Question:  Do breast implants interfere with mammography and can a mammogram damage the implants?

Answer:  This is a question that I address with all of my breast implant patients.

The answer depends upon whether the implant is surgically placed above or below the pectoralis (chest) muscle.  Most of the time in very small or medium sized candidates for breast augmentation (A and B cups), the implants are placed beneath the chest muscles.  This actually allows the patients’ breast to be more easily mammogramed.  The implant pushes the natural breast away from the ribs, allowing the mammographer to get better compression and view of the breast.  Many small breasted women (A cups) are very difficult to mammogram because the tissue cannot be compressed between the x-ray plates.

Occasionally, a patient will opt for an implant above the chest muscles but beneath the breast gland (subglandular).  This placement is generally used for patients who have slight sagging of the breasts (ptosis) and do not want to have a breast lift (mastopexy).

In this case, the implant obscures a percentage of the breast.  Breast implants are radiopaue, which means the mammogram rays cannot see through them.  In this case, a maneuver called an Ekland is performed, to push the implant away from the breast tissue so that it obscures less tissue.  Even with this maneuver though, some tissue will not be seen.

This is important information for a patient to understand prior to surgery and it is valuable for a patient to understand the placement of their implants for future reference.

Although, I have never seen or heard of an implant being damaged during routine mammography, saline implants do have a leakage rate of less than 1%, so it cannot be ruled out entirely as a possibility.  As always, it is important to find a physician with significant experience and training in cosmetic surgery to discuss all options with.

Question:  My husband is a 43 year old man who exercises regularly but is still very self conscious about his appearance because he has breasts. (if you call them that on a man?) He won’t even go to the pool in the summer because he’s uncomfortable being shirtless in public. No matter how much he works out, he’s unable to lose the fat or tighten the skin in this area.  Is there a surgery that could help him?

Answer:   Your husband’s problem is not uncommon and definitely makes a man very uncomfortable in many situations. He has a condition called gynecomastia (male breasts).  True gynecomastia is caused by abnormally enlarged breast tissue whereas pseudo-gynecomastia is the result of an excessive amount of fatty tissue in the male breast area.  The most common deformity is a combination of both, where there is a larger than normal amount of breast (fibrous) tissue in the chest, along with an abnormal amount of fatty tissue.

True gynecomastia can be a normal finding in a healthy male, but there are some medical conditions that can cause pathologic (disease related) gynecomastia.  There are also a number of medications which can cause the development of male breasts. Men are also susceptible to breast cancer and this must be evaluated.

If your husband has the type of gynecomastia that is not related to disease or medications, then he would be a good candidate for surgery.  Surgery is performed on an outpatient basis and requires an anesthetic.  The excess fatty tissue is removed around the chest area with liposuction, and then the breast tissue is removed surgically thru an incision just under the nipple.  This keeps scarring to a minimum.  When the breasts are extremely large, the skin may not shrink completely after the chest area is flattened with surgery.  In that case, additional surgery may be required.

I believe that this surgery gives excellent results and certainly improves the patient’s self esteem and self image. I would recommend that you make a consultation with an experienced board certified plastic surgeon who can evaluate your husband and discuss his options and the risks and complications associated with the procedures.

What is the Natural (Vector) Facelift®?

The Natural (Vector) Facelift® is a method of tightening the face in a manner that gives the most natural and relaxed appearance post surgically. This facelift technique tightens the facial tissue covering underlying muscle in multiple directions or vectors; which counteracts the sagging and laxity that occurs as we age. The tissue is then returned to its younger, original position. After this system of tightening, the skin is then gently positioned over the naturally arranged muscle layers, resulting in a smooth and supple appearance as opposed to the severe, tightened look often seen in facelift surgery. The Natural (Vector) Facelift® is time efficient, taking only a few hours. The tissue is handled with extreme care. which minimizes bruising considerably and facilitates prompt healing.

Most patients can shower and wash their hair within 48 hours of their surgery. The average recovery period is 10-14 days; this allows the sutures to be removed and any negligible swelling or bruising to diminish. We tell our patients that they can return to work in 14 days, safely and with confidence. Most patients experience no pain after this procedure because it is done in such a precise, gentle and efficient manner. For the most part, only minimal discomfort is ever reported.

Surgery is performed in a state-of-the-art out patient surgery center with specialized nursing staff and post operative care. If you are considering facial cosmetic surgery and have some of the concerns noted, be sure to ask us about the Natural Vector Facelift®.

Question:  Since plastic surgery is almost always elective, do insurance companies ever pay for it?

Answer:   In a perfect world we would all be able to make the changes we would like and have it covered by our insurance programs. Unfortunately, that isn’t always the case.  However, because plastic surgery encompasses both reconstructive surgery and cosmetic surgery, insurance will often pay for more procedures than you might expect. Most surgeries that are recommended to improve function, to correct a defect from birth, disease, or injury, or to prevent disease are usually covered by health insurance. Some of the following are examples of surgeries commonly insured:

•           Breast Cancer Reconstruction, which also includes surgery on the breast opposite the breast cancer in order to obtain symmetry.

•           Breast Reduction Surgery, which would require that a specific amount of breast tissue be removed, in order for insurance to consider it “medically necessary”.

•           Reconstructive Breast Surgery to correct a birth anomaly, or malformation.

