Monthly Archives: April 2013

Natrelle 410 Breast Implants in Modesto for Breast Enlargement

Natrelle 410 certified Surgeon - Dr. Tammy Wu, Modesto, CADr. Tammy Wu, Board Certified Plastic Surgeon, was the first Breast Augmentation Surgeon in the Central Valley to be certified to use the Natrelle 410 Breast Augmentation Implants.  She told me that it really is no big deal to have been considered the first.  She said that she was sitting at her computer when a regional-wide email was sent out to all the plastic surgeons in the area.  She just happened to have opened up the email and clicked on the link for the certification on-line course.  When she finished the course, she received a friendly email from the Breast Implant Representative from Allergan that she was the first person to successfully finish the online course and receive official certification to use the implant.

This blog is written by Dr. Calvin Lee, MD.  It is meant to be a self-educational note taking blog for Dr. Calvin Lee to help understand Dr. Tammy Wu’s plastic surgery practice.

Natrelle certificate Modesto

Dr. Wu’s Natrelle Certification from Allergan Academy.

ALLERGAN ACADEMY’s mission is to educate through a unique forum which reinforces product knowledge, encourages practice innovation & allows for the exchange of ideas.

Natrelle 410 Breast Implant Schematics

Natrelle schematics - side view of the breast implant (style 410)

NATRELLE® 410 Breast Implants incorporate orientation marks on the anterior and posterior sides
of the shell surface to assist in aligning the implant vertically in the pocket. Two orientation marks
are present on the anterior side of the implant in the lower pole. Depending on the style, there
will be either 3 or 4 orientation marks on the posterior surface of the implant.

What is the Natrelle 410 Breast Implant?

  • Highly cohesive Anatomically Shaped Silicone-Filled Breast Implants
  • An alternative to round implants
  • More true to the shape of a woman’s breast
  • Approved by the FDA on February 20, 2013
  • Made by Allergan (the makers of Botox, Juvederm, Latisse, Tazorac and much more).
  • Natrelle has a landing page for these implants.
  • It has a gradually tapered slope – thus called “shaped” rather than “round” implants.
  • The highly cohesive nature of the gel holds together and no gel migration has been observed through 7 years in ruptured implants.
  • According to their website, The Natrelle 410 breast implant has a 69% lower capsular contracture rate than Natrelle Round Silicone Filled Implants at 6 years.
  • Allergan has a directions for use webpage for surgeons on this implant.
  • Indicated for women age 22 years or older.
  • The highly cohesive gel has also been called the gummy bear breast implant
  • Reasons to avoid the Natrelle 410 Shaped Highly Cohesive Breast Implant

Natrelle Dimensions

  • The breast implant comes in many different sizes
Natrelle breast implant 3 dimensions

Natrelle width, height, and projection variables


Allergan Natrelle410 - choices of breast implant sizes


Visit Dr. Tammy Wu’s Breast Augmentation webpages for more info


Bits of info about Retin-A (Tretinoin)


Just reading for myself to review some information for myself about Retin-A (Tretinoin).  I was curious to see what info is out there and here’s some info that I gleaned from an article in the NY times, supplemented a bit with my own knowledge.  I’m always bombarded with questions and patients with different brands at our Modesto, CA office location.  Retin-A is a brand name for the chemical name:  Tretinoin or Retinoic Acid.  Derived from Vitamin A.

Other brand name Tretinoin formulations:

  • Retin-A
  • Retin-A Micro
  • Renova
  • Avage
  • Tazorac
  • Aberela
  • Airol
  • Atralin
  • Avita
  • Retacnyl
  • Refissa
  • ReTrieva
  • Stieva-A
  • Vesanoid

Retinol and Retin-A (tretinoin) are not the same thing.  Retinol is a much less potent cousin.

  • Retin-A requires a prescription, Retinol does not.

