Hey Re. Fam, my name’s Kate and welcome back to keeping it real the podcast, stripping it back to basics. To make sure we’re all on the same page, today we’re defining terms and concepts that we use all the time across our videos, podcasts, and all our content. If you’re a dedicated listener to the pod, don’t worry, there is still heaps of interesting tidbits in here.
We go on plenty of tangents and digressions. We cover things like why do we only use silicon implants, define medical terms like ptosis and grafts, and explain why measurement doesn’t necessarily indicate impact when it comes to muscle separation. If you like this episode, let us know. And as always feel free to send us a message with any topics you’d like us to cover next.
We’re going back to basics, explaining terminology trying to find a line between being insanely repetitive and explaining things I think we maybe just take for granted that everybody will understand.
Kim: I think people that are new to the podcast and haven’t, we still see on Facebook people are like oh what’s an MR and what’s a BBR?
Kate: Yeah, so I do think like it’s good to go over and work.
Richard: Is it rapid fire?
Kate: Depends, bit of mix.
Richard: How many have you got?
Kate: Oh, about 15 by the looks of it. Can you explain the differences between invasive and non invasive surgery?
Kim: I don’t think there’s such a thing as non invasive surgery. Surgery is surgery.
Even liposuction, which some people think is non invasive, it is invasive. Even, it’s minimal incision. There’s lots of different operations that are like minimal access or minimal incision. But. Anything that’s called like a mini or a minor or non invasive, I don’t think exists. Is there a non invasive surgery that you can think of?
Richard: No, I think all surgery is invasive. I think the fact doctors, I differentiate between doctors and surgeons, doctors doing liposuction being able to pierce the pancreas. Which is clearly not a superficial organ indicates that it is potentially very invasive. So I go, I agree with Kim, if you’re using the word invasive, then it’s surgery.
And that’s, you can compare that with non invasive techniques like laser treatments or thread lifts. I’d probably just sneak that into non invasive, but I’d also put that in the non useful category. I think the effectiveness correlates well with invasiveness.
What’s the difference between saline and silicon implants and which do we use?
Kate: What’s the difference between saline and silicon implants and which do we use?
Kim: What it’s describing is the contents of the implant, so the outer shell of pretty much all of the implants is actually silicon, so even if you’re like, I don’t want to have silicon. The bag is still made of silicon and so it’s the content. So saline is salty water. Two thirds of our body is made up of that.
And that’s what’s put inside a saline implant. Whereas the other option is silicon implant and the contents of that is a different type of silicon to the bag. And that has a shape to it and that’s what we use. Would use 100 percent of the time.
Richard: Roughly 100%.
Kate: Silicon?.
Richard: Yep, I’ve never done a saline implant.
Kate: Were they like big at a certain time and then have faded off?
Richard: So they were the predominant implant in the US for, since the 90s. And I think that they’re only maybe even still although you can now use a silicon implant. There were two or three Melbourne surgeons who did predominantly saline implants two of the three are now retired, I think there’s maybe one surgeon who, maybe that’s still his Go to implant, but largely replaced with silicon apart from America and one surgeon in Melbourne.
I think no one else in the world.
Kim: Silicon, is a much more natural feeling and a much better outcome.
Kate: You’d think it’d be. The watery one.
Richard: Except a breast, the consistency of breast is not water.
Kate: Yeah. Okay. Controversial. On that thread, what’s a dual plane implant?
Richard: So dual plane is pretty much is a synonym really for submuscular.
So when you’re doing an implant. Apart an aesthetic implant. So not reconstructive implant, although they’re becoming more like that. You don’t put a total, the implant totally under the muscle. ’cause the muscle if you’re watching on YouTube doesn’t come all the way down to where the incision is.
So when we say dual plane, that’s dual two planes. So plane one is under the muscle, which is the upper two thirds, let’s say, of the implant. And then the lower third is directly underneath the breast tissue. So they’re the two planes under the muscle and under the breast, which is compared to not totally under the muscle that doesn’t really exist.
It’s the alternative is. subglandular, which is just underneath the breast tissue on top of the muscle. So that, they’re the two types of pockets that we make for implants. What’s ptosis?
