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Breast Augmentation
The human breast is associated deeply in the minds of men and women with the female image. Since early times, women who developed less than the normal or desired amount of breast tissue have wished that something could be done.
Early attempts by surgeons of yesteryear included moving skin and fat from the buttock up to the breast, with uniformly miserable results because of lack of blood supply in the transferred tissue. The first successful attempts were about 30 years ago, when artificial materials were seriously tried. The silastic rubber prosthesis filled with either silicone gel or saline (salt water) provided a long-term solution, after several other materials were tried with less-satisfactory results.
Our personal experience with breast implants spans more than 20 years, using both saline-filled and gel-filled implants. While nothing made by human beings will ever be perfect, the overwhelming majority of our augmentation patients obtain the desired results.
Much has been made of the breast implant controversy, with TV talk-show hosts drawing large ratings by showing bare breasts on camera. The scientific evidence linking silicone implants with connective-tissue disorders is still lacking, now some seven years after the first headlines. A recent study by European scientists confirmed the safety of implants.
So, what implant options are available? Under present FDA rules, saline implants must be used in all cosmetic breast augmentations unless certain specific criteria are met. In those cases where a congenital deformity of the breast is present (such as Poland's Syndrome, tuberous breast deformity, or certain other problems), a patient may be included in a manufacturer's study, and obtain gel-filled implants. In some cases of severe breast sagging, when a breast lift procedure (mastopexy) is being done at the same surgery, a patient may also be included in the study.
The breast augmentation procedure is an outpatient surgery, best performed under general anesthesia, and most patients can return to office jobs or light housekeeping work in 4 or 5 days. The operation itself takes about an hour and fifteen minutes, with another one or two hours spent in recovery, before discharge home. An adult caregiver must drive the patient home and stay the night with the patient. Most patients can be left alone, if necessary, on the next day.
A skin incision of slightly over an inch is necessary, usually placed in the lower part of the breast, just above the crease beneath the breast. Occasionally a patient prefers to have the incision in the armpit. This is possible in selected cases, but if sagging of the breast is a problem, this alternative may not be best for you.
The implants are usually placed under the pectoral muscle on the chest, since this technique results in decreased incidence of scar capsule contracture. This is the most common complaint following breast augmentation and is the result of the body's normal healing process and its natural tendency to 'wall off' anything not a part of itself. The prevailing opinion among surgeons is that placing the implant under the muscle keeps it from forming such a hard layer of scar tissue and makes the tissue more pliable.
Other problems, much less common, are hematoma (a collection of blood around the implant) and infection. Rarely, a patient will form a hypertrophic scar or keloid at the skin incision site, which may require secondary surgery to correct. Another uncommon problem is decreased sensation in the nipple following surgery. When this occurs, it is usually temporary, resolving in three or four weeks.
As we have already discussed, under present FDA regulations, most patients may only receive saline-filled prostheses, unless certain criteria are met for being placed in a study involving gel-filled implants. Saline implants, of course, are also called 'inflatable,' and can be subject to 'deflation' as well. Since the filler is only saline, however, the body absorbs the salt water uneventfully. When this occurs, the patient only notices that one side is not the same size as it was. The manufacturers have taken this into consideration, and offer a free-replacement, lifetime guarantee on the implant. In addition, they will reimburse the patient for expenses involved in making the exchange for up to ten years.
A word of caution is in order: a slight degree of sagging of the breast can be helped by breast implants. Basically, if the nipple rides below the crease underneath the breast in the upright position, without a brassiere on, a procedure to lift the breast skin may be necessary in addition to the implant
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Breast Lift
Women in western societies generally do not suffer as badly from the early sagging of the breasts as those in less-developed cultures (where brassiere wear is not common). However, ladies who are well endowed or who grow very large during pregnancy or nursing will eventually suffer from exposure to gravity and lose youthful contour. This problem usually takes three forms. 1) Hypertrophy (overdevelopment) of the breast may be so severe that neck, back and shoulder pains are a problem. In these cases, a reduction of the breast tissue may be required, as well as a lifting of the breast. 2) Simple sagging of the breast may be the problem if adequate volume of breast tissue is present, but the contour has suffered from relaxation of the Cooper's ligaments, which are the body's natural attachments of the gland to the muscle of the chest. 3) Sagging with inadequate volume is most commonly the result of atrophy of the breast tissue following pregnancy, nursing, or menopause. In this case it is usually necessary to place a breast implant, as well as do a breast lift procedure.
