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15/Dec/2018

Surveys show that most people consider the doctor or physician as the most trustworthy person. As much as this fact fills doctors with gratitude and joy it is also a massive obligation to not misuse the patient’s trust.

As an expert in the field of Plastic and Aesthetic Surgery, I have come across all kinds of consultation styles being used or performed by colleagues. Some I have witnessed firsthand, most through patient’s reports. Patients expect from their trusted physicians that those will advise them in regards of best possible options to achieve the best possible treatment results. This is the patients’ right and is any way the obligation of each doctor. The fundamentals of this right are derived from the Hippocratic Oath, which was written in the late 5th century BC.

In reality, it’s not black and white. Aesthetic procedures are not performed to cure a physical disease. They are performed to improve one’s appearance and to boost their self-esteem, thus elevating their spirit. The crux is that there are many ways to approach a problem, some equal in efficacy some not.

How does a surgeon choose what to advise a patient about?

My first rule is to determine if what the patient wants is achievable at all. The second rule is to decide for myself is this is something I am ethically ok with and can see the patient’s point. If both rules are covered I engage in an in-depth consultation with the patient. Here is where approaches between surgeons can differ.

Some surgeons know, that what is asked is not achievable or at least not for them, because they may lack the experience or training. In that case, they should send the patient away or refer them to a colleague who can help. And this is exactly what patients would expect, because they trust the profession, as explained above. If a surgeon now chooses not to send a patient away but to propose a less effective procedure just to convert the business, the patient would not know until after. This is a very common complaint I hear from patients who come to us for correction of outside performed procedures.

Some surgeons don’t understand the patients’ point or know what is asked should not be entertained for ethical reasons. For example, performing a liposuction to replace a much-needed diet with weight loss. By performing ineffective or unnecessary procedures on the patients they break the rule of the Hippocratic Oath “you shall not harm”.

From my experience, it is a matter of course that our patients’ needs can usually be satisfied. However, from time to time it can happen that I have to tell a patient, that her / his perception of the treatment result is not realistic and thus not achievable. This can be due to different reasons e. g. former misinformation regarding the treatment/ surgical options and expected results or for the special condition of the respective patient.

If you need to make a decision, which doesn’t meet the patient’s expectations, the patient will understand the reasons and take gratefully the advice, if they feel that you act out of concern for their wellbeing.

The Patient’s Benefit doesn’t allow compromises

Only rarely it happens, that a patient will consult another doctor to hear what she/ he might like to hear, but I truly believe that professional advice for the benefit of the patient does not allow any compromises. Experience shows that those patients, who underwent a procedure elsewhere against better advice, eventually come back to have things rectified.


15/Dec/2018

Having a child is one of the most fulfilling and rewarding events for any parents. One of the possible consequences of a pregnancy, however, can pose a challenge to women. During pregnancy as well as any other type of weight gain the skin, soft tissue and muscles of the abdomen are stretched. After delivery or massive weight loss, an unsightly abdominal skin flap can remain, which does not respond well to conservative treatments or sport. Apart from the skin flap quite often the muscles of the abdominal wall are overstretched, too thus reducing the power to keep the abdominal content at bay.

As a consequence, the patients develop a bulging of the entire abdomen in addition to the skin flap in the lower abdomen. In less severe cases of skin and muscle overstretch a liposuction with muscle training can help. The advantage is less downtime and almost no visible scars.

For all more severe cases the only solution to achieve a massive, long-lasting and effective improvement is an abdominoplasty, also called tummy tuck.

How Abdominoplasty is performed?

During the surgery (of a full abdominoplasty e.g.) the total excess of fat and skin below the navel will be removed, the skin above the navel will be pulled down to cover the entire area and for a harmonization of the proportions, the belly button will be re-positioned.

In order to top off the surgical effect and to create a truly flat and toned abdomen with a long-lasting to permanent effect, I tighten routinely the abdominal muscle which will function as an internal bodice. Depending on the case and necessity a liposuction can give the final touch.

What happens after Abdominoplasty?

This procedure is performed in general anesthesia at a hospital. The patients stay for one or 2 nights. A supportive garment is applied after the surgery to protect the wound and release pressure from the abdominal wall. At discharge, the patients are able to walk and take care of themselves. Sutures are removed after 2 weeks and daily routine can be established after that. Due to the muscle healing time lifting of heavy weights or sportive activities should not be performed until 6 week after the surgery.

