Facelift Surgery

The deep plane facelift is a technique that can be used in conjunction with an upper and lower blepharoplasty as well as a coronal brow lift.

While the deep plane facelift affords excellent correction of the nasolabial folds, jowls, and neck, I have found that the aperture of the upper eyelids can yield a significant positive impact on the aesthetic result on the overall youthful appearance of the face.

It is very common for women as they age to have an accumulation of skin on their upper eyelids. This accumulation of skin has been given the medical term, dermatochalasis. Often this accumulation can be asymmetric-meaning greater on one side versus the other and can create differences in the aperture of the eye. It is important when correcting this asymmetry to note the location of the tarsal fold or eyelid crease.

As you can see in the above photograph the patient's right eye has significantly more skin pre-operatively than the left eye. Careful notation of these asymmetries is important so that post-operatively the eyes can have equal apertures and yield an optimal aesthetic result.

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Vascular and Endovascular Surgery Publication May 2010 44: 315-318

One very important aspect of Plastic & Reconstructive Surgery is the management of complex wounds of the lower extremity. It is of paramount importance for the Plastic & Reconstructive Surgeon to work in close collaboration with Vascular Surgeons in the management of these complex wounds.

I have found that in addition to Vascular Surgeons, close collaboration with other medical specialist such as Orthopedic Surgeons, Infectious Disease Doctors, Internal Medicine, and Renal Physicians is important to optimizing patient outcome.

Brian P. Dickinson, M.D.

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The Impact of Upper Blepharoplasty on Facelift Surgery

Aesthetic and reconstructive facial surgery is particularly enjoyable to me. The deep plane facelift is a technique that I commonly use in my aesthetic practice and which I frequently use in conjunction with an upper and lower blepharoplasty as well as a coronal brow lift.

Analyzing my own results is an important part of my practice so that I can continually improve. While the correction in the nasolabial folds, jowls, and neck are more obvious from the deep plane facelift, I continue to learn more about the impact of the aperture of the upper eyelids as their appropriate placement can yield a significant result on the overall youthful appearance of the face.

It is very common for women as they age to have an accumulation of skin on their upper eyelids. This accumulation of skin has been given the medical term, dermatochalasis. Often this accumulation can be asymmetric-meaning greater on one side versus the other and can create differences in the aperture of the eye. It is important when correcting this asymmetry to note the location of the tarsal fold or eyelid crease. As you can see in the above photograph the patient's right eye has significantly more skin pre-operatively than the left eye. Careful notation of these asymmetries is important so that post-operatively the eyes can have equal apertures and yield an optimal aesthetic result.

I continue to see great improvements in the overall skin texture and quality with the deep plane facelift.

Brian P. Dickinson, M.D.
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Hand Surgery:Flexor Pollicis Brevis

The flexor pollicis brevis is an intrinsic muscle of the hand that originates from the flexor retinaculum of the wrist and tubercle of the trapezium. The muscle inserts on the radial side at the base of the proximal phalanx of the thumb. The recurrent branch of the median nerve and the deep branch of the ulnar nerve provide motor innervation that allows the flexor pollicis brevis to flex the thumb at the first metacarpophalangeal joint.

Laceration of the flexor pollicis brevis due to trauma significantly impairs hand function as the patient is unable to fully oppose the thumb to the small finger.

I prefer repairing the tendon of the flexor pollicis brevis tendon with 3.0 and 4.0 nylon suture with a modified Kessler stitch and horizontal mattress sutures. A 5.0 epitendinous suture allows an adequate contour to the repair and facilitates opposition of the thumb to the small finger.

Brian P. Dickinson, M.D.

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Fitness Model Revsion Aesthetic Breast Surgery

Revision breast augmentation in Fitness Models possess unique challenges to the surgeon. Aesthetic results are usually quite optimal after complete capsulectomy, but the thinning tissue often allows implant visibility or rippling. I often choose to perform complete capsulectomy to allow the breast to re-drape over the implant. It is important for the surgeon to have a thorough knowledge of the previous operations, as implants may have been in prior planes, or neosubpectoral pockets may have been created from prior capsules and have subsequently contracted. I have used the neosubpectoral pocket on many occasions for revision aesthetic breast surgery and have found it useful. However, in women who present with recurrent capsular contracture, it is important to remove the capsules to allow the breast to re-expand and produce an optimal aesthetic shape.

Often in patients who have undergone previous revision aesthetic breast surgery and who are competitive athletes, fitness models, or clothing models, the breast and surrounding subcutaneous tissue is thin. To prevent implant visibility or palpable rippling in this population, I have found Strattice to be quite useful.

The Roxbury Clinic & Surgery Center continues to grow as a center for capsular contracture as well as revision aesthetic breast surgery. An increasing number of women choose to undergo their mastopexy/augmentation, capsular contracture surgery, breast augmentation, removal and replacement, as well as second stage breast reconstruction surgery at the Roxbury Clinic & Surgery Center.

Brian P. Dickinson, M.D.

