Traditionally the mastectomy included the nipple because the nipple is part of the breast and the milk ducts continue into the nipple. Recently it has been shown that when the tumor is small and far from the nipple, saving the nipple is possible and does not change the prognosis. Because the nipple is such an important part of the breast, saving it reduces the psychological impact of the mastectomy and makes the procedure more acceptable to women. With the great advances in breast reconstruction, today it is possible to create a breast that looks natural and when the nipple is preserved, one could believe that a mastectomy was never done. See picture below. There is no question that nipple-sparing mastectomy and immediate reconstruction is very popular and is often requested by the patient, at least in northern New Jersey where I practice. I try to accommodate this demand whenever possible, but it is important to let the potential patients know about the limitation of this operation.

This patient had bilateral nipple sparing mastectomy and bilateral immediate reconstruction through an incision under the breast.

The following are some of the absolute or relative contraindication to nipple preservation.

• Nipple sparing is not considered safe when the tumor is too close to the nipple.
• When the tumor is too large, usually over four centimeters.
• When the breast is too redundant (ptotic) with too much breast skin. In this case, the nipple areola needs to be lifted and it is difficult to maintain its blood supply.
• In cases when the nipple is not ideally positioned on the breast and relocation is desired.
• In cases when the nipple is too large and a change in size is desired.

Mid face lifting through the lower eyelid incision has been done elsewhere but the complication rate has been relatively high. Dr Rafizadeh has developed a new technique in  Morristown New jersey that makes the operation very effective and reduces the complication of lid retraction and chemosis (prolonged swelling of the conjunctiva). The procedure is performed under local anesthesia with conscious sedation and can be done in about an hour.

Call our office at (973) 2670928 for an informative consultation and find out how you can benefit from this incredible procedure.

Recently, I answered a question in the section “Ask the Doctor” for New Jersey Health and Life Magazine about what type of doctor to go to for cosmetic surgery. I said, go to a plastic surgeon because they are the ones in charge of the human appearance. Well, I have been thinking about my answer. I didn’t have much time to reflect before responding and I felt a bit guilty of my self-serving recommendation. I began wondering if I should call back the editor and change my answer. Then, I thought more about what my answer should be. Why is it that plastic surgeons are in charge of the human appearance? Plastic surgery is a subspecialty of surgery that deals with the shape of our body. The word comes from the Greek plastic meaning shaped or moldable . It takes anywhere from three to most often five years of general surgery training to just qualify to be accepted to a plastic surgery residency program. It is so competitive that today most candidates are fully trained in general surgery and some like myself are board certified in general surgery. Some do a year of fellowship in micro-vascular surgery or do research before being accepted and finally some don’t get accepted at all. Then it takes two to three years of training in an approved plastic surgery residency program. After a residency, it usually takes two years of experience to be able to finish the board’s exams in plastic surgery and be certified. To belong to the American Society for Aesthetic Plastic Surgery, one has to demonstrate that they do a number of cosmetic cases in a year and maintain a set number of CME training hours in cosmetic surgery. Compare this kind of rigorous requirements to a weekend course or watching a video on you tube. Why would anyone if they where properly informed, chose to go to someone with less training for their cosmetic procedures?

Why is it necessary to go through specialty training in the first place, if everyone could just declare his or her specialty without being trained in it?

It reminds me of one of our general surgery residents who wanted to become a plastic surgeon, but didn’t make the cut. He couldn’t find a residency program in plastic surgery after five years of general surgery training, so he decided to go back to his home state and simply declare himself a cosmetic surgeon. This guy at least had some training in plastic surgery while he was doing his residency in general surgery. But, I also remember an internist, practicing in a nearby state doing breast augmentation, after starting a cosmetic clinic and giving people Botox and Restylane injections. This gentleman called himself a cosmetic surgeon. I remember asking him, “how did you become a surgeon, never mind a cosmetic surgeon?” He answered, “I watched a surgeon do a breast augmentation and there are a lot videos.” I couldn’t believe that this was happening and without regulation limiting the scope of practice, this kind of thing could happen more frequently. There was a time when there weren’t enough specialists available and general practitioners did some surgical procedures including cesarean sections in areas where there was no gynecologist. General surgeons or general practitioners performed orthopedic procedures when there was no orthopedic surgeon available, but this was years ago and when the proper specialist arrived, this kind of practice stopped. Today there are many plastic surgeons, well trained and eager to do what they spent lifetime training for. The patient needs to know the difference. After much reflection, I decided that my response was correct and that indeed, board certification in plastic surgery (which happens after many years of training in surgery and plastic surgery) is the absolute minimum requirement to qualify a physician to do any plastic surgery procedure. Of course this doesn’t mean that every plastic surgeon is capable of obtaining optimal results. There are differences in people’s natural talent. In plastic surgery, an artistic eye, a creative mind and personal skills are more important than in any other specialty. The public should consider the board certification in plastic surgery, a minimum requirement and then do their homework to find the best plastic surgeon. This is something that is in the public interest and the government officials should pay more attention to it. There should be a limit on what an MD or DO without proper surgical training can do. The reason for this blog is to increase public awareness.