•           Nasal Surgery, for the improvement of breathing.

•           Skin Cancer Surgery and the surgical repair of the tissue after removal of the cancer.

•           Removal of suspicious or premalignant moles (nevi) on the skin.

•           Upper Eyelid Surgery, if the eyelids are shown to cause obstruction of vision.

Procedures that enhance appearance, if not related to birth defects, cancer treatment or injury, anything that isn’t considered “medically necessary” are unlikely to be covered by insurance companies.

Procedures that are generally not covered include: liposuction, breast augmentation (enhancement); tummy tucks; facelifts, cosmetic nasal surgery, cosmetic eyelid surgery, breast lifts (mastopexy); cosmetic hair transplantation, and injectables such as Botox, Juvederm, and Restylane.

There are many gray areas where cosmetic surgery and reconstructive surgery can overlap.  When insurance does not cover a procedure, most offices will offer financing through a third party if you still are interested.

Question:  I have recently read about a new liposuction technique that uses a laser. The article said that there is little bruising, and a quick recovery time? How is this different from standard liposuction?

Answer:  Liposuction has evolved tremendously over the last several decades. In the past two decades alone, a number of new techniques and instruments have been developed for liposuction surgery, the most recent of which is the use of a laser.

In 1987, the Tumescent technique for liposuction was introduced to the cosmetic surgery world.  This procedure was probably the biggest advancement in liposuction thus far in terms of overall patient comfort, convenience, and outcome. Tumescent liposuction was the first technique developed that permits liposuction in small volumes to be accomplished totally by local anesthesia with minimal bruising. The tumescent liposuction technique uses large volumes of a very diluted solution of saline, local anesthesia, and epinephrine that is gently injected into the targeted fat. This injection numbs the area, firms up the skin around it, and reduces blood loss and bruising. Once the area is desensitized, the surgeon makes a small incision in the skin and is able to suction out the fat and fluid using a fine probe. This allows a surgeon with good technique to deliver a smooth, unrippled appearance to the surgical site.

Other advances in liposuction in recent times are ultrasonic liposuction and power-assisted liposuction, both of which utilize the Tumescent technique.  At this time, laser-assisted liposuction is more of a gimmick than an advance in surgery. The word “laser” indicates a more precise and advanced procedure, however the current technology falls short of that.

In laser liposuction, a small laser fiber is inserted in the fatty layer of the tissues, the laser then melts (dissolves) the fat that it comes in contact with. The liquefied fat cells are then either absorbed by the body or removed by suction. The absorption makes accurate measurement of the fat removed impossible. This can create problems with symmetry in the final result. Laser-assisted liposuction is also only designed to be used in small areas of the body.

In my opinion, Tumescent liposuction remains the procedure of choice for both small and large areas of the body because of its minimal bruising and swelling, rapid recovery time, and it’s reliable outcome.

Question:  With all the layoffs that have been occurring and the resulting competitive workforce, I’ve recently been considering plastic surgery. I’m 55 years old and working middle management in a field that has seen a lot of job reductions. I’m wondering what you would suggest to give me a “competitive edge” over some of the younger entrants into the job market?

Answer: In a perfect world, competition in the workforce would be based purely on a person’s ability, knowledge, and experience. Unfortunately, our society
does put emphasis on appearance and image. Cosmetic surgery will not make you land a job, get you a promotion, or save a relationship; however, it can help to give you a more rested and energetic appearance as well as a raised level of self-confidence.

There are a number of options both surgical and non-surgical that can be utilized. Something as simple as a new skin care regimen enhanced with routine microdermabrasions is a good first step towards a more refreshed look. There are also a number of injectable products on the market today that are used to rejuvenate the face in a noninvasive and cost effective manner, such as Botox and Juvederm.

Surgical treatments would vary depending on which aspects of the face are most affected by age; beginning with the eyelids (blepharoplasty), facelift, necklift, browlift or any combination of these.

The bottom line is if cosmetic surgery boosts your confidence, positive things can follow.  People who look tired or older than they feel can certainly get a psychological boost from the restorative treatments currently available. Cosmetic Plastic Surgery does not add years to your life but it can add life to your years.  Realistic expectations are essential when considering any procedure but if you will have greater self-assurance from your enhanced appearance, it can only have a positive effect.  An experienced and reputable plastic surgeon should be able to address your concerns and evaluate your expectations.

Question:  My neighbor recently had a facelift and although she looks much better, her ­­face and neck. Is that normal when you have a facelift? What is traditionally done in a facelift and what would be considered a different procedure?

Answer: This is a good question; generally the facelift includes the face (from the level of the temples to the chin) and the neck (from the jaw line to the adam’s apple). The eyelids (upper or lower) and the forehead, are separate procedures that can be done individually or in conjunction with a facelift. When you are consulting with a surgeon for a facelift, your eyelids and forehead should always be evaluated as well. An experienced Surgeon will be able to guide you through the options available and whether or not you would even be a candidate for each of these procedures. Whether you are interested in the additional procedures or not, the options should be explained so you’ll have a complete understanding of what each can and cannot accomplish, this helps to establish realistic expectations for your outcome.

If deemed beneficial, the eyelids, brow lift, and facelift procedures combined, result in an amazing complete facial rejuvenation surgery. The procedures certainly compliment one another and are considered a safe combination to have during a single operative session.