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Strattice for Revision Aesthetic Breast Augmentation

We are starting to see many patients come from out of state to have their revision augmentation procedures or capsulectomy surgeries performed at the Roxbury Clinic & Surgery Center. I have been using the Strattice in the manner as taught to me by Neal Handel, M.D. When working through small incisions, I have found the use of appropriately and carefully placed marionette sutures to align the Strattice in correct position while the remaining sutures are performed through the limited incision.

I have found Strattice to be very helpful in the revision breast augmentation patient who has rippling, implant palpability, synmastia, bottoming out, and fold asymmetry. I have also found Strattice to be helpful as a barrier between the nipple areola complex incision and the capsule of the breast implant.

I remember repeatedly, the lessons on tendon healing by one of my great mentors, Malcolm Lesavoy, M.D. He would always describe the "one wound/one scar" theory for tendon healing. I find that the same theory can apply to breast implant capsules.

Frequently, I see patients who present for capsular contracture surgery who have a thickened scar beneath their periareolar incision with a "scar rind" that is aggressively fixed to their underlying capsule. It is my belief that the interposed Strattice may prevent the "scar rind" that I frequently see beneath the periareolar incision that is firmly fixed to the capsule. I hope this has great implications for reducing capsular contracture.

Brian P. Dickinson, M.D.
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Autologous Fat Transfer: Self Study

Adipose Derived Stem Cell Fat Transfer for Breast Augmentation

Cell-Assisted Lipotransfer for Cosmetic Breast Augmentation: Supportive Use of Adipose-Derived Stem/Stromal Cells
Kotaro Yoshimura,1 Katsujiro Sato,2 Noriyuki Aoi,1 Masakazu Kurita,3 Toshitsugu Hirohi,4 and Kiyonori Harii3
Aesthetic Plast Surg. 2008 January; 32(1): 48–55.

I have had the great opportunity to reacquaint with a mentor who has sparked my interest in the use of autologous fat transfer for breast augmentation. As I read through the selected reading articles, I have found excellent results published by Japan and Korea on the use of adipose derived stem cells of autologous fat transfer for cosmetic breast augmentation.

My interest in this grows, as I continue to having a growing group of patients who are interested in a small to modest increase in breast size and who do not want an implant of either silicone or saline. In these patients, available fat can be harvested from the lower abdomen, buttocks, and thighs and transferred to the breast for augmentation.

I am very satisfied with the results we are achieving with silicone gel implants and find that there will always be a continued role for them in women who desire a larger augmentation or require replacement of significant breast volume following mastectomy. I believe that fat transfer will not replace silicone breast augmentation, but serves as an alternative for those women who do not want a large volume augmentation and who do not want an implant based augmentation.

Brian P. Dickinson, M.D.

Family Testimonial

Testimonials from patients and family are one of the highest compliments that I could ever receive. This patient family member writes:


Dr. Dickinson,

I would like to thank you from the bottom of my heart for helping my son through this. You are an extraordinarily skilled surgeon and a very special person. You took the time to help him, not many people do that anymore. I cannot thank you enough or express what your kindness has meant to me enough. My family and I will be forever indebted to you. Please tell your staff that they are the most caring people in the world and thank them for me.

Thank you again,

-------------------

Breast Augmentation: Testimonial

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Patient testimonials are one of the highest compliments I could ever receive. This happy patient writes in her testimonial:

"This experience couldn't possibly have been any better, and bless Dr. L for referring me to you! You're the best -- Dr L told me you were going to be the next big bev hills plastic surgeon, and I think he's right.... from the first visit I felt comfortable and am soooooo pleased with my results, you have NO idea!

Every visit has been a true delight, and actually fun and entertaining (not usually the case half naked in a dr office!).... I love that I found a Doc that I didn't feel all weird with, and that I NEVER felt judged, and was always treated with the utmost respect. Thanks!;"

No Touch Teqhnique Breast Implant Delivery

I have been using the Keller Funnel routinely for my periareolar and transaxillary breast augmentation cases. The Keller Funnel allows me to deliver larger implants through a smaller incision without traumatizing the breast implant, the skin, or having the breast implant come into contact with the skin.

I believe strongly that this "no touch technique delivery system" can help reduce the incidence of capsular contracture. It is of paramount importance to me that my patients receive great results and that I try to do everything possible to minimize complications.

Brian P. Dickinson, M.D.

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Microsurgery. Nerve Repair

Microsurgical nerve repair and use of the operating microscope is a particular area of interest for me and has become a significant part of my practice. I enjoy the optics of the Carl Zeiss Pentero microscope. The Pentero provides adequate resolution for nerve repair on the magnitude of 2mm and even less.

Peripheral nerve injuries in the upper and lower extremity are common with the frequent physical activity in southern California. Activities such as biking, surfing, motorcycles, climbing, as well as occupational hazards can cause peripheral nerve injury.

In the photograph above, the blue background contains a grid with 1 mm squares, allowing the surgeon to assess the dimensions of the injured nerve.

Brian P. Dickinson, M.D.

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Revision Augmentation Mastopexy Surgery

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I have found an increasing number of women who present to my office in consultation who had saline breast implants placed ten years ago and who are now requesting removal and replacement of their mammary implants for highly cohesive silicone gel mammary prosthesis.