Hypertrophy of the breast, when severe enough to produce neck, back or shoulder pains, and when the amount of excess tissue is more than a pound, may be covered by insurance. To determine this, a consultation is necessary, and a predetermination from your insurance will be obtained. Sometimes there is only a small amount of excess breast tissue, and in this circumstance the procedure is considered cosmetic (not covered by insurance).
Simple sagging of the breast, when the patient is satisfied with the volume of tissue, requires a straightforward lift of the breast, resecting only skin and basically constructing a skin brassiere. Since all breasts are different (even your own two) the exact planning of the operation, placement of the scars, etc., must be determined in a personal consultation. Some general guidelines can be applied, however.
When the amount of sagging is minimal (the nipple rides low on the breast, but not below the crease beneath the breast, the skin incisions may be kept to a circle around the areola (the brown or reddish-brown area around the nipple) and be fairly inconspicuous. As the nipple rides lower, below the crease, or even to the point where the nipple is the lowest point on the breast, more extensive scars are required. In the worst-case situation, the scar will circle the areola, go vertically down the breast from the 6 o'clock point on the areola to the crease under the breast, and then go both directions to the inside and outside edges of the breast. This scar has been described as looking like the anchor tattoo on Popeye's arm. The exact length of the scar is determined by the severity of the sagging problem and is beyond the control of the surgeon.
Inadequate volume of tissue, with sagging, is both a positive and negative factor. The use of a breast implant (see that page also) will enable a lesser lift procedure with shorter scars than when lift alone is performed, because the implant takes up some of the excess skin. Whenever a mastopexy patient is willing to accept an increase in volume, this technique usually simplifies the lift and decreases the length of scar required.
All of the above procedures can be done on an outpatient basis, but usually require general anesthesia, the exception being some minimal lift operations, where the amount of movement of the nipple required is less than two or three inches. Time off from work varies with the extent of the procedure. Breast reduction may require a month off work, while a minor lift may allow return to some work the next day.
The potential complications of these operations are similar. As with any plastic surgery, risks include hematoma (a collection of blood), infection, and wound healing problems such as excessive scarring, possibility of needing additional surgery, etc. Loss of sensation in the nipple is an uncommon problem in all but the breast reduction procedure, where it does occur, especially with the more extensive operations.
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Abdominoplasty (Tummy Tuck)
Abdominoplasty, most commonly called 'tummy tuck,' is a procedure in which the muscles of the abdomen are tightened and excess skin is removed to recontour the abdomen. While the procedure is most commonly performed in women to restore body shape following damage from pregnancy, men and women who have lost large amounts of weight (usually in excess of 100 pounds) may need this procedure also.
Patients considering this procedure should remember that all plastic surgery involving an incision leaves some kind of scar, and the scar in this surgery is one of the longest we ever make. Also, if the problem is only one of excess fat on the abdomen, with good skin quality and muscle tone, then suction lipectomy is a better choice for the patient, since the scars from that surgery are tiny, by comparison.
Another consideration is that pregnancy after abdominoplasty, if the muscles are to be tightened, is STRONGLY discouraged. We usually recommend tubal ligation either prior to or at the same time as abdominoplasty, having your own gynecologist come in for this part of the surgery.
Before we leave the subject of the scar, we need to describe it for you. It begins at the hip bone on the lower abdomen, runs down the groin crease to the pubic hairline, across and up the other groin crease to the opposite hip bone. In addition, a circular or elliptical scar surrounds the belly button. The belly button, or navel, is not actually moved during the surgery, but is cut around, with the skin being pulled down and redraped, and the navel brought through a new site in the skin. If it were attached to your backbone, it would rest in the same place at the end of the surgery.
The surgery is done as an outpatient procedure, although sometimes patients stay overnight at the surgery center for '23-hour' recovery. The operation itself takes three or four hours, and is done under general anesthesia. Usually we place an elastic binder over the abdomen for support and protection. This binder may be removed for bathing, etc., but is otherwise worn for about three weeks. Most people need a pair of soft rubber drain tubes to collect late oozing of blood and serum and to prevent excessive swelling. These are usually removed about 48 hours after surgery, during a visit to the office.