I cannot stress the importance of a consultation with an experienced surgeon that will be honest with you and help you decide what will benefit you the most. Don’t be afraid to ask questions.  The surgeon’s own before and after photographs will also help you decide what will work for you.

Question:  For years I’ve had a minor amount of puffiness under my eyes. It was not always a problem, I just sometimes looked run down. However, I recently noticed that I’ve developed what looks like a sunken line or ring underneath the puffy part of my lower eyelid. I thought the puffiness made me look tired, this sunken ring makes me look downright old! How can this be treated?

Answer:  What you’re describing sounds like a tear trough deformity. I’ve had patients refer to this as deep circles under their eyes. A tear trough deformity becomes evident when the lower eyelid becomes puffy and a depression underneath it forms. This is a result of age, heredity, and/or chronic fatigue.

The treatment has historically been a lower eyelid lift (blepharoplasty) with or without fat tissue placementto smooth the area. Eyelid surgery is invasive and requires healing time but does give a long lasting result.

Thankfully, there is now a non-surgical treatment that can improve the appearance of the lower eyelids by a simple injection of HA (hyaluronic acid) filler into the tear trough deformity. The result is not as good as it is with the surgical option but can give a significant improvement and in many cases delay the need for
surgery by several years.

The injection of HA filler into the tear trough can be performed in the office with no anesthetic required. This procedure takes minutes to perform, and results are evident within days. Patients should not exercise for at least 24 hours after injection, as this can result in swelling and bruising. Bruising is possible anytime a needle is used to inject into the skin.

This particular procedure is one of the more difficult injection techniques to learn, requiring a precise and conservative approach, so your practitioner should have significant skill and experience. The results of
this treatment can be excellent and without the risks associated with surgery.

Question:   I am 66 years old, and when I was 58 I had a facelift and eyelid surgery. My neck and eyelid skin has gradually loosened again and I’m beginning to develop jowls.  I really want to keep a youthful look and was wondering if it’s safe to have another facelift and eye surgery?

Answer:  Your question is one I frequently hear when consulting with patients your age. The mid forties and fifties are a common time for people to begin facial rejuvenation surgery. People in this age group like to have procedures to refresh their appearance prior to experiencing major sagging and skin laxity. When done at this time, no one suspects that a person has had surgery. I developed the Natural Vector Facelift specifically for this reason; to give my patients an inherently youthful appearance at all ages, whether it’s a person’s initial surgery in their 40s or a second one in their 60s. The Natural Vector Facelift is designed to gently restore the muscular structure and skin tone of the face and neck to it’s primary state, as opposed to a tight, severe, manufactured look.

It is not unusual for patients to undergo additional facial surgery anywhere from 5-10 years after their initial procedures and it is considered relatively safe to have more than one facelift.

I occasionally see patients whose original procedure resulted in unsightly scars and hairline deformities. This is generally the result of the initial surgery being done incorrectly. Though a second surgery isn’t as straight
forward, a significant improvement can usually be achieved if the proper surgical technique is used.

Eyelid surgery can also be tricky the second time around because of scar tissue formation from prior surgery, among other things. Browlifts are often regarded a good alternative to additional upper eyelid surgery.

What is the Natural (Vector) FaceliftTM?

The Natural (Vector) FaceliftTM is a method of tightening the face in a manner that gives the most natural and relaxed appearance post surgically. This facelift technique tightens the facial tissue covering underlying muscle in multiple directions or vectors; which counteracts the sagging and laxity that occurs as we age. The tissue is then returned to its younger, original position. After this system of tightening, the skin is then gently positioned over the naturally arranged muscle layers, resulting in a smooth and supple appearance as opposed to the severe, tightened look often seen in facelift surgery. The Natural (Vector) FaceliftTM is time efficient, taking only a few hours. The tissue is handled with extreme care. which minimizes bruising considerably and facilitates prompt healing.

Most patients can shower and wash their hair within 48 hours of their surgery. The average recovery period is 10-14 days; this allows the sutures to be removed and any negligible swelling or bruising to diminish. We tell our patients that they can return to work in 14 days, safely and with confidence. Most patients experience no pain after this procedure because it is done in such a precise, gentle and efficient manner. For the most part, only minimal discomfort is ever reported.

Surgery is performed in a state-of-the-art out patient surgery center with specialized nursing staff and post operative care. If you are considering facial cosmetic surgery and have some of the concerns noted, be sure to ask us about the Natural Vector FaceliftTM.

Question:  I am a 52 year old woman in good health. I was a 1 pack per day smoker until I quit 5 years ago.  I was also a sun worshiper, as I think most of my generationwas, and would burn and tan every summer of my youth. The skin on my face looks pretty good but I am embarrassed by vertical lines around my mouth. Is there anything I can do about this?

Answer:  The history you’ve just described is a text book example for developing the lines that you have. Vertical creases around the mouth are a combination of smoking, sun exposure and heredity. These lines can be very deep and often difficult to cover with makeup.  Lipstick can creep into the lines creating an uneven lip line or “lipstick bleed” effect.   

Traditionally treatments have been either topical, laser resurfacing or chemical peels, which treat the surface of the skin or injectible, such as botox to weaken the muscles used to pucker the lips and temporary fillers such as collagen, used to plump the lip and lip lines. 