Kim: Oh, that’s droop. And mostly we would be referring to the breast when we’re talking about that, but you can also have ptosis of eyelids, earlobes, noses.
Kate: Which I saw there was a TikTok, he had just very like typically Asian features. And so then somebody messaged him being like, I think you have ptosis. And he was like, I had a medical condition. No one even knew. They just thought I was Asian.
Kim: More noticeable, particularly in the eyelids, if it’s worse on one side than the other.
Richard: But it’s not the same as hooding. So hooding. is where there’s excess skin that hangs over the eyelash or down to the eyelash. Ptosis is actually where the muscle that pulls the eyelid back has separated or dehisced from the eyelid. And so it doesn’t pull back as far. So what you’ll notice is the eyelid covering more of the iris, almost down to the pupil. Now you can get a little bit of ptosis from the excess skin or a heavy brow, but when you’re specifically talking about ptosis, it’s really referring to the muscle apparatus, not working for whatever reason.
Kate: Yeah. He said, put. If you put your hand on your forehead and if you can’t if you lift it, it doesn’t make your eyes any wider.
And then he also, he was like from, he was like, I’m 6’3 so I always look down at people so they don’t really notice. But if you go from above and you like really can’t see his eyes cause he can’t like.
Kim: Often those people would have tons of forehead wrinkles cause they’re using their forehead muscles to pull up their skin and their eyelids as much as possible.
Also.
Kate: spelt with a P. Like a pterodactyl. What are the most common types of anesthesia used in cosmetic surgery and how do they differ?
Richard: No idea. That’s their job. To our anesthetic friends out there.
Kim: Thanks for keeping our patients asleep. So we would use almost exclusively general anesthesia. So that’s patient is completely off to sleep. But within that there’s a whole You know, five years of study to figure out what exactly they do. General anesthesia is when you’re completely off to sleep. People sometimes talk about twilight. And we do occasionally get patients that’ll ask, can I have my liposuction or can I have my breast implants under twilight, which we generally wouldn’t be doing. And we certainly don’t do office.
Kate: What makes it Twilight?
Kim: Twilight is another name for sedation, so that’s where there would still be an anesthetist involved and they’re giving, rather than being completely off to sleep, they’re giving lesser amounts of the same sort of medication. And A lot of anesthetists for the type of surgery we would do would just call that general anesthesia but without airway protection.
So they think it’s, depending on what it’s for, it can be an unsafe, more unsafe type of procedure. Local anesthetic is What’s injected into the area that we operate. So we would both do that everywhere where we operate once the patient’s already off to sleep. So everywhere meaning every body part and that helps with control of bleeding at the time of surgery, but also pain relief afterwards.
And we would also do little minor touch ups in the office under anaesthetics. So small areas, small volume.
Kate: What actually is fat grafting and do you always take fat from your own body?
Richard: Ooh, interesting. So fat grafting is like any other graft so what a graft is taking tissue from one part of the body and moving into another part of the body and it is dependent on the new position for establishing a blood supply.
So that, that’s the same principle as a skin graft, nerve graft. Bone graft, so fat graft is no different. You do a nerve graft. Yeah, nerve graft.
Kate: What’s a scenario you do a nerve graft?
Richard: So if someone’s had trauma. Yeah. And their missing section of their nerve is missing. Yeah. So you would take a less essential nerve, so just say a sensory nerve, and put it in to fill the gap and sometimes…
Kim: I can see your brain, like
Kate: What examples?
Richard: Of where you’d take the nerve from?
Yeah. And where would you put it? So say a sensory nerve into the foot. And
Kate: if I was wondering hypothetically what a sensory nerve was?
Richard: A nerve that say supplies feeling to the outside of your little toe. Okay. So not critical. Yeah. So you would take that and you take a long bit of it and you’d maybe put in a couple of different cables.
Sometimes in the hand, back way back when I was doing hand surgery, if there was a gap, you would sometimes take a vein graft. Now, veins have valves in them, so you need to switch the direction but nerves sprout out from approximately, so where they’re starting from, and the vein graft provided a channel for the new nerves to grow down so they got to the other side.