Time off from work after this operation varies, depending on one's job description. While many patients feel well enough to do light office work after a week, usually a two-week minimum is recommended before returning to office jobs, two or three weeks minimum before driving a car or doing serious stair climbing, etc. For those whose jobs are more physical, up to six weeks MAY be needed.
One of the more common questions asked is, 'Will my medical insurance pay for this?' Unfortunately, the best answer we can give is, 'Maybe.' In order for insurance to pay, the patient must have such weakness of the abdominal wall that a true hernia is present. Pictures are typically taken and sent to the insurance company review board. Sometimes a second opinion is required. A month or more of time may be needed for the predetermination process. After an examination in our office, we will be happy to evaluate your chances of success in pursuing this approach. Attempting to circumvent the rules in such cases constitutes fraud, and we will not participate in such endeavors.
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Liposuction
Suction-assisted lipoplasty
Suction-assisted lipoplasty, also known as liposuction, is a body contouring technique that was unknown in the United States until the meeting of the American Society of Plastic and Reconstructive surgeons in 1982. A French surgeon named Yves-Gerard Ilouz, working independently from a Swiss colleague named Kesselring who was trying for the same idea, arrived at the method most widely used in the world through the 1980s and most of the 1990s.
Since the beginning of plastic surgery, surgeons had held the idea that if subcutaneous fat were removed without removing any of the skin, the skin would be loose and sag in a disfiguring way. What Ilouz and Kesselring discovered was that if fat were removed through a series of tunnels, and the skin were held tightly against the underlying muscles by an elastic bandage or pressure garment, the skin would adhere by the scar tissue to the muscle surface without sagging! The two techniques of Ilouz and Kesselring differed in that Ilouz used a blunt instrument, (known as a cannula) while Kesselring used a sharp one. Surgeons have discovered that the blunt one is safer, and not as likely to damage vital structures.
Common to both surgeons’ technique was the suction pump, basically a very strong vacuum machine with pulls the fat out through the probe by its attachment with a strong vinyl tube. Originally the pump was the same one used by gynecologists to carry out the dilation and curettage (D&C) procedure, although the machines now are custom-designed for lipoplasty.
The outpatient procedure consists of one or two puncture wounds for each treated area, each about 1/8 inch long, and requiring only one or two stitches to close. This allows the cannula to be introduced into the fat between the skin and superficial muscle.
By moving the cannula back and forth, much like vacuuming a carpet, the fat flows out through the tubing into a collection bottle on the machine. The amount removed from any one area varies from a few spoonfuls (such as beneath the chin) to a pint or more (such as from the abdomen or saddlebag area.)
Once an area has been treated, it is important to hold pressure on the site to minimize swelling and bruising. For this we commonly use a compression garment, like a special girdle or binder. Even with proper garment wear, patients swell enough that an early determination of the final result is not possible in the early period after surgery.
In fact, I call this the operation of “3’s” since for the first three weeks most people feel that we must have put in fat, instead of removing it. At three weeks, most of the surgical swelling is gone, and the real improvement begins. For the next three months, about 90% of the improvement takes place. For three months after that the other 10% occurs.
Body contouring by suction lipoplasty is becoming the most common plastic procedure in the United States, since both men and women are candidates. The main thing to remember is that the operation is NOT for weight loss, but just for localized fat deposits. The amount of weight actually lost is not great, even in cases where several pints of fat are removed. But because we see these fat deposits as associated with obesity, the person looks like they have lost weight – a lot more than they actually have.
The complications associated with the procedure are those common to a lot of surgical procedures: bleeding, infection, etc. A few things unique to suction lipoplasty are dimpling, waving or wrinkling of the skin, staining of the skin because of the bruises settling in the skin, and temporary numbness of the skin. All except the last can be causes of additional surgery.
Since the procedure is designed to improve the appearance, it is considered aesthetic, or cosmetic, and not covered by insurance. It does not prolong or save a life, but it can improve quality of life. The improvement in appearance frequently encourages a person to adopt a healthier lifestyle and perhaps a personal fitness program, since they now have something to be proud of and maintain.
Perhaps the most frequently asked question by patients is, “Can the fat come back?” The answer to this is that the fat cells removed by the operation do not come back, but it is possible to gain weight and fill up fat cells in other locations, even those which are left behind in the treated area. Causing the area to become lumpy and uneven, since the fat is no longer distributed the same way it once was. So our recommendation is to maintain body weight approximately where it was on the day of surgery, or even reduce it slightly. Don’t take the operation as an excuse to overeat! Surgery does not make you immune to the rules of metabolism!