Often these women underwent reduction mammoplasty with an implant to maintain upper pole fullness, but now want to change to an implant with a slightly higher profile to deliver more breast projection.

We are seeing more women present from out of state who come to Newport Beach and Beverly Hills who have capsular contracture and who now want to have their breast implant capsules removed, saline implants replaced for silicone gel implants, and a simultaneous breast lift.

These operations are challenging to preserve the blood supply to the nipple areola complex as previous operations contribute to scarring and necessitate experience with these cases to deliver consistent results.

Bilateral capsulectomies, implant exchange, and mastopexy are commonly performed operations in Newport Beach and Beverly Hills.

Brian P. Dickinson, M.D.
www.drbriandickinson.com

Abdominoplasty & Panniculectomy at RoxBariatric

The post-bariatric body contouring surgery program at the Roxbury Clinic & Surgery center continues to grow with more patients enrolling in post-bariatric body contouring procedures.

Patients present to our office and are very excited about having their body contouring procedures done at either the Newport Beach or Beverly Hills, CA surgery centers.

We encourage all patients who desire to have post-bariatric body contouring procedures to bring their insurance cards with them during their consultations. It is a great time to utilize health insurance plans to undergo lap band procedures. Typically after patients undergo their lap band operation they return for their post-bariatric body contouring surgery within 9 months to one year. Patients are very happy after having their panniculectomy and abdominoplasty surgeries and greatly look forward to having their mastopexy, breast reduction, brachioplasty, or medial thigh lift.

Performing post-bariatric plastic surgery is very gratifying for the patient and physician.

Brian P. Dickinson, M.D.

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Roxbury Clinic & Surgery Center: Orbital Fractures

Orbital fractures are very common. There is an increasing frequency of orbital fractures being repaired at the Roxbury Clinic & Surgery Center in Beverly Hills, CA. Orbital fractures are becoming frequently more common in older individuals who may fall and suffer a trauma to the region of their eye.

By nature of the design of the globe and bony orbital frame, the bone tends to fracture first to prevent damage to the eye itself. Repair of the bony defect is often required for greater than 1 square cm defects and/or defects comprising greater than 50% of the floor of the orbit.

Patients who come to the Roxbury Clinic & Surgery Center in Beverly Hills to have their surgery are fortunate to have the expertise of Dr. Kami Parsa. Dr. Kami Parsa is a world renowned ophthalmologist with exceptional talent in oculoplastic and reconstructive surgery of the eye. Smaller orbital floor defects are often repaired with ear cartilage harvested from the ear, while larger defects or defects of the orbital rim often require repair with titanium mesh or porous polyethylene.

Brian P. Dickinson, M.D.

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Revision Breast Augmentation Surgery for Saline Implant Deflation

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Breast implants are medical devices and over time, like all medical devices, are subject to fatigue. Over time, the development of a capsular contracture around a breast implant can cause folds in the shell of a saline implant. Repeated creasing in the fold of a saline implant can cause the shell to fatigue and allow the saline to leak.

The leak of saline into the body is not harmful to the patient, but is nonetheless, psycholocially distressing. These patients have been coming to our office with an increasing frequency and request the removal of their saline implants for silicone implants. Often patients who have a deflation of their saline implants have had their devices for over 8-10 years.

These patients who have undergone removal and replacement of their saline implants for silicone gel implants are starting to tell their friends how happy they are with the improvement in the shape and feel of their breasts. As a result, I am seeing an increase in the number of patients who present to the office requesting their saline implants to be exchanged for silicone implants.



Brian P. Dickinson, M.D.
www.drbriandickinson.com

Strattice in Aesthetic Breast Surgery. Self-Study. Conference. LifeCell-Strattice

I had the great pleasure of attending the LifeCell educational forum this past weekend in Las Vegas, Nevada. The meeting was very helpful to solidify my experience with regenerative tissue matrices.

This conference came at a timely fashion for me as it reinforced my educational experience on the use of Strattice for revision aesthetic breast surgery in women with thinning tissues.

I have seen many women in consultation recently with fitness model physiques and a history of recurrent capsular contracture and severe thinning tissues.

As was taught to me by my mentor, the reinforcement of the thin lower pole skin with Strattice can help visible and palpable ripping in this population. The Strattice held in by marionette sutures and then sutured with long-acting absorbable will decrease the incidence of palpable rippling and may reduce the rate of capsular contracture.

Brian P. Dickinson, M.D.
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Breast Implants. Saline Implant Valve Failure with Capsular Contracture

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I am seeing more and more women in consultation in my office with deflation of their saline breast implants. In fact, twice this month we had women who presented with the development of pain around their breast implant with an associated distortion of the breast shape secondary to breast implant valve failure.

It has been my experience that the development of a capsular contracture around the breast implant changes not only the shape of the breast implant capsule complex, but may incorporate around the valve of the saline implant (as shown in the image above).

Either continued contraction of the breast capsule resulting in a change in the surface area to volume ratio and/or ingrowth of the capsule to the valve disrupts the valve and allows the saline to extravasate. These women often present with continued pain and the apparent deflation of the implant can be distressing to the patient.

