Each year, hundreds of thousands of people around the world are rushed to emergency rooms with serious and even life-threatening injuries, all caused by a common offender: kitchen knives. Here in the United States it is estimated that around 500,000 people a year are treated for accidental hand lacerations due to kitchen knives, accounting for a staggering 42 percent of all hand injuries treated in the ER. For many of those patients, the ER isn’t their last stop. Many of those patients will end up at their local plastic surgeon’s office attempting to repair the permanent scars and tendon damage left behind from their injury.

Since the mid-1990’s, one of the most common foods to send patients to the hospital with hand injuries is the bagel. In fact, bagel related injuries are so common, they earned their own acronym, BRI’s. However, a new food may be poised to steal the laceration injury throne from the bagel: the avocado.

Avocados may seem innocent enough, with their semi-soft skin and mushy interior, but as they increase in popularity in kitchens around the world, avocado-related mishaps are sending people (including Academy Award-winning actress Meryl Streep) to emergency rooms and plastic surgeons in record numbers. Why? Because many people don’t know the proper way to peel an avocado. Much like bagels, the rounded shape and softness of the fruit makes it tricky to cut. But it doesn’t have to be. As the temperatures warm and avocado’s start appearing in produce sections around the world, try these cutting pointers to help keep yourself out of the ER when preparing an avocado:

So, what can you do if you’ve already injured yourself? There are many ways a plastic surgeon can repair damage caused by kitchen knife injuries. Whether you simply want to hide an unsightly scar with scar revision surgery, or you need repair to damaged tendons, your plastic surgeon can help repair your hand and correct much of the damage caused by your kitchen accident.

Unfortunately, in the case of some tendon injuries, the damage may be permanent and can include loss of sensation, tendernes and inability to move or bend affected fingers, however your surgeon can evaluate the damage and determine if surgery is worth attempting.

The average couple is paying nearly $2500 for wedding photos alone. If you’re spending this kind of money on photos of yourself, you want to be sure you’re putting your very best face forward. After all, chances are you won’t be shelling out that kind of money for another photo session anytime soon. Whether it’s you that’s getting married, or if you’ll be part of a wedding party or simply in wedding photos as a guest this summer, here are some tips for looking your very best in photos that are sure to become family heirlooms.

Last year, American brides spent an average of $1564 for a wedding gown and an additional $275 on average for hair and makeup. Add in accessories like jewelry, shoes, and veil, and the median cost for a bride’s total wedding look is well over two-thousand dollars! In fact, according to vaguepenguin.com, the cost of the bride’s look alone rings up at around four percent of the entire average wedding budget. For men walking down the aisle, prices can range anywhere from $300 for a rented tuxedo to over $1500 for a purchased, altered tuxedo. But with all that money being spent to look your best, don’t forget your skin! After all, studies have shown time and time again that no matter how beautiful your outfit or backdrop, when viewing photos, the human eye is naturally drawn to the face. One study even found that using attractive female faces in advertising increased sales by four percent, proving that looking your best in pictures matters.

If you’re searching for a way to put your best foot forward this wedding season but aren’t sure what’s right for you, keep reading!

Each year, millions of plastic surgery procedures are performed in America, and most of them are not covered by medical insurance. This means these costly procedures are often done at the expense of the patient, to the tune of over $12 billion dollars a year. But now, a growing number of plastic surgeons are pushing for health insurance providers to cover more plastic surgery procedures, as many procedures do improve the health and well-being of the patient.

"A popular example many surgeons are using is reconstructive surgery for transgender patients or breast cancer survivors," said Dr. Ryan Mitchell, a plastic surgeon based in Henderson, Nevada. "Many women opt to have breast augmentation following a mastectomy, but most insurance plans don’t cover augmentations. That leaves a woman who has just likely endured a grueling medical battle with the added expense of having to purchase what is essentially a prosthetic breast with her own money."

Ethics aside, this is also problematic because many cancer survivors are low on extra money following a lengthy recovery.

"Paying out of pocket may not be in their budget for some time following chemotherapy,  especially if the patient has been out work, or has had to pay for any portion of her treatment out of pocket," said Mitchell. 

Another problem Mitchell sees with billing cancer survivors for reconstruction is that were it any other body part, it would most likely be covered.

