Craft MD

Buying something for son

Disclosure first. That’s Dr. Anderson, who does injectables in my practice, and this is the setup we charge for. Read the rest knowing that.

The patient came in with a Sculptra nodule she wanted broken up. Sculptra isn’t hyaluronic acid, so there is no enzyme that dissolves it. The tool is saline, injected into the nodule to disperse it. On the screen behind him is her face under ultrasound, in real time. The nodule is the dark shape. The pulsing line beside it is an artery.

They are closer than anyone injecting by feel would guess. That’s the whole video.

Every injection into a face is a bet about where the vessels are. Anatomy diagrams show the average. Nobody is the average. Ultrasound shows the actual artery, in the actual patient, while the needle is moving. That applies to placing filler, dissolving filler, and treating what filler leaves behind, even when the only thing in the syringe is salt water.

Here is what the evidence does and doesn’t say. For treating a vascular occlusion after it happens, ultrasound-guided hyaluronidase has a strong track record across dozens of published cases. For preventing one, nobody has run the trial comparing guided to blind injection. What ultrasound gives you is not a statistic. It’s the picture. If you can see the artery, you can go around it.

Ask your injector one question: how do you know where my vessels are? “Experience” is an answer. It’s not the best one available.

Disclosure first: I do the alternative. Fat under the chin gets liposuction in my practice, under direct control, in one session. I make money when you choose that over a syringe. Read the rest knowing that.

I have never used Kybella for the one thing it’s approved for. Not because it can’t dissolve fat under a chin. It can. Because I’d rather decide exactly where fat comes out than inject a detergent and wait to see what else it reaches.

What I have seen is the other end: patients injected somewhere it was never approved to go, sent to me with the result.

That’s the FDA’s page behind me. Last month they added two things to the label.

One. Since 2015, 129 reported cases of adverse events from injection outside the under-chin area. Blurred or reduced vision when it went near the eyes. Nerve and muscle injury. Facial weakness. Numbness. The label now says don’t.

Two. 117 cases of nodules or masses that hadn’t gone away, present for an average of about five months when reported. Those happened with approved use too.

This is a label update, not a recall. Used where it’s approved, by someone who can manage what goes wrong, it’s a legitimate option. I’m not that someone, by choice. The patients I’ve met weren’t that patient.

Ask what’s being injected, where, and who handles it if it doesn’t go to plan.

I love him so much. But sometimes it’s Montreal versus Boston in here.

Offsetting majors. By dinner neither of us remembers the infraction. He started it.

For the record, nobody drops the gloves. I’m a plastic surgeon and I don’t generate my own referrals. He’s an anesthesiologist and could end any argument in about forty seconds. So far he’s shown restraint.

If you’ve seen Heated Rivalry, you know how these rivalries get settled. Same.

To be clear: the b**r.

Being his dad is the best thing I’ve ever done. Somewhere along the way it also became the thing the rest of my life is organized around. Nobody warns you about that part. I wouldn’t change it.

I’m also good with one. He gets all of me, and I still run a practice, make it to the gym, and occasionally finish a sentence. Add a second and something has to go. Probably the sentence.

He’s a limited edition. The b**r is on tap.

Youn Stitch Reel

Gynecomastia. Same man, six months apart. Frontal, 45, lateral.

He'd done the work. Lean, training for years. The chest didn't move because it was never fat. It was gland, and gland doesn't answer to a deficit.

This is how I do it. Liposuction first, to take the fat around the gland and feather the edges. Then direct excision of the gland itself through a small incision at the lower edge of the ar**la. Then I stop early. I leave a disc of tissue under the ni**le on purpose, because taking all of it is how you get the crater: a ni**le sitting in a dent, which looks worse than what he walked in with and is much harder to fix. Then Renuvion under the skin. Helium plasma, subdermal, to tighten what lipo loosened. It's the one add-on I've kept.

It's common. Somewhere between a third and two thirds of adult men have palpable breast tissue depending on whose series you read. Most never mention it. The ones who do have usually spent years assuming it was their fault.

Photographs unretouched. Exposure and background matched between sessions. Face cropped by patient request, tattoo kept by patient consent.