immediate supervision of an anesthesiologist, alarms would go off when he stopped breathing and simple measures to start him breathing again would be undertaken.

While it’s possible that Jackson suffered a heart attack or had some other cause of death—and we will know for sure only after the autopsy—it’s unlikely. Physicians are trained to think first of the obvious things, and of course it’s obvious that Michael Jackson died of a drug overdose.

We use propofol (Diprovan) as the only medication for our procedures. Our sedation isn’t general anesthetic, it’s “sedation” or “twilight sleep”. We also dilute Propofol about ten to one in sterile salt water and use a special micro-dripper to be sure it isn’t used very quickly and the patient is safe. The typical general anesthetic, on the other hand, employs on average 10 drugs under the supervision of an anesthesiologist. These medications additionally require a sophisticated post-operative care unit including monitoring for hours in order to safely recover. And many times nausea, vomiting, and bad feelings result during hours to days after the general anesthesia procedure is over, when so many drugs are used. We hate to see Diprovan getting a bad name because it was associated with Michael Jackson. It’s a fantastic medication for our patients and very safe when used by itself in the manner we employ it. More information is available at DrYoho.com. See particularly http://www.dryoho.com/dr-yoho-book/chapter13-1.cfm. A medical journal article Dr. Yoho wrote about his technique is at http://www.dryoho.com/dr-yoho/anesthesia.cfm. We no longer use ketamine, incidentally, just Diprovan.

Traditional Breast Lifts/reduction versus the new “Vertical Mastopexy/Ice Cream Cone” Breast Lift (with or without implant or reduction)

When you are unhappy with your breasts, there may be three reasons:
1) volume
2) shape
3) positioning

Positioning really refers to how saggy the breasts are. If your only concern is volume, and you don’t have a problem with the shape or positioning or , breast liposuction or an implant may be the best choice. Most patients can achieve a one to two cup size reduction with liposuction, and a 1 to 2 inch nipple elevation with liposuction alone.

If you are concerned with the shape but you generally like the size of your breasts, then the “Ice Cream Cone/Vertical Mastopexy” may be the procedure of choice for you. This procedure can provide a volume reduction if necessary but it’s primary function is to shape the breast and re-position the nipple areolar area. If for some reason after this procedudre, you decide you want a bit more volume, it’s not a problem to place an implant 4 to 6 months later. About 50 per cent of patients choose to put an implant and 50 per cent are happy with the lift only without implant.

Note that the traditional “anchor” scar procedure is generally regarded as not as satisfactory as the vertical mastopexy. This older procedure needs a scar all around the bottom of your breasts plus a scar up the middle plus a scar around the areola as well. It does not hold up as well as the vertical mastopexy, and tends to sag sooner. Also, the newer procedure needs only a scar down the middle of the front of the breast and around the areolae.

Remember whatever choice you make, if you need an implant, it’s always better to do this procedure in two surgeries. This is because if you have the implant put in and reduce the breast as well, the forces on the breast tend to pull the scars apart. When you do the lift first, then put the implant in later, the breast tissues hold up better and there’s less risk of sag and other unsatisfactory results. .

Note: Dr. Yoho does not usually perform the anchor-type scar procedure, the traditional breast lift. However photographs of the other procedure both with and without implants are available at DrYoho.com.

CALIFORNIA LIPOSUCTION LEGAL STANDARDS

I’ve reprinted the law regarding liposuction standards in California, below. I was involved in developing these standards. I testified several times before the California Medical Board and supplied them with materials and documentation to aid them in their decision-making process. I believe that these rules are important and necessary for safety. I want to make several points.
1) If you are seeing someone who does not start an intravenous line, they are violating the surgeon’s “standard of care” and also California law.
2) The other requirements that are seen below include blood oxygen and blood pressure monitoring, which are simple, modern devices to see how well you are breathing and how well your heart is working.
3) Modern liposuction is a very, very safe procedure in experienced hands. However, there are risks and if you find someone who says that it is risk free, you should look elsewhere. Common surgical complications such as infection are unlikely but possible.
4) If your surgeon uses no relaxation medicines at all, some sort of liposuction may be performed and the risks may be lower. However, like anything in life, there are trade-offs, in other words you have to accept possibly a lower standard of results—in particular less fat removal--in exchange for not going to sleep. Additionally, we have found that many of our patients find the option of having nothing but local anesthetic frightening and sometimes quite uncomfortable. This is not to say that I approve of general anesthesia for liposuction, I don’t. I think this compounds the risk.
5) For individuals who need significant amounts of fat removed, California law requires a certified surgical center, such as a hospital would have. Ask to see the certificate if this is the case.



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( 1 ) I n t r a v e n o u s A c c e s s a n d E m e r g e n c y P l a n . I n t r a v e n o u s a c c e s s s h a l l b e a v a i l a b l e f o r p r o c e d u r e s t h a t r e s u l t i n t h e e x t r a c t i o n o f l e s s t h a n 2 , 0 0 0 c u b i c c e n t i m e t e r s o f t o t a l a s p i r a t e a n d s h a l l b e r e q u i r e d f o r p r o c e d u r e s t h a t r e s u l t i n t h e e x t r a c t i o n o f 2 , 0 0 0 o r m o r e c u b i c c e n t i m e t e r s o f t o t a l a s p i r a t e . T h e r e s h a l l b e a w r i t t e n d e t a i l e d p l a n f o r h a n d l i n g m e d i c a l e m e r g e n c i e s a n d a l l s t a f f s h a l l b e i n f o r m e d o f t h a t p l a n . T h e p h y s i c i a n s h a l l e n s u r e t h a t t r a i n e d p e r s o n n e l , t o g e t h e r w i t h a d e q u a t e a n d a p p r o p r i a t e e q u i p m e n t , o x y g e n , a n d m e d i c a t i o n , a r e o n s i t e a n d a v a i l a b l e t o h a n d l e t h e p r o c e d u r e b e i n g p e r f o r m e d a n d a n y m e d i c a l e m e r g e n c y t h a t m a y a r i s e i n c o n n e c t i o n w i t h t h a t p r o c e d u r e . T h e p h y s i c i a n s h a l l e i t h e r h a v e a d m i t t i n g p r i v i l e g e s a t a l o c a l g e n e r a l a c u t e - c a r e h o s p i t a l o r h a v e a w r i t t e n t r a n s f e r a g r e e m e n t w i t h s u c h a h o s p i t a l o r w i t h a l i c e n s e d p h y s i c i a n w h o h a s a d m i t t i n g p r i v i l e g e s a t s u c h a h o s p i t a l .