When Cynthia Hedgecock tripped on a broken piece of San Diego, California sidewalk in July of 2015, she had no idea that her ordeal was just beginning. Hedgecock is the wife of former San Diego Mayor Roger Hedgecock, who served the city from 1983 to 1985. Following Mrs. Hedgecock’s fall, she reportedly suffered continued pain, but it was not until September of 2015 that she discovered both of her breast implants had ruptured in the fall and were leaking silicone into her bloodstream. The lawsuit alleges Hedgecock sought medical attention for "persistent breast pain and deformities," and that was when the discovery of the extent of the fall’s damage was revealed.

Hedgecock’s lawsuit claims that due to the fall she endured "serious personal injuries" and required an extensive period of recovery following the removal of the leaking silicone, ruptured implants and the subsequent implant replacement surgery. According to the lawsuit, Hedgecock states that the incident cost her and her husband over $25,000 in medical expenses. Her husband has joined the lawsuit as a co-plaintiff, alleging the accident and recovery of his wife caused him to suffer "loss of support, service, love, companionship, society, affection, relations and solace from his wife."

Though the lawsuit will not head to trial until later in 2017, it has already begun to raise a lot of questions about breast implant safety. Dr. Ryan Mitchell of Henderson, Nevada did not treat Hedgecock, but says that a fall like the one Hedgecock experienced could cause breast implants to rupture.

"Though breast implant ruptures are very rare, physical trauma from a fall or car accident certainly could cause an implant to rupture," said Mitchell. 

Other causes of implant rupture include normal wear and tear, damage from surgical instruments, over or underfilling of saline implants, and in 
extremely rare cases, from pressure during a mammogram. Mitchell says if you suspect your breast implant has ruptured, call your doctor as soon as possible.

Did you know that skin cancer is the most common form of cancer in America- and that the deadliest form of skin cancer, melanoma, kills an average of one person an hour? If you’re not already actively screening your skin for skin cancer on a regular basis, or trying to protect your skin from sun damage- now is the perfect time to start. Here are some tips for what to look for when checking your skin for signs of skin cancer- and what you should be doing every single day to prevent it.

This year, 3.5 million Americans will be diagnosed with skin cancer, and 160,000 of those cancers will be melanoma. Melanoma is thought to be caused by unprotected sun exposure, but despite better screening methods and greater awareness, numbers are increasing. Scientists believe this is due to increasing deterioration of the earth’s ozone layer, which is allowing higher levels of radiation from the sun’s dangerous UV rays to reach our skin. In fact, researchers now estimate that 1 in 50 Americans will be diagnosed with melanoma in their lifetime. So, what should you be looking for when checking your skin for melanoma and other forms of skin cancer- and what can you do to help protect yourself from the sun’s dangerous rays?

Melanoma: The deadliest form of skin cancer, melanoma isn’t just an older person’s problem. It’s not only the leading cause of cancer-related deaths in women aged 25-30, but it is also becoming increasingly common in children. About 500 children a year are diagnosed with Melanoma- and that number is increasing at a rate of 2% a year! Melanoma can appear anywhere on the body- even the eyeballs (ocular melanoma), fingernails and scalp- and can affect anyone of any race, age or gender. When checking your skin for Melanoma, the best way to remember what to look for is to use the ABCDE Method.

Basal Cell Carcinoma:  Basal cell carcinomas (BCC) are the most common form of skin cancer. Thankfully, if caught early, they are usually not fatal. BCC’s are also thought to be caused by sun exposure. They appear on the skin as open sores, red patches, scars, shiny bumps, or pink growths. Thankfully BCC does not usually spread- but they can if left untreated. They can also cause permanent scarring when removed and can return to previously treated areas- so regular follow-up care is extremely important. BCC is caused by prolonged sun exposure AND by short-term, intense sun exposure that may result in a sunburn. People most at risk for BCC are those with fair skin, red or blonde hair, and light colored eyes. Though it has traditionally been more common in men, an increasing number of women are developing BCC.

A disturbing new trend is making headlines around the country: unlicensed practitioners known as "pump-doctors" are using industrial grade silicone as a cosmetic filler on unsuspecting patients. The pump-doctor trend is flourishing along the east coast, in places like Atlanta, Florida, and Maryland, where patient fatalities have resulted in a series of high-profile cases. But despite grim warnings from authorities and the medical community about the use of pump doctors, these illegal practices continue to thrive.