Laser resurfacing has good results. Unfortunately, the healing time (several months of redness) and the expense, can be prohibitive. Chemical peels, although more affordable and offering a faster recovery, do not produce a result as a good as the laser.

The injectable methods, such as Botox and collagen products can give a moderate improvement which lasts for several months. The short duration of  these products however makes most patients dissatisfied.

The latest option that I’ve been utilizing is a direct injection of the creases with Juvederm, a new hyaluronic acid (HA) filler. This product absorbs the body’s own water which then swells in the crease causing it to flatten. The results are superior to any other method I’ve used up to this point. Injection of Juvederm is an office procedure that allows you to return to work the following day. I only ask that patients not exercise for 24 hours following treatment to prevent swelling from occurring at the injection site. This treatment generally lasts from 6-12 months.

I have had patients come to my office requesting and willing to pay for laser resurfacing or chemical peels but once they evaluate this option they are almost always pleased with the result, it’s less expensive, has minimal risk, negligible recovery time, and reasonable longevity.

Question:  I have seen ads for cosmetic surgery where you can recover at a spa or resort immediately after the surgery. Are these facilities safe?

Answer:  The people in charge of marketing these places and some physicians often minimize the complexity of cosmetic surgical procedures, as well as the post-operative recovery. By doing this, they hope to entice patients to their facilities by making surgeries seem effortless and painless.

The more complicated procedures such as facelifts, tummy tucks, breast reductions, and those having multiple procedures, may require overnight observation.  This can improve the post-operative recovery and allow the patient and the family to get some needed rest that first night after surgery without worrying about drains, bandages and pain. Physicians and nurses are readily available with all the appropriate medicine, instruments and supplies, should a rare emergency arise requiring immediate intervention.

It is my opinion that patients who require overnight or longer observation need a medical facility, not a spa or resort. Let’s face it; this luxury treatment isn’t free or even cheap. Its intended purpose is to pamper and comfort the patient, but in reality it is impossible to appreciate, much less enjoy a luxurious room, a beautiful view, or gourmet cuisine when you are wrapped and swollen, bruised, dealing with some pain and hopefully, sleeping 90% of the time.  The ultimatecomfort comes in the knowledge that your post-operative care is provided by a facility that follows strict hospital coding laws and offers immediate physician and nursing care.

Question:  I’m interested in having my breasts larger but I don’t want them to be too big.

I am presently an A cup and would like to be a full B cup. I want to enhance my figure but don’t want my breasts to be the first thing people notice. I’m also a runner and concerned that breast implants could make working out uncomfortable. What’s your experience with this kind of situation?

Answer:  Inquiries like yours have actually become more common lately. Several years ago, the most common cup size requested by a breast enlargement patient was a full C cup or larger. Most patients wanted to show cleavage and take on a more “Hollywood” look. However, the trend recently has been women looking for a more conservative appearance. The stigma associated with some breast enhancement can be either positive or negative, depending upon the patient’s persona. For instance, a businesswoman does not want to walk into the boardroom and not be taken seriously because her large breasts are too distracting. For these women, a moderate approach works best for them in their professional life and still allows them the flexibility to look very feminine and sexy if choosing to wear something more fitted or low cut for leisure time.

My more athletic patients, who wouldn’t have considered breast enlargement fearing the stereotypical busty look, are now requesting enhancement that allows them to maintain their freedom of unencumbered movement while giving them more confidence in a larger variety of clothing and fashions.

There has been a definite change in the trend of breast augmentation lately. If you are someone who is interested in a more modest change, it is important is that you consider the proportional aspects of your body frame when thinking about a cup size. A full B cup on a woman who has a petite, 5’4”, size 2 frame is going to look very different than on a woman who is 5’7” wearing a size 8.  It is very important that you choose a surgeon who listens to your concerns, understands what size you wish to be and has the experience to guide you to the correct size implant
for your lifestyle.

Question: I have a small, flat behind and have always wanted a more rounded one. I’m not interested in something as dramatic as JLo’s but I’d like to be significantly more shapely than I currently am. I’ve heard that there are implants for the bottom and I’m wondering how safe they are?

Answer:  There are a few surgical options available for the small or saggy buttock region; they are free fat transfer, gluteal implants, and the Brazilian buttock lift.  Let me just say right off the bat that flat or saggy buttocks are difficult to treat and all of the procedures currently offered have drawbacks. 

The first option, free fat transfer, is the process by which one’s own fat is removed from a donor site and injected into the buttock for enhancement. This requires a substantial volume of fat to be collected and subsequently transferred. The percentage of fat transferred that is viable varies from 0-50%, most of which is absorbed by the body over time. Multiple treatments are required for any substantial change and the results are very inconsistent.

The buttock (gluteal) implants are fraught with problems,the most common of which are infection, hematoma and seroma formation, and migration. Migration is when theimplant moves from its original placement site; this is not only painful but creates an asymmetric appearance to the bottom. Another setback that can occur is the growth of irregular scar tissue formations around the implant (capsular contracture), which can also be painful and make the implant feel hard and unnatural. Even in the most experienced hands, these difficulties occur with high
frequency and are major concerns.