The effect of a skillfully performed abdominoplasty is not only visible immediately, but due to the double tightening up, it can be long-lasting or even permanent. When standing the abdomen is truly flat and even when bending over the upper abdomen does not show bulging or skin laxity. Testimonials from patients confirm the longevity of the effect many years after surgery.

In conclusion: For those, who are not happy with their abdominal shape, I would advise consulting a plastic surgeon with a broad professional experience, who is capable to evaluate what kind of surgery will give the desired result. Unfortunately, I see many patients coming to a consultation with me and having had numerous ineffective procedures on their abdomen elsewhere. Assessing their initial preoperative photographs I can very often confirm that they should have been advised for the abdominoplasty surgery right away. This would have spared them time, discomfort and expenses.

 


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15/Dec/2018

Hand Surgery is beside the Aesthetic Surgery I do, one of my favorite surgical fields. It requires a profound knowledge of the anatomy and superior surgical skills as the hand is packed with tendons, nerves and arteries in close proximity.

What is Dupytren’s Contracture?

The Dupytren’s contracture is a disease of the connective tissue of the hand mainly the palmar aponeurosis which lies right under the skin of the palm and fingers. In patients suffering from this disease, the fibers of the palmar aponeurosis start growing, thickening and contracting. This leads to the fingers being bent in the base joints.  Extending the fingers is not possible, but flexion into the fist still works. The disease usually starts on fingers 3 to 5 (middle to little finger), but can also be seen at the index finger or thumb. In very severe cases all fingers can be involved.

We know four stages with stage 1 being the beginning of the disease with the Dupuytrens cord just being visible to stage 4 being the most severe stage with flexion of the fingers into the fist making them literally unusable. The exact cause is still unclear but linked to genes more spread in Europe and North America.

How Dupytren’s contracture is treated?

In the beginning, the disease can be treated by physiotherapy or application of night splints to keep the fingers stretched. If it progresses to stage 2 and beyond invasive measures have to be taken. In recent years a minimal invasive treatment has been quite popular which uses percutaneous needles to cut the chords and straighten the finger. However, it cannot replace the surgery as recurrences are high. If a surgery is necessary, all affected connective tissue chords will be removed and the underlying nerves, vessels and tendons will be spared. Depending on the severity of the case and in recurrent cases it can be a demanding and time consuming surgery which should be left for the very experienced and trained hand surgeons.  

Do you need physiotherapy after the surgery?

After the surgery usually a splint is applied to keep the fingers straight for 7 to 14 days. The skin sutures can be removed on the 12th to 14th day. After that physiotherapy will help in regaining full function quicker. Most patients can resume their normal daily activity 2 weeks after the surgery.

As a matter of fact, the surgical treatment of Dupuytrens disease was a routine procedure during my time in Germany. Almost every day we would treat patients with this condition. Having operated on more than 1000 of patients the outcome in my hands in reliably positive.

This is of particular importance as the recurrence rate of a Dupuytren is reported to be very high in the literature especially if a non-experienced surgeon performs the surgery.

Whoever suffers from this condition should, therefore, seek for hand specialist with a proven track record of successful surgical treatments of Dupuytren’s disease and sufficient experience in the field.

Last but not least surgeons who operate on this disease should also be versed in the repair of vessels and nerves to be able to reconstruct these structures if during the surgery damage to them happens.


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15/Dec/2018

“Can you avoid a rejuvenation surgery of face and eyes by undergoing repeatedly filler and/ or botulinumtoxin procedures?”

This topic is discussed quite controversially and the answer is not that simple.

Patients, who are looking for rejuvenation treatments of face and eye area, have the option to consult medical practitioners with different backgrounds, thus there can be more than one medical specialization engaged. According to their specializations, the practitioners will give their professional advice for a treatment, which can turn out very differently.

For instance, if a doctor does not perform surgeries at all, she or he will most probably advise to avoid surgeries and opt for non-invasive treatments for as long as possible. Does this work for a patient in his or her late 30’s? Yes, definitely, but maybe not that well for someone older than 45 years.

The crux is, that if you wait for too long before you opt for a surgery, the skin may have relaxed to an extend that an optimum result is difficult or not at all to achieve. Very often I need to tell patients, who are in their 60’s, and ask for my advice in my clinic, that it would have been better, if they had visited me a few years earlier. The majority of them tell me, that they have spent ten thousands of dollars over the past 2 decades for non-surgical treatments and that these procedures have not delivered the desired results after a certain age.

So what is the best solution? Every treatment has its rightful place for the right patient at the right time. A medical practitioner, who is able to offer both, non-surgical and surgical treatments of a broad spectrum, like a Plastic Surgeon, is the best person to seek advice regarding the right time/ age to opt for a surgery.