Plastic surgery procedures to increase the size of your breasts, buttocks and lips can be a big expense.  For patients determined to get the kind of results only plastic surgery could create, shopping around for the best price can have its benefits. Perhaps that’s why illegal practitioners known as pump-doctors are flourishing in US cities. With their promise of major results at a fraction of the cost, pump doctors are offering patients what they may have thought was both physically and financially unattainable in the past. But buyer beware! These unlicensed and often untrained individuals are making promises they can’t deliver on, and it’s costing some people their health and even their lives.

Not to be confused with the medical grade silicone found in breast implants, industrial grade silicone is often used as an ingredient in shampoos, cement, glass and ceramics.  Injected directly into the body, victims of pump doctors have alleged that these individuals often use no anesthesia, and practice in unsterilized hotel rooms with dirty equipment.

"The unsanitary conditions in which these injections are given are dangerous enough," Mitchell said. "But then when you realize the injections are being given by untrained people who are literally injecting poison anywhere they want into the body, it’s a wonder to me that more people haven’t died." 

Indeed, in several cases it was not the silicone that killed victims but an embolism, a condition where arteries in the lungs become blocked by a blood clot. 

A recent report by the Food and Drug Administration has once again confirmed a link between certain breast implants and an extremely rare form of cancer called BIA-ALCL, or anaplastic large cell lymphoma. In light of this new report, doctors like Henderson, Nevada plastic surgeon Dr. Ryan Mitchell are ramping up their efforts to warn patients about this uncommon disease, which is now estimated to affect 1 in 300,000 women. 

When most women consider getting breast implants, they are aware that their implants carry a certain level of risk. Though not common, any type of surgery or implant can have complications. But now some patients have a new risk to consider- the non-Hodgkin’s lymphoma known as BIA-ALCL. Though his extremely rare t-cell lymphoma has only affected 359 people since its discovery in 2011, it still poses enough of a risk that surgeons like Mitchell are bringing it up to patients considering breast augmentation.

"Though BIA-ALCL is extremely rare, it is being found in an increasing number of patients with textured breast implants,"  Mitchell said. "According to the FDA, of the 231 reported cases of BIA-ALCL that included information about the texture of the implants, 203 were textured, while only 28 were smooth." 

Textured implants are not as commonly used in the US as they are in other countries, but there are still some US-based surgeons who use them. In light of these new findings, however- that could change. 

"As more patients become aware of the increased risks of BIA-ALCL in those with textured implants, I suspect more women will opt for smooth implants," Mitchell said. 

You may have heard the term "board certified" used when discussing plastic surgeons, but you may not know what that is- or if it really matters. After all, you can save a lot of money going abroad for surgery or to a spa for Botox injections from someone who isn’t board certified.  So, what’s the big difference between board certified, board eligible, and not- and do those credentials really justify the difference in cost for the same procedure?

In order to practice any kind of medicine here in the United States, a doctor must be licensed in the state or states that they practice in. But just because a doctor holds a valid medical license, does not mean he or she is board certified in a medical specialty. Board certification is a voluntary certification that means a doctor has undergone additional training in a specific field and has completed an additional evaluation process beyond the licensing process in his or her field. Board certification is usually peer-conducted and is not a ‘one-time’ thing. Doctors who undergo the rigorous process of board certification must complete additional internships and both written and oral testing following their training. Once they pass their testing, the doctor must continue to attend training and keep current with the newest advances in their field in order to remain board certified.  Board certified doctors must also adhere to board standards and best practices. To do so could be a violation of their certification, and could be grounds for having that certification revoked.

 The purpose of board certification is to add an extra level of security to a doctor’s credentials beyond simply being licensed to practice. When a patient sees that his or her doctor is board certified, they can rest assured that their practitioner is well-versed in the most current science and adheres to all ethics and best practices in their field.  They can also rest assured that if a doctor violates the best practices set forth by the board, they can lose their board certification, and possibly their license. This helps not just the doctor to keep current on his or her education but should reassure the patient that their doctor is current in his or her methods, and compliant with laws and ethics.

With an increase in both "mommy makeovers" and male cosmetic surgery procedures, a lot of parents are going under the knife these days. But while the change in your appearance may be a welcome change to you and maybe even your partner- it may not be as easily embraced by your children. If you’re struggling to figure out how to tell your kids that you’ll be changing your look, or if they know and are having fear or anxiety about your upcoming or recent surgery, here are a few tips to help explain your decision to them, and hopefully ease some of that stress, too.