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( 4 ) R e c o r d s . R e c o r d s s h a l l b e m a i n t a i n e d i n t h e m a n n e r n e c e s s a r y t o m e e t t h e s t a n d a r d o f p r a c t i c e a n d s h a l l i n c l u d e s u f f i c i e n t i n f o r m a t i o n t o d e t e r m i n e t h e q u a n t i t i e s o f d r u g s a n d f l u i d s i n f u s e d a n d t h e v o l u m e o f f a t , f l u i d a n d s u p r a n a t a n t e x t r a c t e d a n d t h e n a t u r e a n d d u r a t i o n o f a n y o t h e r s u r g i c a l p r o c e d u r e s p e r f o r m e d d u r i n g t h e s a m e s e s s i o n a s t h e l i p o s u c t i o n p r o c e d u r e .

( 5 ) D i s c h a r g e a n d P o s t o p e r a t i v e - c a r e S t a n d a r d s .

( A ) A p a t i e n t w h o u n d e r g o e s a n y l i p o s u c t i o n p r o c e d u r e , r e g a r d l e s s o f t h e a m o u n t o f t o t a l a s p i r a t e e x t r a c t e d , s h a l l n o t b e d i s c h a r g e d f r o m p r o f e s s i o n a l l y s u p e r v i s e d c a r e u n l e s s t h e p a t i e n t m e e t s t h e d i s c h a r g e c r i t e r i a d e s c r i b e d i n e i t h e r t h e A l d r e t e S c a l e o r t h e W h i t e S c a l e . U n t i l t h e p a t i e n t i s d i s c h a r g e d , a t l e a s t o n e s t a f f p e r s o n w h o h o l d s a c u r r e n t c e r t i f i c a t i o n i n a d v a n c e d c a r d i a c l i f e s u p p o r t s h a l l b e p r e s e n t i n t h e f a c i l i t y .

( B ) T h e p a t i e n t s h a l l o n l y b e d i s c h a r g e d t o a r e s p o n s i b l e a d u l t c a p a b l e o f u n d e r s t a n d i n g p o s t o p e r a t i v e i n s t r u c t i o n s .

Dr. Yoho's Chapter published in a Breast Augmentation Book

See

http://books.google.com/books?id=4BOrAg3hkGIC&pg=PA1&lpg=PA1&dq=Robert+Yoho+MD&source=bl&ots=mPNw5NmxUT&sig=vAUcPuLZX0g7UVhe-lwmzasVOMw&hl=en&ei=4Dw8Sqi0LpDcsgOa44D0Cw&sa=X&oi=book_result&ct=result&resnum=6

for a large sample of this book. Dr. Yoho's article was about how to alter the implant pocket without going into the implant space. The ideas it contained were originated by Dan Metcalf and Roy Morgan MDs. The technique consists of suturing the skin to the underlying tissues to make a breast implant pocket smaller.

Complications of Breast Implant Surgery: Hematoma

One of the common problems with breast implant surgery is bleeding around the implant right after the surgery. When the pocket for the breast implant is placed, it’s sometimes impossible to do this in a way that produces no bleeding, though we try as hard as we can. Additionally, after the surgery, a compressive wrap is often placed in the hope that this will help. Sometimes however the area surrounding the implant will end up with significant blood in it within a few hours and other times it will even fill up with blood. This space is closed and sealed, so the pressure that develops in the cavity will generally stop any bleeding before it becomes dangerous to your health but it can be uncomfortable. The tip-off is usually that one breast becomes much bigger, more swollen, and more bruised than the other one. We can look at the breasts with a bright light in a dark room and this can help distinguish whether the area is just swollen or contains blood.

The blood should be taken out by returning the patient to surgery, opening the incision, taking the implant out, washing the area with a few quarts of sterile salt water solution, putting the implant back, and then sewing up the incision. Sometimes if bleeding vessels are found, they are “cauterized” or burned with the special device used for this purpose. This procedure is usually done at 24 to 48 hours after the original surgery. Only rarely does bleeding become apparent after this time.

Why is this important, and why can’t we just depend on the body to clean up the blood on it’s own? Well, “capsular contraction” or firm to hard scarring around the implant (later) is much more common when there’s blood surrounding the implant initially that the body has to remove. Recovery time is also much longer when there’s a “hematoma” or blood in this area. This complication happens in perhaps a few percent of all breast cases, and is probably more common in secondary cases, in other words in cases where the breast has been operated on before.

See also http://www.dryoho.com/dr-yoho-book/chapter10-8.cfm#risks for a discussion of other breast implant risks and http://www.dryoho.com/dr-yoho-book/chapter14-1.cfm for a general discussion of complications in cosmetic surgery risks.