I’d like to divide the rhinoplasty procedure in two distinct parts one of them and probably the most challenging one is the reshaping of the tip (tip rhinoplasty). It is not a different rhinoplasty, but it’s part of the rhinoplasty procedure. In my practice in Morristown New Jersey, there are many patients who do not require ant changes in the shape of their tip. Therefore they don’t need a tip rhinoplasty. These patients will have the best and the most natural results in the long run.
Today a tip rhinoplasty is normally done with an open approach which requires an incision across the columella which extends inside the nostrils. The columella is the part between the nostrils. The skin is lifted to show the cartilages in their natural shape after a careful assessment, these cartilages are reshaped by fine sutures, partial trimming and occasionally by adding cartilage grafts. in the past these maneuvers were done through the nostril incisions. The open rhinoplasty allows better visualisation, and suturing without disturbing the shape of these cartilages and gives a more dependable, stable result.

This is a question that thousands of people ask themselves every day. The number of doctors and even non-physicians providing these services is multiplying at an alarming rate and there seems to be no government regulation controlling the situation. Every specialty is offering cosmetic procedures in order to boost their income and the public is confused about who to trust. I would like to give a few examples. We all know that after a car accident, one would bring the vehicle to a body shop for repair. We might also get some references to make sure that this body shop does a good job, so it doesn’t look like the car had work done on it.

You wouldn’t bring the car to a mechanic who normally repairs engines or transmissions. You also wouldn’t trust your car to your neighborhood gas station and you would certainly not let the carpenter or the roofer fix it.

In medicine today, many doctors allow themselves to inject Botox and Restylane, offer skin care and use laser treatments. If they can, some doctors will also try to get patients to agree to some surgical procedures without having had any significant training in that specific field.

Without any oversight from the regulatory agencies, it really comes to Caveat emptor (buyer beware). The buyer (public) needs better information about who is who in medicine and surgery. They need to know what kind of training makes a good internist or cardiologist. What kind of training and discipline is needed to make a good surgeon, urologist or brain surgeon and finally, what makes a legitimate plastic surgeon better for assisting in their cosmetic needs. Plastic surgery is in charge of our appearance just like the body shops are in charge of the look of our car. It takes seven to eight years of painful competitive training after medical school for most plastic surgeons to start a practice. All of this training is in the field of surgery and plastic surgery, which is very different than medicine where training is mainly directed toward diagnosis and medication.

Why is it that I see patients allowing doctors in other fields than plastic surgery, perform procedures on them to improve their looks?

I think we have failed to give adequate information to the public. We are a relatively small group, don’t have the same lobbying power as compared to other specialists or general practitioners, and we can’t get the regulators to limit their scope of practice. The situation is likely to get worse as many doctors would simply give up taking care of sick patients due of declining reimbursements and declare themselves specialists in cosmetic medicine.

So Caveat emptor (buyer beware).

pre and post op picture of patient who underwent face lift under local anesthesia and concious sedation.

This is truly the best way to perform a face-lift. The patients recover faster. There is less nausea and vomiting from heavy sedation or general anesthesia, therefore less bruising and swelling. There is only one requirement you have to know how to pick the right patient for this procedure and know how to give an efficient effective local anesthesia. The sedation is secondary and plays a supportive role. The key to the procedure is the knowledge of the anatomy and the sensory nerve distribution of the face. This knowledge allows me to anesthetize the face with fewer injections and make the patient more comfortable.

As far as picking the right patient 70 t0 80 % of my patients chose this procedure rather than getting general anesthesia or heavy sedation by an anesthesiologist. This has become a specialty for me and about 20% of my patients are ecstatic when they learn that I offer this option.  I like the fact that the patient is awake and can cooperate with me. For example they can hold their head to one side and stay still. They can open their eye, lookup and open their mouth when I do the lower lid and remove the excess skin. This allows me to remove the exact amount of skin without over resection. Once the operation has started and the patient realizes that they don’t feel anything and they are comfortable, they totally relax. We typically use intravenous sedation and a pain medicine to prevent anxiety and take the edge out of the slight pain of injections. We often have interesting conversation with the patient. This make the time pass faster. Good relaxing music is also part of the experience. Sometime patients tell us that they had a good time. Saving on the anesthesia fees is another side benefit.

Of course if the patient likes to be totally unconscious during the injection of the local anesthetic, we would have an anesthesiologist present. We would also use an anesthesiologist if the patient has any medical condition like high blood pressure that needs control during anesthesia. This is also a better option for patients who are supper anxious and have a hard time relaxing. Call us if you have any other question about this blog. We would be happy to talk to you and explain anything that is not clear.

This could be a blow to medical tourism. There is apparently an unusual rate of silicone leakage from the implants made by a french firm by the name of Poly Implant Prosthese (PIP). This company was liquidated in 2010, but 300,000 implants were already sold for cosmetic breast augmentation world wide. The implants were used in Australia, South America and many European countries. The french government would pay to remove all PIP implants, but only the reconstructive patients would be eligible for replacement of their implants. The silicone in the PIP implants were of industrial grade which is not approved for breast implants. There is also concern about the risk of cancer with these implants. This should serve as a warning for people who would go to other countries to get inexpensive plastic surgery.Tweet