How do I tell my children I’m having surgery without them getting scared?

Telling your kid you’re about to have major surgery can be very scary- for you and for them. While it is recommended that you discuss what is about to happen with them, depending on their age there are varying degrees of detail you should give them about the procedure. For preschool aged children and younger, telling them that mom or dad are going to see the doctor so they can feel better about themselves is a great, vague way to summarize what’s about to happen. Nothing in their lives is changing, you will just be happier with how you look, and after you heal, you’ll feel better, too.

It probably comes as little surprise that plastic surgery can have a positive effect on your self-esteem. Correcting an issue with your appearance can do wonders for how you feel about the person staring back at you in the mirror- but did you know that when it comes to cosmetic procedures, self-esteem is just the tip of the iceberg, so to speak? Studies have shown that in addition to the boost in self-esteem and confidence most patients notice post-surgery, there are some other surprising benefits you may not have even thought about! Dr. Ryan Mitchell shares some surprising new findings.

In 2013, when researchers at the University of Melbourne surveyed 121 patients at prominent local plastic surgery clinics, they weren’t sure what to expect. They knew that plastic surgery would likely improve the self-esteem of their respondents, but they were surprised to find that it also improved their job satisfaction, too! Why job satisfaction, though? The answers might surprise you!

In the study, published in Asia Pacific Journal of Human Resources, researchers Alicia Kalus and Christina Cregan found that patients returning to work after surgery experienced not only higher levels of job satisfaction, but lower levels of job-related burnout than they did prior to their surgery. Kalus and Cregan theorize that in addition to benefitting from a deeper sense of self-esteem which boosted the overall happiness of the post-op patients, the responding patients also benefitted from a boost in what Kalus and Cregan refer to as a "beauty premium." This theory states that beautiful people are said to be treated better in the workplace (and in society) than those deemed less attractive. This is also known as an "attractiveness bias," and it has been shown to unwittingly cause employers to overestimate the confidence they have in an employee’s abilities, based solely on their appearance. In other words, the study respondents’ employers may have -whether correctly or incorrectly- believed their newly-refreshed employee was capable of more challenging work following their surgical procedure!

Ultimately, the most positive finding in this study was that patients returning to work had a more positive outlook on life and their job. This means that even if nothing else changed for the majority of the responding patients meaning their employers’ opinions didn’t change, and did not afford their employees the benefit of an attractiveness bias or beauty premium- the patient’s own boost in inner-happiness had enough of a positive effect in the patient’s job-life that it helped the patient view their job in a more positive light!

You could have them already- those two little dents where your lower back meets your buttocks, commonly known as ‘Venus dimples.’ But while many people probably have never given them more than a passing glance, Venus dimples are on track to be the number one new trend in plastic surgery for 2017, thanks to their increasing popularity from bikini shots of models and Instagram-celebrities like the Hadid sisters, Kylie Jenner and Miranda Kerr. We spoke to Henderson, Nevada plastic surgeon Dr. Ryan Mitchell about this popular new procedure.

Venus dimples get their name from the Roman Goddess of Beauty. When naturally occurring, Venus dimples are two sagittally symmetrical indentations on the lower back that appear at the site of the two sacroiliac joints, where the sacrum and ilium of the pelvis connect. Venus dimples contain a channel of veins that is often used as a guide in spinal surgery- specifically in procedures to place sacral pedicle screws in the spine. They are also said to increase blood circulation in the pelvic area and are believed to enhance sexual pleasure in those who possess them.

But now there’s good news for women who don’t have Venus dimples, but would like to have them- there’s a trendy new plastic surgery procedure called the "V-spot treatment" that can create the look of these trendy dents- and women are paying up to $5,000 for it!  Named for the diamond-shaped area of the lower back, the v-spot procedure uses a cannula to break up the fat on the lower back and basically carve the ‘v’ shape, and two indentations into the body, explains Mitchell. The broken-up body fat is then suctioned up by the cannula, and after about two weeks of minor pain and discomfort, even patients who weren’t born with Venus dimples can look like they were. According to Mitchell, recovery from the v-spot procedure is relatively easy.