The New York times talks about “crystal-clear demonstration…”

“To my knowledge, this is the only drug for which there has been crystal-clear demonstration that it works on the molecular level,” said Dr. John J. Voorhees, the chairman of the dermatology department at the medical school of University of Michigan”

Retin-A (Tretinoin) is used for:

  • Diminish Acne
  • improve skin texture
  • diminish wrinkles
  • fade brown spots
  • fade freckles

“There is so much historical evidence that this ingredient works better than anything else,” said Dr. Joel L. Cohen, clinical assistant professor of dermatology at the University of Colorado and a consultant for OrthoNeutrogena, the maker of Retin-A Micro. And the effects are more than superficial. “It actually works to remodel skin on a cellular level,” Dr. Cohen said.

Helping to normalize cells:

Skin cells contain retinoid receptors that help regulate how the cell functions. As people age, their cells behave more erratically. “But consistent use of Retin-A helps normalize the cells,” said Dr. Min-Wei Christine Lee, a dermatologist in Walnut Creek, Calif.


Retin-A does double duty in helping to boost collagen. According to research at Michigan, it has the potential to stop photoaging before it starts. “The retinoids prevent the rise of collagenase after UV exposure,” Dr. Voorhees said. Collagenase is what breaks down collagen.

But regular use of a retinoid product also increases the amount of new collagen formed, research has found, and that new collagen will last for years.

Not just cosmetic – it treats pre-cancerous lesions too

The results are not just cosmetic. Dr. Voorhees said that retinoids have been used to treat precancerous skin cells. Studies show that after two years of use, those abnormal cells returned to normal.

So if Retin-A is so effective and so well studied, why isn’t everyone using it? Many dermatologists blame a lack of patient education. “It’s one of the most misunderstood drugs,” said Dr. Kenneth Beer, a dermatologist in Palm Beach, Fla., and a clinical investigator for Allergan, the maker of prescription Avage and Tazorac. He is also an Allergan shareholder. People use Retin-A too much, use it too often, experience negative side effects and then give up on it too soon, doctors say.

The problem with Retin-A is that it may actually make skin look worse — with redness, flakiness and peeling — for up to eight weeks. “But by 24 weeks, patients will see dramatic, marked improvements,” Dr. Lee said.

We found this same thing.  Most of our patients will have dry skin, some redness, and mild peeling for about 2-3 months first before seeing the full benefits.

25 years old – but still the best:

“I can’t say there’s anything on the horizon that will rival Retin-A,” Dr. Cohen said. “It’s exciting to see all the research going into this area, but kind of funny that the thing we’re still recommending most is something that’s 25 years old.”


We carry several formulations of Retinoic Acid / Tretinoin in our office:

  • Mainly Obagi 0.025%, 0.05%, and 0.1% strengths

Our Modesto Plastic Surgery office is Surgical Artistry, 2336 Sylvan Ave. Suite C, Modesto, CA 95355.  Tel 209-551-1888.




1 hour Lecture by Grace Nadolny, MD on 4/20/13 in Modesto, CA, CME provided by Sutter Gould Medical Foundation as part of it’s Subspecialty Lecture Series.  4 hours total of CME was provided.  Part of the 4 hours of CME included discussion about back pain and ovarian cancer.

Why this is interesting to me

  • I have learned some of this before in my NeuroScience years at Brown University.  It was good to review.
  • I have an acupuncture practice which has a good number of patients with depression.

Learning points (not all points were made in the lecture, but they were learning points for me):

Evidence Based medicine supported treatment of depression

  • includes the use of methylphenidate, exercise, and sertraline


  • Ritalin
  • NE and DA reuptake inhibitor.  (Norepinephrine adn Dopamine)
  • Psychostimulant
  • Used for ADHD, Narcolepsy, and Depression


  • Also known as Zoloft, Lustral
  • SSRI – selective serotonin reuptake inhibitor


  • Population affected: 20%
  • Depression is a state of chronic stress
  • CV risk
  • Diabetes risk
  • Anatomically there is decreased amount of gray matter in the brain.  Decreased size of  Cortex and Hippocampus has been found.


The hippocampus is involved in several functions of the body including:

  • Consolidation of New Memories
  • Emotional Responses
  • Navigation
  • Spatial Orientation

Current concepts of depression

  • glutamatergic theory of depression: exposition to stressful stimuli increases hippocampal glutamatergic neurotransmission and triggers excitotoxic changes.
  • Another theory: depression is closly correlated with neuronal atrophy due to a decrease in BDNF (Brain Derived Neurotrophic Factor)
  • Monoamine hypothesis is considered old school:  deficiency in monoaminergic neurotransmission.  Monoamines being Catecholamines (NE, DA) and Indolamines (5-HT).