The buttock lift, aka:Brazilian is the method of cutting, lifting and tucking the buttock skin. The result is a much nicer shape, however, the scars are conspicuous, and often unsightly. Scars in this area greatly limit the type of bathing
suits that can be worn, and frequently make patients more self-conscious than they were prior to surgery.

In my opinion, there aren’t currently any great surgical options for enhancing or lifting the buttocks. For a person who wants to achieve more definition, I recommend hiring a personal trainer who can direct you in exercises to build up the gluteal muscles; this will enhance buttock shape safely and be money well spent.

Someday, there may be better surgical options available. Even though some patients are happy with the procedures described above, there are many more unhappy patients to consider them generally successful.

Question: I have been seeing advertisements for laser liposuction. Is this a significant breakthrough in liposuction surgery and, if so, what are the benefits?

Answer:  To be very frank, laser-assisted liposuction is purely gimmick. The technique of tumescent liposuction remains the gold standard for excellent results and rapid healing. Other so-called advances such as ultrasonic
liposuction were the rage and have since proved to be just another device to attract publicity.  When done correctly, tumescent liposuction is every bit as non-invasive as a laser when done in small areas, such as under the chin (submental). Physicians looking for a niche in the cosmetic surgery market often use attention-grabbing techniques which lack true long-term substantiation. You will not find experienced, well-known surgeons doing procedures like this unless they have been established as having results that are extremely superior to a traditional method.

In the past decade a number of medical treatments have been created specifically for use in physicians’ offices. Such treatments offer easier accessibility and lower costs to a patient compared to utilizing a hospital, while creating a specialized market for a doctor’s practice. When the surgery in question involves multiple sites or larger areas, however, it is always a much safer route to have the procedure done in an accredited surgery center or hospital. There, trained emergency staff and services are readily available if necessary. Laser-assisted liposuction is a procedure only available in physicians' offices.

Your best bet is to consult an established surgeon with proven experience in liposuction surgery and ask to see their results.

Question: Recently I’ve been seeing a ton of commercials on TV for facelifts with different names. Are they truly facelifts or different kinds of procedures? Are any of these something to be leery of?

Answer:  A lot of the surgeries being advertised (I’m not able to list their real titles) have names like the rapid lift, weekend lift, mini lift, lifetime lift. These are surgeries designed to reduce recuperation time and money spent. There are a number of reasons you should be guarded about these ads; they can be very misleading. The most significant reason is the patients shown in the commercials have results that couldn’t possibly be achieved by only the lift that is being advertised.

The surgeries that some doctors claim are “rapid” or “faster” are usually just abbreviated surgeries. If important steps are omitted in a surgery, making it faster, the results may not last as long as the full procedure. This makes the savings irrelevant.

Another concern, the surgeon you visit for the advertised lift may not be the doctor responsible for the pictures used in the commercial. Many of these advertisements are run by surgical groups, and you aren’t guaranteed the physician that actually did the work you saw.

Facial cosmetic surgery has improved over the years, and patients tend to base their perception of facelift surgery on old results and outdated recovery.  Americans are eager to look better with little down time, minimal pain, while keeping it as inexpensive as possible. Traditional training in facial cosmetic surgery was to pull the facial tissues up and back, as tight as tolerable. This resulted in significant bruising, pain and an unnatural appearance. Today’s methods are much more refined, as are the outcomes, and this makes the surgery much more marketable than in the past. This explains why there has been such an increase in advertising for the procedure.

Since it is your face that you’re thinking about altering, an area that obviously can’t be hidden, doesn’t it make sense not to cut corners doing an expedited and cheaper procedure?

Question:  Why is it that you see so many celebrities having bad plastic surgery? Some of them were very attractive people, who are now morphed and look nothing like they did prior to surgery.  They make their living on their looks; why wouldn’t they go to the best surgeon available to protect their assets?

Answer:  Some celebrities who have recently undergone bad facial surgery have been quite vocal about their unhappiness with the outcome.  Others may be very happy with how they look or are just silent about their discontent.

Facelift surgery for one, should not morph your face; it should return it to a more youthful and natural appearance not a tight and abnormal one. For many years, plastic surgeons and the public felt that the tighter the lift, the younger the face. The technique that was taught was to pull the skin in a direction that resulted in distortion of the eyelid, corner of the mouth and the earlobe. A surgeon who regularly revises his training will know better.

Another procedure known to drastically change a person’s appearance and not always for the better, is nasal surgery (rhinoplasty). The old trend in rhinoplasty was to shorten the length of the nose, often  too dramatically, remove the bump on top of the nose, then form a slope going toward the tip. This was designed when the ”upturned nose” was in high style. Unfortunately, the result was often more of a shortened piggy nose. Today people like to keep some level of their natural appearance changing only a few aspects of the nose and doing so in a very subtle manner. That’s why it is so important to choose a physician who stays updated on new techniques and has a lot of experience in facial surgeries.

I don’t have an answer as to why celebrities aren’t thoroughly evaluating a surgeon’s work prior to embarking on facial surgery. One explanation could be that they are too concerned with people knowing that they’re considering plastic surgery, so they don’t talk to people who they know have had work done. Word of mouth and seeing the results of an actual patient first hand are often some of the best ways to determine if you like a surgeon’s work. From there, you check out the doctor’s credentials. 