"Patients who undergo v-spot surgery can expect some minor discomfort for the first few days following the surgery, and may find relief in wearing a compression garment during the first few weeks of recovery, but most pain generally subsides within a few days," Mitchell said. 

The good news, and perhaps, for some, the bad news, is that Venus dimples are genetic- you either have them, or you don’t. For those who have them, they’re present no matter what shape you’re in- though carrying extra weight may make them harder to see. For those patients, a v-spot procedure can still help to make the Venus dimples more defined, so just because you already have them doesn’t mean you can’t make them deeper. For those looking to improve the appearance of their entire lower back area, according to Mitchell, v-spot surgery can be done at the time of other procedures, such as liposuction or the recent favorite, the Brazilian butt-lift.

You’ve probably heard that salacious marketing motto, ‘What happens in Vegas, Stays in Vegas.’ Coined in 2003 as part of a Las Vegas tourism campaign, the phrase (and campaign) took off like wildfire, creating some of the most memorable commercials in recent history- and inspiring everything from songs to major motion pictures. Designed to invoke feelings of both freedom from inhibition, to privacy in the form of an unspoken brotherhood-like ‘code,’ that everyone in the area knows and abides by. So it’s not surprising at all that people around the world are flocking to the greater Las Vegas area, and to Mitchell Plastic Surgery, for their plastic surgery procedures.

Destination plastic surgery, or surgery vacations, are not a new concept. For years we’ve been hearing about patients booking travel to foreign countries for "cheap" or "affordable" plastic surgery procedures. These controversial trips have been long-discouraged by board-certified doctors and federal agencies for decades. Leaving the US for surgery poses significant risks- especially if the practitioner performing the surgery is not board-certified, or worse. Many travel surgery horror stories have ended with patients learning post-surgery that their surgeon wasn’t even a licensed doctor- usually, after something has gone horribly wrong. Botched surgeries can cause everything from severe infection to permanent scarring, disfigurement, and in some cases, even death of the patient. So, it’s no wonder that the trend of domestic, board-certified, destination surgery is on the incline.

The Greater-Las Vegas area boasts many benefits for booking your destination surgery. For example, our high concentration of board-certified plastic surgeon offers several benefits to the patient. First, because there is so much competition, prices and package deals designed to save you money over local competitors are everywhere. Furthermore, with so many surgeons to choose from, you have the freedom to choose someone who specializes in the specific procedure you’re considering. Another way the patient benefits from the friendly competition between surgeons is the need for surgeons to stay on the ‘cutting edge’ of plastic and cosmetic surgery procedures. In order to stay competitive, your surgeon must keep adding new procedures, products, and techniques to his portfolio- or risk losing patients to someone down the street who knows more or offers more.

In a society that is seemingly obsessed with celebrity culture, the desire to look more like a specific celebrity is surprisingly, perfectly healthy. After all, who wouldn’t want to share features with an extremely beautiful person? But did you know that in addition to being a totally normal behavior, for patients seeking plastic surgery, paying attention to celebrity features can actually be very useful in identifying what you do and do not want to change with your own features? If you’ve ever caught yourself staring at a magazine or television show, wishing you had Angelina’s lips or Kerry Washington’s cheekbones, you’re not alone.

Each year, patients around the US seek the assistance of plastic surgeons, armed with photos of their favorite actors, musicians, and models for inspiration. This practice is not only extremely common, but it’s also extremely useful to your surgeon, too. In addition to helping your surgeon identify current trends in the beauty world, your facial or body inspiration also helps your surgeon use those trends to improve the options for other patients who may not know how exactly to voice which changes they are seeking. For example, when a lot of people come in requesting a specific celebrity’s nose, your surgeon gets better at recreating that look. He can turn to the next patient who isn’t sure what he or she wants and say "a lot of patients like this look," which could help inspire the patient to narrow their focus.

With the rise in popularity of male plastic surgery, more male patients are requesting to look like celebrities, too. In fact, a recently compiled list of trends is showing surgeons exactly what faces men admire, and which features they wish to change on their own faces. Topping this year’s list of most popular male faces is New England Patriots quarterback Tom Brady, whose overall face, and more specifically his cheekbones, are in high demand among male patients. Not surprisingly, the most popular facial plastic surgery procedure among men is a cheek lift.  Other male favorites include Dwayne "The Rock" Johnson’s strong jawline, and other features from actors Chris Hemsworth, Chris Pratt, and John Hamm, as well as male supermodels Sean O’Pry and Tyson Beckford.