In these cases I recommend that women undergo removal and replacement of their breast implants and capsulectomy. Many women are opting now to exchange their saline implants for silicone gel breast implants.After these surgeries, patients are very happy with the new contour of their implants and their pain is often markedly improved.

Brian P. Dickinson, M.D.
www.drbriandickinson.com

Rox Bariatric: A Team Effort

The Rox Bariatric program continues to grow. I was very fortunate today to hear some excellent feedback from one of our patients who is recently post-op from her panniculectomy and medial thigh lift.

She was very thankful for her results as well as to have had an excellent team of surgeons tend to her care. This group of surgeons not only pays close attention during her surgery, but also to the post-operative care that is so important to ensure proper healing.

I was truly thankful to hear how highly our patient spoke of our team of doctors. Specifically, the patient expressed her gratitude to Dr. Jay Calvert, Dr. Anita Patel, as well as the USC plastic surgery resident Dr. Joe Carey was so helpful during our case.

Dr. Patel has been taking a great interest in post-bariatric body contouring surgery and post-bariatric patients. Together with Dr. Patel, Dr. Shafipour, and the help of the USC residents we are able to provide complete and excellent care to these great patients who have lost massive amounts of weight. I am very proud of how hard our patients work to achieve their goals.

Brian P. Dickinson, M.D.

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RoxBariatric. More Body Contouring. More Patients Enroll for Lap Band.

The Rox Bariatric program continues to gain significant traction. We are seeing many patients return for the second stages of their operations. I continue to be impressed by the power of panniculectomy to facilitate weight loss.

Not only does the removal of the abdominal pannus seem to allow patients the ability to workout and exercise, but also significantly motivates them to loose weight through appropriate dietary measures.

Today in the operating room I was truly impressed with a patient who returned for her bilateral mastopexy and bilateral brachioplasty after she continued to loose weight after her panniculectomy a few months ago. I continue to be very proud of how hard our patients work to improve themselves and their health.

Brian P. Dickinson, M.D.

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The Keller Funnel for Silicone Gel Implant Delivery

Today was truly a great day of cases. As the breast augmentation, revision breast augmentation, and capsular contracture surgery practice grows, I continually look for ways to improve patient outcomes, reduce patient recovery time, reduce incision length, and prevent capsular contracture.

I have found that the Keller Funnel facilitates delivery of silicone gel implants through smaller incisions and allows me to employ a no-touch delivery technique whereby the gel implant does not come into contact with the nipple areola complex or the axillary skin when placing implants. I found that the Keller Funnel greatly facilitated today's cases and I will use it for the breast augmentation cases later in the week.

I anticipate that the no-touch delivery technique is one method to further reduce the prevalence and incidence of capsular contracture. I look forward to continued success with is device.

Brian P. Dickinson, M.D.

Deep Inferior Epigastric Perforator Flap Publications

Reconstruction of Total Laryngopharyngectomy Defects with Deep Inferior Epigastric Perforator Flaps:

Otway Louie, Brian Dickinson, Jay Granzow, J. Brian Boyd

Journal of Reconstructive Microsurgery. 25(9):555-558, November 2009

It is truly a great honor and distinct pleasure to publish in the Journal of Reconstructive Microsurgery with Dr. Otway Louie, Dr. Jay Granzow, and Dr. J. Brian Boyd. I received outstanding microsurgical training from them during my time training at Harbor-UCLA.

Brian P. Dickinson, M.D.

Self Study:Book Chapter Review Notes.

Surgery of The Breast Principles and Art Ed. Scott Spear
Chapter 33. Prosthetic Reconstruction in the Radiated Breast.

Prosthetic breast reconstruction in the radiated breast is a complex issue.

-Radiated reconstructions tend to be of poorer quality than non-radiated reconstructions.
-Radiation increases the complication rates associated with reconstructive options
-Not all radiation is the same.


The dose, location, type, and purpose of radiation substantially affects the local tissue response and thus indirectly the hospitality of those tissues to reconstructive surgery.

Radiation may be delivered to the breast under a variety of circumstances:

-As part of breast conservation treatment, along with lumpectomy and axillary sampling.
-Postmastectomy, according to the American Society of Clinical Oncology Guidelines
-Postmastectomy for a local recurrence.
-After immediate reconstruction for unfavorable tumor
-After immediate or delayed reconstruction for recurrence

If radiation prior to reconstruction:

Indications
Dose of radiation
Quality of tissues after radiation

Lumpectomy and radiation often 5,000 cGY
Patients radiated after mastectomy more likely high-dose radiation because radiation recommended on basis of extensive or aggressive disease.

Lower dose radiation: tissues look and feel reasonably normal
Higher dose radiation: tissues look tight, inelastic, thickened.

All radiation increases risk of complications.
Obvious radiation damage advised to undergo autologous or autologous assisted types of reconstruction.

Indications for radiation by American Society of Clinical Oncology:

Tumor greater than 4 cm.
4 or more positive lymph nodes
Tumor near resection margins (skin or chest wall)

Radiation dose for these indications is usually substantial 9,500 to 10,000 cGy.

Capsular Contracture: Reconstructive Breast Surgery or Revision Aesthetic Breast Surgery?