Results of Star*D Trials

Sequenced Treatment Alternatives to Relieve Depression

  • Officed based – what is done after a patient fails first line treatment for depression?
  • Level 1 through Level 3 choices in medication to switch to.

After the lecture:  What about Acupuncture for Depression?

I asked Dr. Nadolny about what she thought of acupuncture for depression.  And she seemed very excited.  She said that she didn’t know that acupuncture was readily available in Modesto, CA.  I do hope to recommend some of my patients to Dr. Grace Nadolny in the future and other psychiatrists too, because I feel that at times combination treatment with acupuncture and excellent psychiatric care would be of greatest benefit.

Disclaimer:  I am not an expert on the topic of Depression.  These are notes from a lecture that I took and feel free to use this as a springboard for your own studies.


No need to go to Harvard University for a great education!

Our education is what we make of it

Granted, going to a place like Harvard has its benefits.  There’s the prestige, and there’s the opportunities, resources, and networking.

But all those great educational things that are associated with Harvard are available elsewhere.

I had my chance to go to Harvard and I turned it down.  They were very gracious in giving me an opportunity.  But I felt that there were also many other great school out there that suited my style better.  I wanted to give myself a great education, and I felt that education is what I made of it for myself and I didn’t need the oldest university in the US to feed that to me.  Plus great universities aren’t about spoon feeding info.  You have to go out there and get it yourself.

Never before has there been so much information available to us at our fingertips.  If we want the best education for ourselves.  We already have that staring right at us.  Let’s just take advantage of it.  And there’s always more effort that we can put into taking charge of our own education.

You don’t need Harvard for that.

Most of the great Harvard graduates are great, not because Harvard made them great.  I would say that it’s because these folks were able to take the bull by its horns and educate themselves and make connections for themselves and transform habits for themselves that lasted a lifetime.  They didn’t need Harvard either.  But they happened to enjoy going to Harvard as part of their journey in life.  Good for them!

Don’t get me wrong, I love Harvard.  I even spent some time studying at Harvard, and one summer I was concertmaster (violin) of the Harvard Summer Orchestra.  Many of my good friends are from Harvard.  But I’ve had a few students I’ve known who were heartbroken about not getting into Harvard.  I have been on the admission side (interviews) for another Ivy League school, I know that the decision making process is a tough one and not always perfect.  And I would say the same with changing the title of this blog entry to “No need to go to Brown, etc.”  But I still think a college education is worthwhile for personal growth and opportunities – and once at college, there are so many opportunities which we need to actively seek out.  That’s what “Education is what we make of it” means.

And I try to tell all this above to myself, and I felt a need to write it out.  This way, I hope to continue my own active education with the resources which are available to me.

Let me know what you think.

What is CME?

CME stands for Continuing Medical Education – for doctors.  It’s what’s called lifelong learning.

Certain boards, such as the American Board of Surgery, require it a minimum amount every so often to keep up with certification.

Most doctors do it because they value lifelong learning.

In general I use Continued Education loosely to mean any sort of effort that improves myself as a doctor or as a human being for that matter.

CME in this world stands for a specific form of Continuing Education, and to be deemed official CME, it is regulated by the AMA and the ACCME (Accreditation Council for Continuing Medical Education)

Then officially CME is separated into Category 1 and Category 2 and then there are self assessment variations of Category 1.

CME credits are for M.D.’s and D.O.’s only, and are designated on an hour for hour basis (minus social activities and breaks). Continuing Education Units (CEUs) can be provided to others and are designated as 1/10 credit per 1 contact hour. There is often concern about this “value” difference, but 1 hour of AMA category 1 credit (CME) and 1/10 Continuing Education Unit (CEU) represent the same 1 hour of contact.

For me, learning is more for myself and not for any other organization, but all these great organizations put together great official CME learning opportunities which I’m happy to be a part of.

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