Monthly Archives: June 2015


Every so often a patient will ask me if they need antibiotics before their surgery.  I think part of it is out of fear of getting an infection which can be devastating.  The rules have changed.  There was a recent article in the white journal that was a review of 4300 articles.  The results of this exhaustive review was that in the majority of cases NO antibiotics are needed.

Clean surgery with the exception of Cosmetic Breast Surgery do not benefit from antibiotics. Contaminated cases II, III and IV benefit from antibiotics.  Usually, the antibiotic was given as a single dose pre-operatively.


Who Is Administering Your Botox? Why Credentials Matter.

NBC’s recent story, about the major consequences of seemingly minor facial treatments calls our attention to a scary but true scenario- doctors you trust for significant care in certain areas of your life –from dentistry to internal medicine–are not likely the best option to administer facial Fillers or Botox. But until you know what qualifications to look for, you may be swayed to get an enhancement at the hands of a Botox novice.

To gain some perspective on what we should look for when considering Botox and other facial fillers, Michael C. Edwards, MD, FACS, the president of the American Society for Aesthetic Plastic Surgery gives us the basics on why credentials matter, even for routine aesthetic enhancements.

Mary Joan Cunningham: What have you seen as the most common negative results when someone receives Botox from an unqualified medical professional?

Dr. Edwards: The goal of Botox treatment is to relax the specific facial muscles in a manner to soften lines from muscle action and even lift the eyebrows a bit with proper placement. Treatment by an unqualified injector can lead to dropping the eyebrows, one or both sides, making some patients feel they look worse than they did before. Also, treating too close to the mid eyebrow can lead to a sagging or lazy eyelid called ptosis. These things can happen in the hands of a qualified injector, but I think you can feel confident the incidence will be rare.

Mary Joan Cunningham: Dr. Edwards, in your post about the difference between cosmetic and plastic surgeons, you explained that Plastic Surgeons receive far more training and have a deep knowledge of their specialization. While we understand why that is important when undergoing major surgery, does that carry a benefit for those only seeking Botox or fillers?

Dr. Edwards: Botox treatment should not be equated with surgery and although the laws differ state to state, there are differing levels of injectors (nurses to physicians of different specialties). If a doctor goes to a weekend course to bring this into their practice as a financial supplement, they should have a solid knowledge of the anatomy and action of the treatment administered. They should also have an understanding of potential risks and possible complications so they can recognize and treat these if they were to occur.

Mary Joan Cunningham: With that in mind, should patients seek out a member of ASAPS when choosing who to administer Botox injections?

Dr. Edwards: They can be rest assured that members of ASAPS have a detailed and comprehensive training about facial anatomy. Patients should feel confident seeking care from a board-certified plastic surgeon, facial plastic surgeon, occuloplastic surgeon and dermatologist.

Mary Joan Cunningham: What do you hope that those curious about Botox will take away from this interview?

Dr. Edwards: That they will realize Botox is a medication with intended positive effects. There are virtually millions of very happy and satisfied patients who undergo treatment every 3-6 months. Everyone should do their homework and seek out care from a properly trained and credentialed board-certified plastic surgeon, facial plastic surgeon, occuloplastic surgeon or dermatologist.

Want to know what specific questions to ask? Check out my interview with Miami’s Dr. Adam Rubinstein

Not all health care professionals administering Botox have the same credentials and experience with facial muscles. Remember, this is the only face you have. Choose wisely.


Cellulite is a perplexing problem that affects millions of women. It is a genetic condition that affects the connective tissue of the individual that pulls down on the skin creating divots or dimples. At the 11th annual Las Vegas Cosmetic Surgery show Dr. Jason Emer, a Dermatologist from Beverly Hills, echoed what so many of us have said – at this moment in time there is NO real cure for cellulite.

There are non-invasive technologies such as radio frequency that can improve the appearance of cellulite but none are curative. These non-invasive technologies manipulate the soft tissues whether through radio frequency, heat, suction, rolling, whatever. Some current treatment modalities include cellulaze or cellfina but I think people need to understand going into it, it is expensive and temporary. But in the end it is I guess kind of like Botox.


It is so ironic how trends change – whether it is in fashion – skinny tie trends then fat ties – short hemlines then longer hemlines –  liposuction and fat removal were the craze but now that’s reversed.  When I went to the Cosmetic Surgery meeting in Montreal, fat grafting and fat augmentation were the “hot” new procedure.

We are now adding fat to the face, the breasts and the buttocks.  Another new procedure on the horizon is labioplasty which is the removal of excess labial tissue.  Old standbys such as Breast Augmentation still are very popular.


There was a recent study done to investigate the incidence of galactorrhea and galactocoel following Breast Augmentation.  The study involved 832 patients.  In this group 8 patient’s experienced galactorrhea.  They all wre bilateral and 3 presented with a galactocoele.  Using a peri-aerolar incision increased the incidence.

The average time from surgery to occurrence was about 18 days.  The main culprit is increased production of prolactis which is a hormone that leads to increased milk production.  If there is an increase in prolactin levels use a dopomine agonist such as bromocriptine.  Usually galactorrhea is bilateral with a milky discharge.  Aspiration of a galactocoele may be necessary.  Usually with appropriate therapy patients return to normal in a matter of weeks.


Often times I’m faced the dilema in a patient who wants a facelift or ANY Cosmetic Procedure but are on blood thinners like Plavix or Coumadin. I read an interesting study designed to answer the question; do patient’s on blood thinners experience a higher rate of complications following a face lift versus patient’s who do not. The study looked at over 9200 Surgical Procedures.

They looked at patients who received peri-operative anti coagulants such as Plavix or Coumadin versus those who received none. Patients on ASA had no ill effects while patients on coumadin did show some increased peri-operative bleeding and post op infection. However, serious complications such as flap necrosis or wound separation did not occur which would require a return to the operating room. But in my opinion if they can safely be discontinued before surgery than I think they probably should.


What is a Composite Breast Augmentation?  It is placement of an implant – silicone or saline – with transplantation of the patients own fatty tissue.  I have done this now several times and it really does make a difference in that the result is more natural.  The added benefit is you get a little extra fat taken off another area.  Like a two for one!

I recently read an article from a Dr. Francisco Bravo in Madrid Spain who wrote about sternal fat placement.  One of the things women want in a breast aug is nice natural cleavage.  By adding fat to the space between the two Implants, this transition zone can be  made to be more natural.  I have done this several times and it is a nice adjustment to breast augmentation.