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As I continue to learn about both aesthetic and reconstructive breast surgery, I find that the same tools, skill sets, and planning that I use for aesthetic breast surgery apply to reconstructive breast surgery and vice versa.

Frequently, I see many women in consultation who have undergone first a breast augmentation, second a breast reduction, and often present desiring further reduction of their breasts or require surgery for capsular contracture.
I enjoy these challenging cases as it is important to be knowledgeable of the blood supply of the nipple areola complex, the prior surgeries, and how to most effectively manage the capsular contracture.

Women who present after numerous operations often have thinning skin or breast tissue, asymmetry, capsular contracture, or unwanted motion of the implant, and desire correction.

I have found that the breast surgery techniques taught to me by Handel have been very effective for identifying, addressing, and managing these difficult cases. Capsular contracture can be very painful for the patient and interfere with daily activities and be psychologically distressing.

The patient in the above photograph is happy with her removal of her saline implants in exchange for silicone implants, change of implant plane, nipple areola reduction, and mastopexy. The scars are still hyperemic in this early one month post-operative result. I routinely educate patients that scars tend to be the most indurated and red approximately one month after surgery and then soften as the collagen in the scar remodels.

I have found that as larger saline implants are removed and exchanged for smaller lighter silicone implants, it is easier for patients to excercise, return to the gym, and loose weight.

Brian P. Dickinson, M.D.

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Mastopexy Augmentation Reductions.

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Frequently, I encounter more women in consultation who present to my office desiring a revision of their breast augmentation from 8 to 10 years prior. Frequently these women have had saline breast implants in for almost ten years and now want to exchange their saline breast implants for silicone breast implants.

Often women who have had larger implants and now want to downsize desire to have the breasts placed more centrally on their chest wall away from their armpits, with a reduction in the size of their areola, and a lift of the breast.

Depending upon the age of the patient and whether or not she has had children and/or breast fed, the incision pattern used to make the breast appear more youthful depends upon the degree of breast ptosis. Breast ptosis or the "breast fall" can be corrected by different methods or incisions patterns depending upon the degree of breast ptosis. The youthful appearance of the breast is best corrected by the relationship of the nipple areola complex to the breast crease or inframmary fold.

I use in consultation, the breast ptosis method as classified by Regnault with modification: Grade 1 ptosis - The nipple areola complex has descend to the level of the inframammary fold. Grade 2 ptosis - The nipple areola complex has descended below the inframammary fold. Grade 3 ptosis - The nipple areola complex has descended below the inframammary fold with no lower pole tissue below nipple.

In general I have found that Grade I ptosis can be corrected with the placement of an implant and/or a superiorly placed crescent mastopexy incision. Often a Benelli type mastopexy can be incorporated to reduced the diameter of the nipple areola complex. Grade II ptosis often necessitates a vertical incision with/without a lateral limb extending from the nipple areola complex. Grade III ptosis often requires a vertical component and horizontal component(s) to make the breast appear youthful.

As one can understand from the photograph above in the after picture on the left, the breast appears more youthful based on the relative size of the nipple areola complex and its position relative to the breast crease. Furthermore the breast has been centralized with its take-off no further lateral than the anterior axillary line. This position of the breast on the chest wall facilitates physical exercise. At three weeks post-operatively, I anticipate that the scars will soften and the swelling will subside giving an even more natural and youthful appearance to the breast as time progresses. Full post-operative change and swelling takes approximately 6 months to one year.

Brian P. Dickinson, M.D.
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RoxBariatric:Putting Patients First

The RoxBariatric program continues to grow as more patients enroll for the lap band procedure. Upon enrollment patients meet with Bariatric Medicine Specialists who calculate their BMI.

BMI stands for body mass index which is in units of (kg/m ^2)

BMI (kg/m2) = Weight in kilograms/Height in meters ^2.

People with a BMI below 18.5 are Underweight.
People with a BMI between 18.5-24.9 are Normal.
People with a BMI between 25-29.9 are Overweight.
People with a BMI above 30 are Obese.

Many insurance companies will authorize lap band surgery if patients meet the following indications:
1. An individual has clinical severe obesity, BMI >40, or BMI> 35 with co-morbidities such as heart disease, diabetes, hypertension, sleep apnea, or degenerative arthritis.2. An individual has suffered from morbid obesity for at least five years. 3. An individual has failed non-surgical attempts at weight loss over the years.4. An individual is at a high-risk for obesity-associated morbidity or mortality. 5. An individual is motivated and has an acceptable operative risk.

Once individuals have had their lap band surgery, they are usually candidates for post-bariatric body contouring surgery 9 to 12 months after. I stress to the patients in our program the importance of adequate protein intake prior to their body contouring operations. For the post-bariatric body contouring patients, it is important to eat 1-2 mg of protein for every kilogram of ideal body weight (IBW) provided they have normal kidney function.

When pre-operative labs are drawn before surgery, it is optimal to have serum albumin levels between 3.5-5 g/dl. It is optimal to have serum pre-albumin levels on the high end of normal levels 17-40 mg/dl. Pre-albumin has a half-life of 1.9 days compared to the half-life of albumin which has a half life of 21 days. Therefore pre-albumin levels tend to be more reflective of the more recent nutritional protein intake.