So you’d stitch the vein between the two ends of the gap.
Kim: For a small gap. But if it’s a bigger gap, you’d just fill it with
Kate: And they would make their own tree.
Richard: Correct. On that. Branches, maybe.
Kim: The other place, the face. We were talking earlier about facelift, and so the really important nerve in the face that moves all the muscles of your face.
So some people are either. born without that nerve or have had tumor or trauma and it’s been injured. So what you can do is a cross face nerve graft. So get one of those non essential nerves from somewhere else and plug it into the opposite side and tunnel it across so that when they try to smile it’ll activate on both sides.
Richard: Or you can take a muscle with its nerve supply and blood supply, put it under the skin, connect it down low down in the face and anchor it somewhere back up here, connect that to the stump of the facial nerve, if that’s been damaged, and the artery, and then the muscle over time will learn to contract.
Kate: But thinking about it I’m like, Oh, those nerves all have a specific job for it. Like I didn’t think that they could go on a holiday, it would be like, Oh, I just thought it was,
Kim: They just use the tunnels. To join up,
Richard: Think of it like electrical cabling.
Kate: My other area of expertise.
Richard: It’s the outside casing. Because the inner part, when you do a nerve graft and we’re digressing a little bit. But people find this stuff interesting. The inner part of the nerve actually, so the wires, [00:12:00] they actually dissolve, so they don’t live.
So that’s why the vane graft also works, because the outer part of the nerve, it just provides a casing for the new nerves to go down, so they don’t just, they don’t just spread out, and not know where to go. But the same process still goes. Nisi had a blood supply. So initially all grafts, the blood supply takes a week or so to develop.
So initially they just get nutrients through diffusion and that’s the same with fat. And then Sort of a two or three week period, they’ll develop a blood supply. So initially the artery stuff growing into it and then veins, which would be the same with fat to answer your other question, always your own fat and you don’t store it and then use it later.
So we can’t we can’t take some of that, put it in the fridge, leave it for a year or so, come back and top you up and things like that. So it’s used at the time. Lots of different ways that we treat it and harvest it, which I go through in my Facebook live. But I think that answers it.
Kate: Yeah.
Richard: Extensively. More than you expect.
Richard: That is part year four of the plastic surgery training program.
Kate: Oh, is it?
Richard: That’s why you didn’t know about it.
Kate: Yeah. So I have that on cosmetic surgeons.
Kim: Same hospital that asked me about the expense of unnecessary dressings the other day when I was doing some fat grafting asked me if I wanted to store the leftover fat.
Richard: Did not.
Kim: Not a word of a lie. So true. They were like other surgeons and I’m like what?
Richard: They do not.
Kim: I got asked that question. Less than seven days ago
Richard: If you want to store fat?
Kim: I’m not joking
Richard: And they said other surgeons do it?. Wow.
Kim: And I asked the nurses if they wanted to take it home and store it in their own fridges because that was on TV a year or so ago.
Yeah. Allegedly. But it was on TV.
Richard: Up until about 15 years ago people when they were doing an upper blepharoplasty, they would store the skin in the fridge.
Kim: What do you mean up until 15 years ago? I guarantee there’ll be people doing it.
Richard: No. I guarantee there will be. Outlawed. Outlawed.
Kim: No. People store skin grafts.
Richard: They would store it. Because the problem is, if you took out the skin, and then they kept it in the fridge, The next day patient couldn’t close their eyes because there wasn’t enough skin. They could take them back to theatre and they’ve got the skin that they took out and they could put some back in.
Okay. I don’t know that anybody ever did it, I don’t think anybody ever did it, but what they found at one hospital, which I’m not going to name, like they’d go back years later and the skin was still there.
Kate: Have you ever, anytime, anything. It’s like the fridge here. I was about to say, anytime, anything’s like
Richard: multiple people’s responsibility,
Kate: there’s no chance.
Richard: There’s a sandwich in there from a couple of weeks ago that I saw this morning.
How does liposuction actually work?
Kate: How does liposuction actually work?