Therefore, the best candidates for body contouring are those who have adopted a reasonable program of exercise and sensible eating, and who have developed localized fat deposits in areas resistant to fat loss (abdomen, love-handles, saddlebags, buttocks, double chin and the male breast.) Most of these people can be benefited by removal of excess fat by suction lipoplasty.
Ultrasound-assisted Lipoplasty
Ultrasound-assisted lipoplasty, abbreviated UAL, is a newer version of suction-assisted lipoplasty (SAL.) The procedure, like the original, was invented in Europe. An Italian plastic surgeon with a degree in acoustical physics –the study of sound energy—Dr Michele Zocchi invented a technique whereby a sound wave generator is attached to a sterile handpiece with a titanium rod which is caused to vibrate at a very high, but slightly audible pitch. This sound wave delivers energy to the fat tissue just beyond the end of the probe so that fat is liquefied, making it easier to remove.
In fact the fat is so liquefied that only low-pressure suction is required to remove it. Whereas the traditional lipoplasty machine removed the fat quite roughly and traumatized the fat and adjacent tissue rather severely, UAL is a gentler procedure, for the surgeon and patient. Because the machine breaks up the fat, areas which had been poorly responsive to the older technique are now more effectively treated. Some examples are the “love-handles” and abnormally large breasts on men, and the back area around the shoulder blades on both sexes.
Another advantage of UAL is that the less-traumatic technique allows removal of larger volumes of fat with a lower percentage of blood in the material removed. We have been commonly removing twice the total volumes we were previously able to do. Recovery times seem to be slightly shorter, though individual results will vary. Bruising and swelling appear to be less severe, possibly relating to the less traumatic nature of the technique.
Other aspects of the two procedures are essentially the same, with regard to necessity to wear compression garments postoperatively, etc. The complications associated with the procedure are likewise comparable.
Liposelection™ by VASER®
The newest ultrasound technology involves using pulses of sound energy to more effectively break up fat deposits, while sparing critical structures such as vessels, nerves, etc. The VASER® company was granted a service mark for the technique, calling it liposelection,™ referring to the specificity of the machine for emulsifying fat.
There are three steps in the process carried out in the operating room. First we instill fluid into the tissue to firm it up and stabilize the fat for further work. This is not the commonly referred to tumescent technique, which involves much larger volumes of fluid placed in the tissue and has led to complications such as fluid overload, pulmonary edema (fluid buildup in the lungs) and other complications. The second step is the application of the pulsed sound energy to the fat to break it up and make it easier to remove. Finally, low-power suction is used to evacuate the fat from the space.
Because of the more effective liquefaction of dense fat with the pulses of energy, we have been able to extend the procedure to areas not previously treated with traditional suction: lower legs, lower back, etc. Additionally, more complete removal of fat from the male breast, hip rolls, posterior shoulder and other areas is possible.
While ultrasound-assisted suction has traditionally been less traumatic and resulted in fewer bruises, the more aggressive use of the new machine and treatment of more areas at the single surgical procedure have worked somewhat against this rapid recovery. Because we lose less blood with this machine, we no longer “stage” the procedure by planning multiple trips to the operating room for treating additional areas.
Complications remain the same as for traditional lipoplasty, with minor touchups which can usually be done in the office at little expense being the most commonly occurring. General anesthesia is necessary because of the heat generated by the probes, and there are certain risks attendant with this, which the anesthesiologist will discuss with you in detail.
The expense of the procedure is slightly higher because of the cost of the machine, but our opinion is that the benefits are absolutely worth this additional money. Where your health is concerned, cost-cutting is not the primary concern; your health and the final aesthetic appearance are uppermost.
In summary, we now have tools that will help the conscientious patient who is trying to achieve a better appearance through diet and exercise to reach his or her goals. No surgery is a substitute for a healthy lifestyle, but those who seek the best possible appearance, and are unable to achieve this with diet and exercise alone, now have 21st century assistance.
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Rhinoplasty (Nose Surgery)
Alteration of the nose for cosmetic reasons, rhinoplasty, is one of the oldest of aesthetic operations. Common complaints patients express when considering this procedure are a bump on the top of the nose, a tip that is too wide or droops, a nose that is too long from top to bottom, or one that sticks out too far.