If you’ve ever seen an earlobe piercing with an enlarged opening and a large silver hoop lining the inside of that opening, then you’ve seen the trendy piercing known as a "flesh tunnel." Though flesh tunnels are becoming increasingly popular today, they date back to ancient times, where they were used as a sign of wealth and status in tribes throughout Asia and Africa.

Gauging one’s ears is the process of stretching out the lobes to accommodate a flesh tunnel. Gauging works by inserting a wide bar (called a gauge, plug, or spacer) into a piercing to stretch the opening. As the hole in their ear grows, the gauge is replaced with a larger sized gauge, until the desired size is reached. Gauges typically run the range from .8mm to all the way up to 50mm (2 inches), but they can often get much bigger- in fact, he Guinness World Record for the largest piercing is 109mm or 4.3 inches! But while the wearers of these piercings think they look cool now, what happens when they grow tired of wearing them- or they must accept a job that requires the piercings to be removed? While the skin of the ear has some inherent elasticity, there is no way to heal a 2" piercing without intervention. This very dilemma has given rise to a new form of plastic surgery:  earlobe reconstruction.  We spoke to Henderson, NV plastic surgeon Dr. Ryan Mitchell about what patients can expect from this increasingly popular procedure.

Youth is a time of rebellion, adventure, and figuring out who you are. For many young people, It’s also the first time out on their own, away from the watchful eye of caregivers, and usually without the responsibility of a 9-5 job. It's also the perfect time to do something wild with your appearance, like shave your head, get a tattoo, or yes- stretch your ears out with gauges. But while most of these acts of rebellion are either temporary or at very least, easy to hide, ear gauges are neither- a fact that many young people don’t seem to realize or aren’t bothered by-  until it’s too late.

We asked Mitchell if he’s noticed an uptick in patients requesting earlobe reconstruction surgery. "Yes, absolutely," he says "Many patients who seek this surgery were surprised to discover just how little their ears closed up without intervention. Unfortunately, I think many of the people getting gauges are either misinformed, or they just don’t think far enough into the future."  After all, circumstances change, and life has a way of throwing a monkey wrench into your plans. Mitchell says patients have cited everything from new jobs, to change of style, to even just frustration with the piercings getting in the way of daily life as reasons for wanting to surgically correct their earlobes. "Inconvenience can be a major factor," he explains "You may not realize how often your hands, phone, or clothing touch your ears each day."

For many patients, cosmetic surgery is something they’ve looked forward to for years. Whether they’re removing a much-despised bump in the nose, want larger breasts, or are ready for a full facelift, cosmetic procedures offer patients hope that they can finally look on the outside the way they feel on the inside. But many patients are surprised when, following their procedure, they are left feeling hopeless and depressed. Post-surgical depression is real, and it happens more often than you might think. Learn the triggers of this type of depression, the warning signs to look for following your procedure, and what to do if you think you are experiencing post-surgical depression.

While nobody knows exactly what causes post-surgical depression, there are many triggers. Anything from anesthesia to unrealistic expectations to isolation or lack of support network can all be huge contributors to a patient feeling depressed following what should be a time of renewed hope. Worse yet, many people are ashamed to come forward and discuss their feelings because of the stigma associated with depression- and the shame they feel for experiencing depression following an elective surgery.

Before we get into what to look for, though, there are some depression risk indicators patients should be aware of prior to their surgery. If you fall into any of these categories, be honest with yourself and with your surgeon. Often, discussing these risks ahead of time can help alleviate them- or at least allow you and your doctor to form a plan in case you do begin to experience signs of depression following your surgery.

-If you have unrealistic expectations for your surgical results, you may be headed for disappointment if the procedure doesn’t live up to your expectations. Your surgeon will do his or her best to explain the possible side effects and give you a realistic idea of what to expect - but it is understandably difficult for patients to imagine what they’ll see in the mirror following their surgery. Another issue some patients have following surgery is that the healing process can often take much longer than expected. Depending on the procedure, you may not be able to see your final results for a year or longer. This is especially true with rhinoplasties because the swelling of the nose takes a very long time to go down. Even then it is a gradual process, so patients may not realize it has reduced in size for months- or that it still needs, even more, time to progess.