Brian P. Dickinson, M.D.

Hand & Microsurgery:Fight Bite

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The "fight bite" injury typically occurs during altercations where the clenched fist of one individual comes into contact with the incisor teeth of another individual.

These injuries can be serious for two reasons: 1. There is often a laceration of the extensor tendon that crosses the metacarpal joint that strikes the teeth, 2. There is often an injury to the underlying joint capsule that not only causes injury to the joint capsule, but also introduces bacteria into the joint.

I prefer to treat these injuries in stages, with the first stage being washout, irrigation, debridement of the joint followed by antibiotics. Once there has been no declaration of infection I find it safe to proceed with repair of the extensor tendon. The goal is to minimize extensor lag and permit full flexion of the digit.

Brian P. Dickinson, M.D.
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Hand & Microsurgery: Flexor Tedon Injuries

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While I enjoy all aspects of plastic and reconstructive surgery, hand and microsurgery are particularly enjoyable as the anatomical dissections closely resemble the diagrams in the text books. In fact, surgery of the hand is what stimulated my interest in plastic & reconstructive surgery. I find that I use mostly the techniques taught to me by Dr. Miachael Hausman, Dr. Prosper Benhaim, and Dr. Neil F. Jones.

I find that studying and performing surgery of the hand, improves techniques for microsurgical breast reconstruction and vice versa.

It is important when repairing flexor tendons in zone II of the hand, to preserve the A2 and A4 pulleys. After fenestrations have been made in the synovium between the pulley system of the hand the injured flexor tendon can be easily identified. Occasionally I have found that the cruciate pulleys often need to be partially excised so that adequate purchase can be made on the flexor tendons to ensure a strong and durable repair.

Immediate post-operative mobilization with the Duran protocol is important to ensure adequate flexor tendon gliding.

Brian P. Dickinson, M.D.
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Breast Augmentation Porportion

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I find that the most important aspect of breast augmentation, is that the operative plan needs to be individualized for each patient. I have found that different breast implant profiles work very well and can produce a similar aesthetic look depending upon the anatomic dimensions of the patient and tissue characteristics.

It is important when operating on a patient with a short nipple to inframammary fold distance to select a breast implant that not only is proportionate to the base diameter, but also to the breast height. While it is important to maintain superior fullness of the breast it is important that the "take off" of the breast contour is not placed to superiorly or that the chest to breast angle is not too acute.

This patient is very happy with her breast augmentation as her breast/waist/hip ratio is in better proportion. Selection of appropriate breast implant size and dimension is paramount to an optimal outcome.

There are three different dimensions and profiles of breast implants. Mentor corporation makes a moderate, moderate plus, and high profile silicone gel breast implant. Allergan produces a style 10, style 15, and style 20 for their breast implants. These labels respectively correspond to breast implants with increasing projection to base diameter ratios.

Brian P. Dickinson, M.D.

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Breast Reconstruction Post-Op Protein Requirements.

Proper nutrition should be an important part of everyone's daily life. Both aesthetic and reconstructive surgery place an increased metabolic demand on the body. It is important both pre-operatively and post-operatively to ensure adequate protein intake before and after surgery. Frequently nutrition comes up in consultations, so I have included below a standard post-operative diet protocol as well as an easy method for patients to understand the amount of protein they will need post operatively.

The post-operative diet below is for tissue expander/implant reconstruction. It is modified for TRAM, DIEP, and SIEA reconstructions.

Post-Operative Breast Reconstruction Diet Protocol Pathway

Post-Op Day 0

Clear Liquid Diet as Tolerated.

Post-Op Day 1

Regular Diet. Ensure 1 can three times per day between meals.

Post-Op Day 2

Regular Diet. Ensure 1 can three times per day between meals.

Discharge Diet:

Breast reconstruction surgery is very energy consuming to the body. There is also protein loss from drain output. It is important to maintain a high protein diet for two to three weeks post-operatively to maximize healing.

Regular Diet high in protein + Ensure three times/day between meals.

Goal is to eat 1 gram of protein per kg of bodyweight:

For example, if your body weight is 140 lbs, then your weight in kg is 140/2.2 or 63 kg. Therefore, patient with normal renal and liver function should eat at least 63 grams of protein per day.

Ensure 1 can: 9 grams of protein
Glucerna 1 can : 10 grams of protein

Therefore, three cans give you 30 grams of protein.

1 can of tunafish contains approximately 25 grams of protein.

or

1 chicken breast contains approximately 30 grams of protein.

Breast Reconstruction Post-Op Pain Protocol

Post-operative patient comfort is of paramount importance in breast reconstruction following mastectomy. Controlling pain can be challenging for both the patient and surgeon. The patient's goal is to have a pain score of close to zero. While this is also the surgeon's goal, many of medications used to treat pain may contain their own inherent undesirable sequelae such as nausea, vomiting, insomnia, hives, disorientation, etc.

I have found that using several different medications that work on slightly different pain receptors or that have slightly different pain targets to be the most effective. I have posted the following pain protocol pathway that I am currently using so that patients can know what to expect during their hospital stay. If significant side effects occur from the pathway or the pathway is not effective, adjustments can be made accordingly based on age, allergies, weight, and renal function.