The operation is done as an outpatient, usually with general anesthesia, and takes about two hours. Only in rare cases do we make any incisions on the outside of the nose. Through cuts made inside the nose, both bone and cartilage can be removed and reshaped.
Sometimes, if breathing is a problem, we can obtain partial insurance coverage for the portion of the operation that addresses the airway. If the nasal deformity is because of documented trauma (a fracture from sports or an assault) insurance coverage may also apply. In both these instances, a visit to the office and pictures with a letter to the company in advance is necessary to assure such coverage.
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Thigh Lift
Thigh lift surgery, sometimes also referred to as a 'fanny tuck,' is probably the most drastic cosmetic surgery that a plastic surgeon does. As you have already learned from these pages, plastic surgeons cannot perform invasive surgery without leaving scars; we just attempt to minimize the scars that we leave. But the thigh lift operation leaves the most onerous, most lengthy, and generally most visible (when unclothed) scars. The scars commonly start high on the hip in the back, curve down and around the inside of the thigh, then up the groin crease to about the hip bone on the front. Obviously, one must have a serious need to even consider this operation.
Thigh lift is the least-commonly-performed aesthetic procedure in our practice, and probably in the United States. I believe there are two reasons for this. First, the scars are so significant that many patients are dissuaded from the operation. Second, the number of people who are really in need of this drastic measure is fairly small. So who is a candidate for the procedure?
In our experience, two categories of patients should consider having thigh lift surgery. Patients who have had massive weight loss, and whose thighs are now larger in circumference a few inches BELOW the crease underneath the buttock would benefit from having this done. In these people the skin is frequently thin and stretched out, with less subcutaneous fat high on the thigh than a few inches below. The operation is designed to cut away the thin skin and scant fat area and pull up the lower fat and skin, sewing it to the area above where the skin and fat thickness match up better. The second category of candidates would be those who have already had suction lipectomy and whose results were not adequate, possibly because of inadequate skin contracture following fat removal.
As already mentioned, this operation is the most extensive of aesthetic procedures. The time in the operating room is generally six hours or more. General anesthesia is required, and at least one overnight stay for recovery. Two to four drains are necessary and may need to be left in for 3-4 days or more. In most cases patients are not able to bend at the hips enough to sit upright for several days to a week. An average time required off from work would be 4-6 weeks.
Is this operation ever covered by insurance? In very rare cases, such as following massive weight loss (after gastric bypass procedures, etc.) some patients have been able to secure insurance coverage, if they were having hygiene problems, with skin infection in the redundant folds. Such instances are rare, unfortunately, and usually require more than one letter of predetermination with pictures, review by an insurance company committee, and one or two months' patience.
In addition to the scars, which are NOT complications but an expected part of the surgery, problems can occur, such as excessive blood loss, build-up of a pocket of blood under the skin, infection, problems with wound healing, numbness in the skin of the thighs, and possibly additional surgery.
Nevertheless, for those patients whose need is great enough, this operation may be the only way they can don a bathing suit or even wear reasonably revealing sportswear. Since every situation is different, only a personal evaluation will allow us to assess your suitability as a candidate for the procedure.
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Facial Rejuvenation
Face and neck lifting are usually part of the same procedure, but are tailored to the patient’s need; each person will need some combination, with more or less tightening in either the lower face or neck. The patient coming for consultation typically has already spent time in front of the mirror at home, using the fingers to tighten the skin and observe the results.
This procedure is a major undertaking, with incisions in front of and behind the ears, so that the skin can be elevated down to the corners of the mouth. We usually remodel the superficial layers of the facial musculature at the same time, much like making up a bed. This produces a more complete and longer-lasting facelift, in our experience. We are also addressing the midface on more patients now, either through the lower eyelid incision used for blepharoplasty (eyelid-lift) or using that incision solely for the purpose of lifting the midface. This additional work increases the facelift benefits to the folds alongside the nose and upper lip.
Another area we are addressing more commonly now is the forehead. In the past, when we had to make a long incision across the top of the head from ear to ear, this required more time in surgery and for recovery, We now use an endoscope, a device like general surgeons use to remove the gall bladder, so that minimal incisions can be made. Usually this consists of three vertical scars, each about ½ inch in length, located just at the hairline of the forehead. This allows us to remove a portion of the frown muscles if needed, and reposition sagging eyebrows to a more youthful location.