It has been shown over the last decades, that in order to achieve the best and longest lasting results with lifting procedures of face and eyes, the best average age bracket is between 45 and 55 years. In this age group you already see clear signs of ageing, but tissue quality and elasticity of the skin are still good enough to achieve an optimal lifting effect. On top of that, it plays an important role which surgical principals your surgeon follows and which technique is used, but that will be the topic of my next blog.


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15/Dec/2018

The most common aesthetic procedures in the world are filler and botulinum toxin injections. Filler serve the purpose to smoothen deep wrinkles and adding volume to face and body where needed. Botulinum toxin is applied for dynamic wrinkles of the face by paralyzing the underlying muscle temporary.

The vast majority of fillers are not permanent, which means that they will be absorbed or metabolized by the body within 3 to 12 months depending on the ingredients and brand. Some fillers, meant for very deep injections to add volume, might stay for up to 18 months.

The vast majority of filler patients are pleased with the treatment results and continue to undergo this procedure in appropriate intervals. The filler is available readily and the procedure is quickly performed with little downtime afterwards.

However, those who seek long lasting or even permanent results with fillers, can’t be satisfied with the existing products. The best solution for them could be a fat transfer. The technique of injecting fat as body’s own tissue filler is described and already used worldwide for decades. There are sterile single-use kits available, which make the procedure safe and cost effective for patients and practitioners alike. One should know however, that fat cannot be used for very superficial fillings like intradermal injections. Otherwise there are no restrictions regarding the area and layer of injection.

Fat can be applied for facial filling including lips or even body contouring including buttocks and breasts. There is a downside however. Not all of the harvested and injected fat will survive in the injected area. On average, if done properly, up to 70% of the injected fat cells can stay alive and function as a permanent filler.

This fact requires the practitioner to “over-correct” to some extend while injecting and also to advise the patients, that touch up session might be necessary.

My approach is, that I recommend patients, who come for the first time for a filler treatment, to decide on ready-made fillers. This way the patients can experience the filling effect on a temporary basis and think of going for a longer lasting solution at the following filler session. If so, I usually propose fat filling to the patient.

Getting back to the question in the title: Yes, for those patients, who seek filler treatments on a regular basis, fat might be the best option as a long lasting solution.

 


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15/Dec/2018

eye

Whenever we meet somebody, the first look is at the eyes. This is the reason, why the orbital/ periorbital region is perceived as the most important part of the face, when creating an impression on another person.

The human face is divided into different aesthetic units; the periorbital region consists of the upper and lower eyelid, the eye socket, the eyebrows and the upper cheek area.

When aging, different parts of this area can age at different speeds. Usually the upper eyelids will start, drooping and creating some excess skin. Thereafter under eye bags may form and the lower eyelid skin will show wrinkles and laxity. Eventually eyebrows will drop , worsening the sagging of the upper eyelid skin.

When rejuvenating the periobital region, optimally these signs of ageing can be addressed in one and the same procedure. Most commonly upper and lower blepharoplasties or eyelid lifts are performed with or without eyebrow lifts.

Although upper eyelid lifts are usually effectively performed, unfortunately this does often not apply to lower eyelid lifts. In many cases, patients are quite rightly dissatisfied with the results due to insufficient surgical corrections. Utilizing the correct surgical techniques and having sufficient experience, one can achieve truly wonderful and long lasting rejuvenation effects, not only for the lower eyelid as such, but also for the entire mid face area. In the course of the surgery, excess fat from the periorbital area will be removed and used to spread over the bony rim of the eye socket and the muscle is used to lift and suspend the entire mid face area upwards, reversing signs of time. These changes proof to be long lasting, even after 10 years my patients appear still younger than before the surgery.

In conclusion, the periorbital rejuvenation surgery is a rewarding and long lasting improvement of the overall facial appearance and impression, provided that the surgical methods are correctly applied.  For optimal rejuvenation effects, patients need to make sure to choose a surgeon with extensive experience, who is also capable to include the mid face area in the lifting process.


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15/Dec/2018

Before moving to Dubai I worked as a Plastic Surgeon and Hand Surgeon in Germany for almost 18 years. Amongst the most common hand surgeries I performed were Carpal Tunnel syndromes. At some days we would treat up to 6 patients for this.

What is Carpal Tunnel Syndrome?