It is evident, that even when money is no object, a good result is not a given. Choose your surgeon carefully. Evaluate his or her work, their discussion, and their staff.  Are  the before and after photos you review actually the work of the surgeon with whom you are consulting? A good surgeon will also be evaluating you to see if you are a good candidate for the procedures discussed and if your expectations are realistic.

Question:  I have seen ads for cosmetic surgery where you can recover at a spa or resort immediately after the surgery. Are these facilities safe?

Answer:  The people in charge of marketing these places and some physicians often minimize the complexity of cosmetic surgical procedures, as well
as the post-operative recovery. By doing this, they hope to entice patients to their facilities by making surgeries seem effortless and painless.

The more complicated procedures such as facelifts, tummy tucks, breast reductions, and those having multiple procedures, may require overnight observation.  This can improve the post-operative recovery and allow the patient and the family to get some needed rest that first night after surgery without worrying about drains, bandages and pain. Physicians and nurses are readily available with all the appropriate medicine, instruments and supplies, should a rare emergency arise requiring immediate intervention.

It is my opinion that patients who require overnight or longer observation need a medical facility, not a spa or resort. Let’s face it; this luxury treatment isn’t free or even cheap. Its intended purpose is to pamper and comfort the patient, but in reality it is impossible to appreciate, much less enjoy a luxurious room, a beautiful view, or gourmet cuisine when you are wrapped and swollen, bruised, dealing with some pain and hopefully, sleeping 90% of the time.  The ultimate comfort comes in the knowledge that your post-operative care is provided by a facility that follows strict hospital coding laws and offers immediate physician and nursing care.

What is the Natural (Vector) FaceliftTM?

The Natural (Vector) FaceliftTM is a method of tightening the face in a manner that give the most natural and relaxed appearance post surgically. This facelift technique tightens the facial tissue covering underlying muscle in
multiple directions or vectors; which counteracts the sagging and laxity that occurs as we age. The tissue is then returned to its younger, original position. After this system of tightening, the skin is then gently positioned over the naturally arranged muscle layers, resulting in a smooth and supple appearance as opposed to the severe, tightened look often seen in facelift surgery. The Natural (Vector) FaceliftTM is time efficient, taking only a few hours. The tissue is handled with extreme care. which minimizes bruising considerably and facilitates prompt healing.

Most patients can shower and wash their hair within 48 hours of their surgery. The average recovery period is 10-14 days; this allows the sutures to be removed and any negligible swelling or bruising to diminish. We tell our patients that they can return to work in 14 days, safely and with confidence. Most patients experience no pain after this procedure because it is done in such a precise, gentle and efficient manner. For the most part, only minimal discomfort is ever reported.

Surgery is performed in a state-of-the-art out patient surgery center with specialized nursing staff and post operative care. If you are considering facial cosmetic surgery and have some of the concerns noted, be sure to ask us about the Natural Vector FaceliftTM.

Question: My friend’s mom was telling her about  a new facial procedure that was supposed to be amazing. I think she called it a “Natural Vector”?? I’m wondering if you’re aware of what she’s talking about and what kind of surgery it is?

Answer:  It’s very ironic that you asked me about that because the system she was referring to is actually something that was developed in my practice.  The Natural (Vector) Facelift is a technique used to renew the appearance of the face in a manner that results in a natural, youthful look instead of a tight, obviously altered appearance.

This facelift method strategically tightens the underlying facial tissue in multiple directions (vectors), counteracting the sagging and laxity that occurs in the aging process. The muscles are returned to their original position then the skin is gently positioned over the muscle layers, resulting in a smooth and younger profile as opposed to the tight, stretched look seen after many facelift surgeries.

The Natural (Vector) Facelift is time efficient, taking only 2-2 ½ hours.  The underlying muscle is handled with great care to minimize bruising and discomfort and to speed recovery. The majority of patients will be able to wash their hair within 48 hours, with the recovery period generally taking 10-14 days; this allows the sutures to be removed and the minimal bruising to fade. We tell our patients that they can return to work in 14 days safely and with confidence.

Most patients experience no pain after the surgery because of the gentle and proficient manner in which it is performed. Typically, nothing more than slight discomfort is experienced. Surgery is performed at a state-of-the-art out-patient surgery center with specialized staff and post operative care.

Question:  On a frequent basis, I see advertisements for products that are “better than Botox”, lunchtime laser liposuction, weekend facelifts, non-surgical tummy tucks, facial exercise equipment for jowls, and products that can thicken your hair and fill in balding areas in one treatment. Is there any truth to these claims; do they work even a little?

Answer: If it sounds too good to be true… well, you know the rest. The golden standard for treatment of these areas of the body cannot be found in a bottle or box but in the office of a reputable physician; that’s
why I am still in business. Although taking a quicker or cheaper route can be very appealing and hard to resist, ultimately, you get what you pay for.

Many of the companies offering these products just want you to try them once, that’s where they plan to make their money. Statistically, very few people will ask for a refund and fill out the necessary paperwork to get their money back.  Millions of dollars are made annually on unproven and false claims made by companies and there really is no government entity to oversee these goods. The products are not illegal, only unethical.

This is not to say that there are not exceptional products on the horizon that may sound too good to be true; those that will ultimately pass the test of extensive research and time.  I tell my patients that if they encounter such a product or procedure that my staff and I will be more than happy to discuss those that we are familiar with, and research those we are not.