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How can I finance my cosmetic surgery?
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How much does plastic surgery cost?
Since most cosmetic surgery procedures are done on an outpatient basis, the cost in real dollars is much less that it was years ago. Depending upon the procedure, the cost can be as little as $500 for a scar revision, done in our office, up to several thousands of dollars for a full face lift, tummy tuck, or other major procedure.
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Can all plastic surgery be done as an outpatient?
As a rule, most cosmetic procedures are done on an outpatient basis. A few extensive operations may require overnight stay in recovery. We do prefer our out-of-town patients stay in town overnight so that we may be able to meet immediately if they have complications or concerns. A nearby budget-priced motel is available if you have no local relatives or friends.
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What type of anesthesia will I need?
Minor procedures, such as scar revisions, some eyelid surgery, and tattoo removal can be done under local anesthesia, perhaps with some preoperative sedation. More involved operations are safest under general anesthesia. Attempts to use local anesthesia when general anesthesia would have been better frequently lead to regrets on the part of the patient and entire operating team.
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How long do I have to be off from work when I have plastic surgery?
The answer to this question varies depending upon the procedure you have done. A chemical peel of the face may allow you to return to work the next day. A thigh lift procedure may require six weeks off. In practice, however, most common procedures, such as breast implants or suction lipectomy, will allow patients to return to general office work occupations after a long weekend. Procedures on the face may require longer time off if the patient wants to keep friends and co-workers from knowing about the cosmetic surgery. For procedures such as face lift, eyelid lift, or rhinoplasty (nose job), a period of two weeks is usually necessary for bruising and swelling to resolve enough to return to work without too many visible signs.
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Why do breast implants get hard?
The answer to this question requires an explanation of the body's normal healing mechanism. Every foreign object left inside the human body, from internal stitches to various surgical implants, becomes encased in a layer or wall of scar tissue. If the object is a stitch or grandpa's pacemaker generator, no one cares or even notices. But the female breast is not supposed to be firm. A natural characteristic is that it is supposed to move about and 'flow' around on the chest with activity. So when the layer of scar tissue forms around a breast implant, it must form loosely and thinly enough to allow this movement of the implant. When the pocket of scar is too small and closely formed around the implant, it actually compresses the implant and makes it feel abnormally firm. If the implant that feels so firm in the chest were removed, it would look and feel just like it did when it was inserted. The problem is not with the implant itself, but with the scar tissue around it. While certain measures can be taken to decrease the risk of capsule contracture, no completely failsafe measure has been devised. This very complex issue is being researched constantly by plastic surgeons and implant manufacturers.
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Do you do tumescent liposuction?
The science and art of lipoplasty, or liposuction has advanced rapidly in recent years. The term tumescent comes from a Latin word meaning 'to swell up,' and came on the scene a few years ago with the idea of using very large volumes of intravenous fluids, with a local anesthetic added. This technique allowed the suction procedure to be done without general anesthesia. The volumes of fluid used were frequently two or three times the volume of fat that the surgeon estimated would need to be removed for correction of the defect. The technique attained some notoriety when some patients became fluid-overloaded and had complications. A more-recently-adapted idea is the 'super-wet' technique, in which we add the intravenous solution and local anesthetic solution in a ratio of about one-to-one with the estimated fat removal. This method is safer, in our opinion, and is necessary to utilize the latest advance in lipoplasty, the ultrasonic-assisted lipoplasty (UAL.) The simplest explanation is to say that it is like having a tiny microwave oven on the end of the cannula with which we perform the suction, so that the fat is actually partially melted before it is removed, with fewer traumas to the surrounding tissues; higher proportions of fat removed, and lower blood loss. This is now our preferred instrument for most areas of the body, but especially the lateral thighs and shoulder-blade areas on ladies and the 'love-handles' on men.
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How much weight can you suck out with liposuction?
The problem of determining the amount of weight that you actually lose in lipoplasty is difficult. If one weighs on the morning of surgery, has the procedure done (complete with the fluid that is given at surgery) and weighs again the day after surgery, the weight may actually have gone up because of the swelling that always accompanies all soft tissue surgery, especially lipoplasty. With this fluid retention, it actually takes weeks, or even months, for the true body mass to be measurable. Advertising claims such as, 'Lose 65 pounds in one day!' are false and misleading and have led to disciplinary actions against surgeons making such claims. Surgery to lose a significant amount of weight in one day is fiction, however, changing the shape of the body by removing localized fat deposits is fact.