Pre-operatively:

Emend 40 mg by mouth with a sip of water the morning of surgery to prevent nausea.

In Hospital Pain Regimen:

Post-Op Day 0:

Toradol: Loading Dose 30 mg IV x 1 then:
Toradol: 15 mg IV 4 times per day x 48 hours.
Dilaudid PCA pump. PCA. Patient controlled analgesia. 0.2 mg IV every 6 minute lockout for max of 2 mg/hr.
Diazepam 5 mg by mouth every 6 hours as needed for muscle spasms (tissue expander reconstruction)

Post-Op Day 1:

Continue Toradol 15 mg IV 4 times per day
Dilaudid PCA pump. PCA Patient controlled analgesia for ½ day with transition to:
Percocet 5mg/325mg i-ii tabs by mouth every 4 to 6 hours as needed.
Diazepam 5 mg by mouth every 6 hours as needed. (tissue expander reconstruction)
Colace 100 mg by mouth twice a day.

Post-Op Day 2:

Discontinue Toradol IV and transitio to Toradol Oral 10 mg po qid
Percocet 5mg/235 mg i-ii tabs by mouth every 4 to 6 hours as needed.
Diazepam 5 mg by mouth every 6 hours as needed. (tissue expander reconstruction)
Colace 100 mg by mouth twice a day.

Discharge Medications Home:

Percocet 5/325 mg i-ii tabs by mouth every 4 to 6 hours as needed.
Diazepam 5 mg by mouth every 8 hours as needed. (tissue expander reconstruction)
Ambien 10 mg by mouth at night as needed for sleep.
Colace 100 mg by mouth twice a day.

Brian P. Dickinson, M.D.

www.drbriandickinson.com

Capsular Contracture Treatment

Capsular contracture symptoms usually begin with the patient noticing a distortion of their breast implant shape or the beginning of an occasional pain around the implant or the breast.

To explain the changes in the shape of the implanted breast with the development of capsular contracture it is important to understand the following:

Most breast implants while they may vary slightly depending upon profile are the shape of a disc. When the lining around the implant starts to aggressively contract symmetrically, the shape that forms is a sphere. Now the breast implant which was once a fixed volume in a defined surface area is now changed to the same volume being compressed into a smaller surface area by the capsular contracture. This change not only distorts the augmented breast, but the augmented breast also becomes firm. This firmness can cause capsular contracture symptoms such as sharp pain, dull pain, pain with movement of the breast, or with exercise. When the capsule implant complex becomes painful, the patient has developed a Baker IV capsular contracture.

Typically in these patients, my preferred method of capsular contracture treatment is total "en bloc" capsulectomy so that the entire capsule and implant contents can be removed in their entirety. Removal "en bloc" allows for an optimal plane with which to attempt implantation.

In the picture shown above, the one appreciates the spherical shape of the hard capsule lining which has compressed the discoid silicone implant. In this case the silicone implant shell was ruptured with the silicone remaining within the capsule.

I will continue to research capsular contracture treatment and prevention.

Brian Dickinson, M.D.
www.drbriandickinson.com

Capsular Contracture and Saline Implant Valve Failure

http://www.drbriandickinson.com/

There are an increasing number of patients who come into my office for consultation regarding capsular contracture pain. Recently, I am seeing more patients come to both the Beverly Hills and Newport Beach offices from the South, Midwest, and East Coast with capsular contracture symptoms.

Frequently these patients present with signs and symptoms related to their capsular contracture such as change in shape of their breast, asymmetry, pain, and more frequently I see women who present with malfunction of their saline breast implants. Occasionally if saline implants have been in place for a long period of time, the shell may undergo “fold flaws" and rupture at the weakest location of the shell.

Most recently, I have seen several cases where a capsular contracture has started to cause breast pain and soon after the patient experiences a deflation of their saline implant. While the leakage of saline does not cause any physical harm to the patient, it is nonetheless very distressing and post rupture may cause more pain to the patient.

In a recent case, as depicted above, I noticed that a small portion of the capsule had grown into the saline valve. While I cannot prove this, I believe that the continued pain experienced by the patient is the adherence of the capsule to the chest wall, muscle, or skin and the mobility of the ruptured implant within the capsule lining.

This motion with exertion, movement, etc. can be extremely painful to the patient and warrant surgical removal and replacement of the mammary prosthesis. More frequently, I am seeing more patients from outside of California who present with either Baker Grade IV capsular contracture or Baker Grade III capsular contracture who also have a malfunctioning of their breast prosthesis. Capsular contracture surgery is frequently performed at both the Beverly Hills and Newport Beach, CA surgery centers.

Brian P. Dickinson, M.D.

http://www.drbriandickinson.com/

Surgery After Weight Loss: RoxBariatric

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The RoxBariatric post-bariatric plastic surgery program continues to grow and expand. Post-bariatic body contouring surgery is becoming very popular as we are seeing patients not only from Southern California, but now patients from the Midwest who travel to Beverly Hills and Newport Beach to have their post-bariatric surgery performed. More patients are coming to the RoxBariatric Center to meet our team of plastic & reconstructive surgeons and then be introduced to a bariatric surgeon who will perform either a lapband procedure or gastric bypass procedure.