Kim: It vacuums out fat cells. That’s the way I explain it to people. It’s essentially, it’s a pretty imprecise technique because you make small incisions, you’ve got a long skinny tube with some holes on it.
on the end of it and the skinny tube has various diameters and you’ve got different types of holes on the end but essentially and then it’s attached to different types of machines but essentially they all suck that out and so the cannula goes where we place it. And the machine sucks the fat from where we put that cannula.
So our job, which I think I genuinely think it’s one of the trickiest techniques that we do because other surgeries, you make a line, tummy tuck, abdominal plasty, you cut out the skin, exactly what are you going to cut out? You know exactly how it’s going to heal, where it’s going to go.
You put the cannula under the skin. You, your brain is having to work in 3d and planes. And the goal is to get an even amount of fat removed from all the areas. Because if you don’t, if you overdo one area or underdo one area, or because it’s a long skinny tube, like it’s. It doesn’t suck a whole patch out.
It just sucks from the end of that. So it’s it’s tricky. It’s very good for small areas of excess fat that are resistant to diet exercise. I think we both agree it’s not good for large areas.
Kate: There’s only a set amount of fat cells, right?
Kim: Yeah. So everybody’s body has a set number of fat cells and we do commonly get asked the question like if you take the fat from here, will it grow back or will it all go somewhere else?
In a way, yes. So if you remove all of the fat cells from one area and if then the patient person puts weight on, that area will not gain as much fat as somewhere else. Having liposuction is important. In itself is not causing someone to put weight on in other areas. Putting weight on is meaning that it goes elsewhere.
And so that’s one of my goals would be never to remove all the fat from one area. It’s to contour it. So it’s even with other areas. So they do then put weight on. It goes more evenly. And the last thing I would say on that is that, yeah, when people put on weight, the fat cells that they have just expand.
And when they lose weight, they reduce.
How do you keep the patient’s nipple in a reduction or lift?
Kate: How do you keep the patient’s nipple in a reduction or lift?
Richard: So the nipple areola complex is kept alive on a pedicle. So the pedicle is its blood supply. Now the older way of doing that was inferior or the blood supply from below, but Kim and I both use a technique which has been modified over the years, but there’s been popular for 20, 30 years, which is called a super medial pedicle because the main blood supply comes from between the ribs either between the first and second or second and third, and sometimes even third and fourth, but a distribution of them in vast majority of cases.
And so that We keep that in the pedicle. So that is all under the skin. So folded back on itself in some circumstances, particularly in very heavy or long breasts. So where the nipples hanging down, maybe neither. near the belly button and where someone wants to be, have a really big reduction then we would convert that to a free nipple graft where you actually remove the nipple areola complex and then put it back on as a graft.
Vast majority of patients that’s going to be as a pedicle.
Kim: In both ways they end up with a similar scar around the outside of the areola because you’re always having to shift it in some way. Okay, what is muscle separation? So what you’re talking about there is the rectus abdominis muscles, which are the six pack muscles that all of us have in our abdomen.
And what happens predominantly during pregnancy is that the gap between those muscles it’s a tissue that’s called the linear Elba. So it’s a fibrous band that sits between the six pack muscles that gets stretched out and thinned. Very commonly in pregnancy, particularly pregnancies twins the more pregnancies a woman has, the more likely that area will get stretched.
And It’s your six pack muscles that are getting separated. It’s not the muscles themselves that are stretching. And because there’s no muscle in that gap in between, there’s not a lot that people can do that will actually naturally bring that back together. Sometimes it’s just good genes, and sometimes it’s that the tissues have got more elasticity in them, and so that returns, and so some women end up pretty good, and some may have not that big a baby, one pregnancy, and may end up with a significant gap.
So it’s super unpredictable, I think, sometimes. And I also think, I think you tend to agree, that the actual, gap between the muscles doesn’t, in terms of distance, doesn’t necessarily correlate with a woman’s symptoms and their appearance and their function as well. So I’ve seen women with a pretty small gap have really floppy tissues and really bad back pain.
And it had a great response to repairing that gap surgically. And conversely, I’ve had women that have had quite big separation that didn’t really even notice that they had a whole lot going on.