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How do I know whether I need a tummy tuck or liposuction to correct my abdomen?
This answer is really a judgment call on the part of the examining surgeon, but some general guidelines can be applied. If the skin has good tone, and stretch marks are not too bad, suction may be all that is required to re-contour the abdomen. If the muscles are strong and have not separated in the midline from childbearing, and you are not able to lift handfuls of skin, suction may be enough surgery for you. If a woman is considering having more children in the future, abdominoplasty should not be done, in our opinion.
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How big is the incision for breast implant surgery and where is it located?
Although three incisions are described in plastic surgery literature, we exclusively use only two of them. The one around the areola (the pigmented skin around the nipple) causes scars within the breast tissue itself and sometimes distorts the nipple. We utilize either one underneath the breast, or sometimes in the armpit. In either case, the scar is three to four centimeters long (an inch is two-and-a-half centimeters.) Several factors enter into the choice of incision sites. Fewer people will be likely to see the scar underneath the breast. With bathing suits or other sleeveless attire, the scar under the arm may be visible when the arm is raised. If sagging of the breast is a problem AT ALL, the incision under the breast is preferred, since it allows more control of the placement of the lower border of the implant, and therefore our ability to correct some degree of sagging with the implant.
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How much correction of facial lines can I expect from a chemical peel?
The modern generation of facial peels, commonly done with trichloroacetic acids (TCA), can be done with varying, increasing strengths of acid to customize the degree of improvement for the individual. These peels, good as they are, are not a substitute for a face-lift. What they are is help for the fine lines that begin at the corners of the eyes and mouth, then become secondary lines on the cheeks, forehead, etc. We usually recommend a series of three peels, carried out monthly, using increasing strengths of the TCA. Depending upon whether one wants to keep the process a secret from friends and coworkers, it may be possible to return to work the next day. Many patients prefer to take a few days off when the stronger solutions are used, for privacy reasons. The face mostly resembles severe sunburn for several days. So, in spite of what you may have seen on television, the 'lunch-hour face lift 'is not reality.
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How do I choose my plastic surgeon? (The seven check ups you should do.)
As with any surgery, the single most important factor in the success of aesthetic plastic surgery is the surgeon you select. Do not take this responsibility lightly. Conduct your own research to verify the surgeon's training and experience; then weigh your decision carefully.
There are a number of ways to evaluate which surgeon is right for you.
- Check for certification by the American Board of Plastic Surgery. American Board of Plastic Surgery (ABPS) certification means that the surgeon has completed undergraduate college, medical school, an approved surgery residency of at least three years and an approved plastic surgery residency of an additional two to three years. Board certification then is obtained only after the candidate has been in plastic surgery practice for at least two years and has passed rigorous written and oral examinations administered by experienced plastic surgeons.
- Don't be confused by other official sounding boards and certifications. The American Board of Plastic Surgery is the only board recognized by the American Board of Medical Specialties (ABMS) to certify in the plastic surgery specialty. There is no separate, ABMS-recognized certifying board for cosmetic surgery.
- Remember that in most states, it is legal for any physician who holds a medical license, with or without surgical training, to advertise as a plastic or cosmetic surgeon. That's why understanding board certification is so important for the prospective patient.
- If there is confusion about a surgeon's board certification, you may consult the ABMS Directory of Certified Medical Specialists available at most libraries or online at www.certifieddoctor.org.
- Check for membership in the American Society of Plastic and Reconstructive Surgeons (ASPRS) or the American Society for Aesthetic Plastic Surgery (ASAPS). Members of these professional societies are certified by the American Board of Plastic Surgery. ASPRS represents the full scope of plastic surgery (reconstructive and aesthetic). Members of ASAPS are also fully trained in plastic and reconstructive surgery but have a special interest in aesthetic procedures.
- Check the surgeon's hospital affiliation. Qualified hospitals have been accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). An appointment to the surgical staff of an accredited hospital indicates that a surgeon's capabilities and performance have been reviewed and judged acceptable by medical colleagues. Be sure that your surgeon has hospital privileges to perform the specific surgical procedure in which you are interested, even if you plan to have your surgery performed in an office based surgical facility.