Question:  I’ve been thinking about getting breast implants and have no idea what size would be best for me. How would I determine that? What is your most commonly requested size?

Answer: There are many things to think about when deciding on an appropriate postoperative breast size. The first thing that you would want to consider is whether or not you want to go with a very natural look or a more “stand out” appearance.

As we all know, breast enhancement can be a very subtle change or incredibly dramatic. With this in mind, you need to take into account your body frame. A 5’ tall, size 4 petite person will look quite different with a small C cup breast versus a woman who is 5'9" and wears a size 12. This is simply a matter of proportion and balance.

Another thing you will want to think about is your lifestyle. For instance, if you are a runner, a DD breast may not be the most comfortable option. However, women that prefer exercise with less impact may be perfectly happy with this size.

Unfortunately, the bra industry, like the clothing industry in general, has not standardized its sizes; cup dimension varies from manufacturer to manufacturer, making size comparisons somewhat subjective and
therefore challenging to determine.

Taking all of this into account, the majority of women in the Midwest are choosing a full C cup, whereas women on the West Coast, are more likely to request the D to DD size. A cup size that is in proportion to the rest of the body will offer a woman more wardrobe options right off the rack, where a larger breast size and smaller frame will generally require tailoring.

Question:  I'm 55 years old with the face of a 45-year- old but the neck of a 70-year-old.  When I cover my neck I look so much younger.  I can only use a scarf to do this though, because a turtleneck emphasizes my gobbler.  I don't know if a facelift could help this or not.  Is there anything that can be done? A scarf in 90º weather is torture!!

Answer: The neck is every bit as important as the face when it comes to gaining a rejuvenated appearance. It's not that unusual to see an older Hollywood star with a face beautiful for their age, hiding their neck behind scarves or in clothing. Once jowls begin to appear, it is a sign that the skin from the face, jaw and chin are beginning to loosen. People assume that all they need is a facelift when this happens, when in reality what is often needed is both a face and necklift. If the neck is overlooked, or poorly done, the entire facial surgery can be a waste of time and money. In most cases a necklift and facelift go hand in hand.

Although it is possible that some patients may only need a necklift, it is more often the case that procedures such as a chin implant or a facelift are made complete with the addition of the necklift.  A good surgeon that is capable of performing one will address both areas and discuss options with their patients.

The key to a natural necklift is in addressing the multiple directions that the muscle and skin must be tightened for a smooth transition from the neck to the face. The directions of tightening for a natural necklift are called vectors. The fat of the neck needs to be sculpted with liposuction and the thin muscle of the neck (the platysma), needs to be tightened so as to smooth the bands of the neck which become evident with aging.  It is also important to lift the neck low enough to allow complete exposure in clothing and for jewelry. Everyone is familiar with the very harsh, "I've had plastic surgery" look that comes with a procedure not done properly; this illustrates the importance of choosing a plastic surgeon who is experienced in doing this procedure. The best way to do this is to ask how many a surgeon has performed and to see multiple before-and- after photos.

A few younger patients may benefit from liposuction of the submental (under the chin) area also referred to as a waddle. These patients do not have concerns about their jowls or skin laxity. Submental liposuction, with the addition
of a chin implant, if needed, can result in a dramatic improvement that will last for years. It is important to consult with a plastic surgeon that will listen to your concerns and address them honestly. You may or may not require a more extensive procedure, and you certainly would not want to pay for a lesser procedure and be unhappy with it. This is where choosing the right surgeon is most important.

Question:  I heard that the FDA has allowed silicone gel implants back on the market. Does that mean that anyone can get them now?

Answer: It is true that the FDA has recently approved the use of silicone gel implants for primary breast enlargement.  Previously, they could be used in restricted conditions: the patient had to be meet specific criteria and the physician doing the surgery had to be part of an ongoing national clinical study.  Now that all the data from this study has been reviewed and the implants were deemed safe, they have been made available to the public in general.

Both companies that manufacture and distribute silicone gel implants still have an ongoing clinical evaluation taking place in which you may or may not choose to participate in.  Presently, the only conditions set for women choosing to have breast enhancement with silicone gel implants are that the patient must be at least 22 years of age (an arbitrary age set by the FDA), cannot be pregnant or nursing at the time of surgery, cannot be treated for infectious diseases at the time of surgery, and cannot have an existing breast cancer that is untreated at the time of surgery.  This follows the common sense pre-surgical screening that most qualified surgeons would follow, with the exception of the subjective age qualification.

Question:  I have seen ads for cosmetic surgery where you can recover at a spa or resort immediately after the surgery. Are these facilities safe?

Answer:  The people in charge of marketing these places and some physicians minimize the complexity of cosmetic surgical procedures, as well as the post-operative recovery. By doing this, they hope to entice patients to their facilities by making surgeries seem effortless and painless.

The more complicated procedures such as facelifts, tummy tucks, breast reductions, and those having multiple procedures, may require overnight observation.  This can improve the post-operative recovery and allow the patient and the family to get some needed rest that first night after surgery without worrying about drains, bandages and pain. Physicians and nurses are readily available with all the appropriate medicine, instruments and supplies, should a rare emergency arise requiring immediate intervention.