Occasionally, in patients who undergo bariatric surgery or simply loose weight through a bariatric diet, they develop excess of overlying abdominal skin termed a “pannus”.

Patients are coming to the RoxBariatric Plastic Surgery Program from out of state to have their panniculectomy or body contouring surgery performed by our team of plastic & reconstructive surgeons.

Insurance companies will pay for patients to have a panniculectomy performed or removal of this overhanging skin as long as certain criteria are met that deem the procedure medically necessary. These criteria include:

1. Panniculus hangs below the level of the pubis; and
2. Patients have chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs for a period of over 3 months while receiving appropriate medical therapy, or remains refractory to appropriate medical therapy over a period of 3 months.
Frequently patients with subcostal scars present for these operations. Subcostal scars are normally right sided scars used to remove the gallbladder. We have seen many patients who have been turned away for abdominoplasty or panniculectomy operations due to the presence of these scars.

These operations can be performed, but need to be performed carefully by plastic & reconstructive surgeons who have demonstrated experience in these operations to ensure proper wound healing. When addressing panniculectomy or abdominoplasty in these patients it is important to respect the remaining blood supply to ensure rapid healing and prevent infection. Adequate nutrition is paramount for proper wound healing.

Brian P. Dickinson, M.D.

http://www.drbriandickinson.com/

RoxBariatric Health & Lifestyle Program

The RoxBariatric program continues to grow with as the most recent five patients who underwent lap band procedures continue to loose weight. We are starting to see not only significant reduction in weight of these patients, but ancillary physical signs improve as well. Notably one patient has lost a significant amount of weight in his neck and no longer snores at night. Not only has this improved his sleep patterns, but also those of his spouse.

Bariatric patients often loose greater than 100 lbs of weight over the course of six months to one year post surgery. Not only do these patients desire body contouring surgery, but also rejuvenation of their face and neck. I have found that facelift and necklift techniques provide a significant change in the facial aesthetics and be quite rewarding to these patients.

Traditionally when body contouring and facelift procedures, our patients stay over one night at an aftercare facility where they are examined by a physician that evening and the next morning at the aftercare facility or at the office.

RoxBariatric Health & Lifestyle Bariatric Program

Post-Bariatric Body Contouring Surgery is very rewarding to both the patient and Plastic & Reconstructive Surgeon. It is truly a great to be a part of the RoxBariatric program in Beverly Hills, CA. The RoxBariatric program is a Comprehensive Health & Lifestyle program initiated by Plastic & Reconstructive Surgeons and Bariatric Medicine Specialists.

Many patients ask me, Dr. D. what is bariatric surgery?

Bariatric surgery, or weight loss surgery, are procedures performed on people who are dangerously obese, for the purpose of losing weight and improving their overall health. Weight loss is achieved by reducing the size of the stomach, through removal of a portion of the stomach, or by resecting and re-routing the small intestines to a small stomach pouch. These procedures are called gastric banding, sleeve gastrectomy, or gastric bypass surgery, respectively. Not only can these surgeries produce significant long-term loss of weight, but also improve diabetes, lower blood pressure, improve cardiovascular risk factors, and reduce mortality.

Many patients then ask me, Dr. D. can bariatric surgery be covered or partially covered by my insurance?

Generally insurance will assist in covering these procedures for obese people with a BMI over 40 or people with a BMI of over 35 with coexisting medical conditions.

Finally, patients will ask me, Dr. D. can the post-bariatric body contouring procedures be covered or partially covered by my insurance?

Patients who have bariatric procedures loose over 100 lbs of weight and are left with excess skin that they find impossible to loose. Occasionally, the abdominal skin that overhangs the pubis can cause rashes in the area between the skin. Typically, if patients have these rashes and they are not relieved by prescription medications or other conservative measures to treat them for over six months, then insurance will cover or partially cover a panniculectomy. A panniculectomy is the removal of the overhanging skin or pannus. Other post-bariatric procedures may be covered or partially covered by health insurance or patients may pay for these procedures out-of-pocket. The RoxBariatric program is unique in that patients develop a relationship primarily with the Plastic & Reconstructive surgeons who will be performing their post-bariatric body contouring procedures. The initial consultation into the program includes a consult with a plastic & reconstructive surgeon as well as Dr. Pouya Shafipour and his colleagues who are Bariatric Medicine specialists. Once patients are deemed physically fit for surgery, they undergo their lap band or gastric bypass procedure. The patients are closely followed by the physicians and physician assistants at RoxBariatric to guide them through their weight loss to their post-bariatric body contouring procedures.

I am frequently asked, Dr. Dickinson-What can I do nutritionally to prepare for surgery?

Post-bariatric body contouring procedures are significant surgeries that require a lot of energy expenditure for the body to heal. I typically tell patients to eat one to two grams of protein per kilogram of body weight 4 weeks prior to and 4 weeks after surgery to optimize their healing. This diet improves outcomes and prevents wound complications.