- Talk candidly with the surgeon. After you have checked the credentials of a plastic surgeon, you should make an appointment for an initial consultation. During this consultation, the surgeon will examine you, explain the operation and may give you literature describing preoperative considerations and postoperative care. You should feel comfortable discussing your expectations and questioning your surgeon on any aspect of the surgery. A qualified and reputable plastic surgeon will be happy to answer your questions and to inform you of the possible risks and side effects associated with surgery.
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What about fees and insurance?
Fees for aesthetic plastic surgery traditionally are paid prior to surgery. Costs vary widely and depend on the complexity of the operation, where the surgery takes place and which anesthetic is administered.
As a rule, aesthetic plastic surgery is considered "elective surgery" and is not covered by most insurance plans. Sometimes, however, there is a fine line between whether the surgery's prime objective is to improve appearance or to improve function. For example, protruding or large ears may be considered a birth defect and ear surgery deemed necessary to correct it. Similar judgments may be made regarding eye surgery if drooping lids impair vision, or breast reduction if the weight of the breasts causes pain or interferes with normal activity. If this is the case, contact your insurance company before surgery to determine how it views your particular surgery.
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What about surgical facilities and anesthesia?
Surgery can be performed in a number of locations, depending on the procedure and what your plastic surgeon regards as appropriate. Generally, aesthetic plastic surgery takes place in a hospital or an ambulatory care setting, such as an outpatient center or your surgeon's office-based surgical facility.
In many cases, a local anesthetic will be administered to numb the area to be treated, along with a sedative to relax you. For some aesthetic surgical procedures, however, you will be given general anesthesia so that you sleep through the entire operation. Postoperative discomfort is normally controlled with medication.
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What about potential risks and complications?
Although some of the procedures described on this website appear to be relatively simple operations, it is essential for you to understand that aesthetic plastic surgery, like all surgery, has attendant risks.
Plastic surgeons perform thousands of successful aesthetic procedures each week, but as with any type of surgery, a patient can have an adverse reaction to the anesthetic or be affected by postoperative complications such as blood clots, infection or poor healing. These problems can occur even when the surgeon has performed the operation with the utmost skill. Since smoking may interfere with proper healing and aspirin may increase the risk of excessive bleeding, you may be advised to avoid them before and after surgery. Occasionally, surgical revisions may be desirable to achieve optimal results.
It is important to remember that aesthetic plastic surgery molds and reshapes living tissue, and the results are not absolutely predictable. No surgeon can offer risk-free surgery or guarantee a perfect result.
Your plastic surgeon will inform you of any restrictions to your normal activities following surgery. In general, you should avoid strenuous exercise and other activities that raise your blood pressure, including bending, for several days to weeks (depending on what type of surgery was performed). It takes time as well for the visible signs of healing to subside.
Do not expect to see the final results of your surgery right away. Plan your social activities to allow sufficient time for recovery.
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What are some other things to consider?
The results achieved in some aesthetic surgical procedures, such as surgery of the nose, ears and chin, are permanent. In others, particularly those that diminish the effects of aging, results may be long lasting but are not permanent. Plastic surgery may be able to turn back the clock, but, it will not stop the clock from running.
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What to bring when you come in for your first consultation
Here are the 4 things that you will want to remember to bring with you for your initial consultation with Dr. Johnson.
- Medical history (past surgery, allergies, and current medications--name, dosage, etc.)
- Social security number
- Drug store (name, branch location and phone number)
- In case of emergency: name, address and phone number of emergency contact person (not someone in your own household)
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Do you offer the "featherlift" or other one-day facelifts?
While we have investigated the various "threadlifts" that have been drawing attention from the media, as well as creating advertising buzz, we have some concerns. A study was presented at The American Society for Aesthetic Plastic Surgery in 2004. Ten patients underwent this technique and were photographed before surgery and at six weeks, three months, six months, nine months and one year postoperatively. At the end of a year, only ONE of the ten patients had retained any significant improvement from the preoperative pictures. The cost (to the surgeon or facility) of the barbed threads which are used in these procedures is $95/each, and most of the patients underwent placement of eight to ten threads. With the surgeon's fee and operating room fees, they had invested more than half of the cost of a more complete facelift, which should retain improvement for seven to ten years! This is an evolving technique, and we will continue to monitor progress in this area. We want to offer our patients the best available procedures, while remaining conscious of the expense involved.
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