Richard: In addition, there’s another muscle, the oblique muscles, which attach into the rectus muscle on the sides. And so bringing, closing that gap puts all of that on better tension so that all of the whole muscle wall gets tightened.
It’s not about tightening the muscle, the whole muscle wall and narrowing the gap. So when that gap gets narrowed, the muscles on the side get put on stretch as well. And so they’re splinting the six pack muscles and so they can function better as well. So the whole tummy wall in a muscle repair.
Gets gets tightened and that’s why the whole thing functions better. So it doesn’t give you core strength, but it puts your muscles in a better position so that you can do Pilates and strengthening exercises and develop better core strength.
We’ve spoken a lot previously about how breast lifts and breast reductions are points on a spectrum, but why does the distinction exist?
Kate: We’ve spoken a lot previously about how breast lifts and breast reductions are kind of points on a spectrum, but why does the distinction exist?
Especially because I know they have different Medicare numbers.
Richard: That’s the reason I, they’re both reshaping procedures from my point of view. I’m always removing breast tissue in a lift, and I’m always lifting in a reduction. And it’s just a matter of, how much of each.
And I don’t think you need to remove much breast tissue for a woman to get symptom relief. From a reduction. So you don’t have to remove, 400 grams for that woman to actually be relieved of neck, back, shoulder pain. So hopefully, although I doubt it, a number, a weight number will never come into the Medicare item number.
Although that’s certainly the trend and seems to be the trend in Australia where they’re putting more and more restrictions on when you can and can’t. Can’t use item numbers, but hopefully not in our time.
Kate: You’re right. So do you, don’t have to know the answer to this, but overseas, do they also have the distinction?
Kim: In the US, definitely. It’s weight, patient BMI and weight height related of how many grams they have to remove to, for insurance to be able to call it a reduction. And there’s Tons of different insurance companies and I think they’re all potentially different because they don’t have an overarching Medicare which sets the item numbers so yeah, it would be Ridiculous for that to be brought in because you could every one of our patients that had between 50 and 2500 grams removed from their breasts would have some symptom relief for sure.
Kate: So in both scenarios, it’s not medical at all, it’s just admin related?
Kim: Yeah, and they would only bring it in to try and reduce the number of women that are going to get benefit from it. The criteria to get a Medicare item number to have it covered for insurance for a breast lift, so pure ptosis operation, is almost impossible to meet that criteria, that the criteria is so strict.
And from memory, it’s two thirds of the breast tissue has to be below the fold, and the nipple has to be at the very bottom of the breast. A lot of women would meet the two thirds below the fold and the nipple low, but not necessarily as the nipple at the very bottom. It’s pretty difficult to allocate that number.
Richard: Similar restrictions with prostate surgery for men.
Richard: It’s wild.
Why can’t you hide a thigh lift scar in the groin?
Kate: Why can’t you hide a thigh lift scar in the groin?
Richard: Because you’re, you’d be trying to defeat gravity. And gravity always wins as Sir Isaac Newton proved so going back a fair way there. So the groin crease scar for a thigh lift tries to anchor it to either to the pubic bone or to the muscle there but it’s never strong enough.
It can’t hold up all of that weight. Also that’s not the direction of where the loose skin is. But one of the big complications that you see from using that technique is that it pulls the scar down and just above the scar is the labia. So it pulls some of that into the groin. Which is devastating.
So two reasons. One, you can’t bear gravity. And two, that’s not where the skin excess is. It’d be like doing a tummy tuck on the sides or something.
Kim: Or an arm lift in the armpit. Yeah. You can’t just tuck the skin in the armpit, hide the scar up there. Cause the skin is the whole area.
Kate: If you liked that episode, there’s plenty more where that came from. Maybe start with some of these or head to our channel for your peek into the mysterious world of plastic surgery.
For more information, book a consultation with expert plastic surgeons Dr Richard Bloom and Dr Kim Taylor. Call 03 8840 0000 or visit Re. Plastic Surgery at Level 3, 36 Jackson Street, Toorak, VIC.