Patients with this condition suffer from numbness of the first 3.5 fingers of the hand (thumb, index finger, middle finger and radial side of the ring finger). Sometime they can’t sleep a full night, because the pain in the concerned hand wakes them up mainly in the early morning hours. Usually, this condition is progressing and can lead untreated to a permanent numbness of the affected fingers and a weakness of the thump opposition, making it difficult to reach the tip of the little finger with the thumb. This thumb opposition is what distinguishes our hand from the ape’s hand.

What Are the Causes of Carpal Tunnel Syndrome?

The underlying cause for a Carpal Tunnel Syndrome is an increased pressure on the median nerve, which runs through a tight tunnel when entering the hand on the wrist level. The reasons for this increased pressure can be very different, but Caucasians seem to suffer more frequently from this condition than others. This explains the fact why this condition is so common in Europe and North America but not in Asia. The pressure leads to a slow but progressing reduction in the speed of the nerve conduction. This, in turn, reduces the sensation of the fingers affected and also the muscle responsible for the thump opposition.

Does Carpal Tunnel syndromes requires surgery?

If conservative therapy like splint treatments or cortisone injections don’t help a surgery is required to release the pressure from the nerve. This is been accomplished by dissecting a ligament called the transverse ligament in the wrist level which builds the “roof” of the carpal tunnel. In most cases, a surgery has to take place eventually, as most of the conservative treatments don’t cure the disease.

An exception is the pregnancy-related Carpal Tunnel Syndrome, which occurs during pregnancy and disappears usually a few weeks after delivery. The cause for this is the pregnancy-related water retention in the soft tissues of the body leading to increased pressure in the carpal tunnel, too. A small percentage of pregnant women develop this condition. It is best not to operate on them and count on for it to go away after delivery. Only in very severe cases with pain and function impairment, a surgery should be considered.

Walant Anesthesia and Carpal Tunnel Syndrome

Nowadays skilled hand surgeons perform this procedure in local anesthesia as an outpatient procedure in a matter of minutes. The most recent development for this surgery is the use of WALANT anesthesia which removes the need for an upper arm tourniquet, making the surgery even less stressful than before. The success rate is quite high and patients are usually relieved from pain the day after the surgery. However, if numbness was present, this may take up to 12 weeks to fully recover.

Look out for those who complain about not sleeping well anymore because they think they slept on their arm and this caused the hand to go numb, maybe they can be helped with a simple procedure.

 


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15/Dec/2018

In my earlier article I shared the statistics of the ASPS 2014 for the most common plastic/ aesthetic surgery procedures. Breast Augmentation was ranked on number 1.
To enlarge or correct a lack of volume or an asymmetry of the breast, one needs to insert breast implants. The vast majorities of implants consists of a silicone shell and are filled with silicone gel. Although there are still the saline filled ones in the market, they are not been used that often anymore.
In terms of shape one has to distinguish between the anatomical and round shape. The anatomical shape imitates the shape of a natural breast with more volume in the lower part and less in the upper, whereas the round implant is shaped like a dome. I will not go any deeper in the science of shape and dimension of the base, the gel cohesiveness and shell texture in this article.

My focus today is on the difference between round and anatomical implants. It is an interesting fact that depending on the region of the world you live in the ratio between anatomical and round implants used in breast augmentation differs immensely.
For instance, in Europe much more anatomical implants are used, than in USA or the Middle East. The reason for this may be, that European women prefer a more natural look of the breast, thus preferring the anatomical implants, whereas in the USA and Middle East tendency is more towards a fuller upper pole by using round implants.
Another reason is that surgeons prefer round implants because they think using anatomical ones is more complicated and bears the risk of implant rotation.
From my personal experience in using routinely both anatomical and round implants, I can firmly say, that using anatomical implants is as safe and practical as round ones. Only the breast condition of the patient should dictate which implant to choose. I still see too many slim patients with round implants resulting in a fake or “done” looks, whereas they would have been served much better with the anatomical ones. I am confident that over time and with constant education of the health professionals we will see less and less of this artificial looking breasts.

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15/Dec/2018

I am sure everybody has heard about surgeries which are meant to improve the appearance. How do we call these specialists, who actually perform those surgeries?

Well, in the western world it is quite clear. A Plastic/ Aesthetic Surgeon is the person who has actually undergone the extensive training and exams and is a board certified member of the respective country authorities.

However, Cosmetic Surgery or Beauty Surgery are not recognized specializations with any health authority in the world. This means, that Cosmetic or Beauty Surgeons may perform such procedures, but may not have undergone the required training.

So, to be safe, look out for the proper trained and licensed ones, who are board certified Plastic/ Aesthetic Surgeons.

Wish you a beautiful day!


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