It is my opinion that patients who require overnight or longer observation need a medical facility, not a spa or resort. Let’s face it; this luxury treatment isn’t free or even cheap. Its intended purpose is to pamper and comfort the patient, but in reality it is impossible to appreciate, much less enjoy a luxurious room, a beautiful view, or gourmet cuisine when you are wrapped and swollen, bruised, dealing with some pain and hopefully, sleeping 90% of the time.  The ultimate comfort comes in the knowledge that your post-operative care is provided by a facility that follows strict hospital coding laws and offers immediate physician and nursing care.

Personally, I wouldn’t even have a root canal and want to check into a spa for a massage and French cuisine dinner immediately following the procedure, let alone major cosmetic surgery.  My suggestion is to save your money and enjoy a posh resort or spa after you have healed adequately and can enjoy the experience with your new face and/or body.

Question:  I have seen ads for cosmetic surgery where you can recover at a spa or resort immediately after the surgery. Are these facilities safe?

Answer:  The people in charge of marketing these places and some physicians often minimize the complexity of cosmetic surgical procedures, as well as the post operative recovery.  By doing this they hope to entice patients to use their facilities by making surgeries seem effortless and painless.

The more complicated procedures such as facelifts, tummy tucks, breast reductions, and those having multiple procedures, may require overnight observation.  This can improve the post operative recovery, and allow the patient and the family to get some needed rest that first night after surgery without worrying about drains, bandages and pain. Physicians and nurses are readily available with all the appropriate medicine, instruments, and supplies, should a rare emergency arise requiring immediate intervention.

It is my opinion that patients who require overnight or longer observation need a medical facility, not a spa or resort. Let’s face it; this luxury treatment isn’t free or even cheap. It’s intended purpose is to pamper and comfort the patient but in reality it is impossible to appreciate, much less enjoy a luxurious room, a beautiful view, or gourmet cuisine when you are wrapped and swollen, bruised, dealing with some pain and hopefully, sleeping 90% of the time.  The ultimate comfort comes in the knowledge that your post operative care is provided by a facility that follows strict hospital coding laws and offers immediate physician and nursing care.

Personally, I wouldn’t even have a root canal and want to check into a spa for a massage and French cuisine dinner immediately following the procedure, let alone major cosmetic surgery.  My suggestion is to save your money and enjoy a posh resort or spa after you have healed adequately and can enjoy the experience with your new face and or body.

Question:  I have recently read about a new liposuction technique that uses a laser. The article said that there is little bruising, and a quick recovery time? How is this different from standard liposuction?

Answer:  Liposuction has evolved tremendously over the last several decades. In the past two decades alone, a number of new techniques and instruments have been developed for liposuction surgery, the most recent of which is the use of a laser.

In 1987, the Tumescent technique for liposuction was introduced to the cosmetic surgery world.  This procedure was probably the biggest advancement in liposuction thus far in terms of overall patient comfort, convenience, and outcome. Tumescent liposuction was the first technique developed that permits liposuction in small volumes to be accomplished totally by local anesthesia with minimal bruising. The tumescent liposuction technique uses large volumes of a very diluted solution of saline, local anesthesia, and epinephrine that is gently injected into the targeted fat. This injection numbs the area, firms up the skin around it, and reduces blood loss and bruising. Once the area is desensitized, the surgeon makes a small incision in the skin and is able to suction out the fat and fluid using a fine probe. This allows a surgeon with good technique to deliver a smooth, unrippled appearance to the
surgical site.

Other advances in liposuction in recent times are ultrasonic liposuction and power-assisted liposuction, both of which utilize the Tumescent technique.  At this time, laser-assisted liposuction is more of a gimmick than an advance in surgery. The word “laser” indicates a more precise and advanced procedure, however the current technology falls short of that.

In laser liposuction, a small laser fiber is inserted in the fatty layer of the tissues, the laser then melts (dissolves) the fat that it comes in contact with. The liquefied fat cells are then either absorbed by the body or removed by suction. The absorption makes accurate measurement of the fat removed impossible. This can create problems with symmetry in the final result. Laser-assisted liposuction is also only designed to be used in small areas of the body.

Question:  I know that in the case of a serious illness people will often consult with more than one doctor about their diagnosis. In your area of medicine, when people are having an elective surgery, is it common to get a second opinion?

Answer:  Getting a second opinion on an optional surgery can be quite important for many patients. When it comes to an elective surgery it’s of the utmost importance for you, as the patient, to be comfortable with both the procedure and the physician performing it. Unless you’ve been to a surgeon before and had surgery with a favorable outcome, you may not be completely comfortable booking a surgery during your first consultation with that person.

Probably the most critical level of comfort has to do with the physician you’re conferring with. Hopefully, you will have done your homework and determined that the surgeon you are seeing has good credentials, board certification, hospital affiliations, etc.  A personal recommendation by someone who’s had work done by this doctor is invaluable or a referral by one of the doctors’ colleagues is a good indicator of the doctor’s status in the local medical community. A surgeon that shows you multiple before and after photos of their patients is a good indication of the experience the physician’s had with a given operation.  You definitely want a doctor who welcomes your questions without hesitation, fully explains all the benefits and the risks associated with a surgery, and if you are in fact getting a second opinion, offers their insight about the procedure you’re interested in, not about the surgeon that you saw first. A true professional doesn’t need to run other doctors or their preferred techniques into the ground; they only need to provide you with all the facts.

This brings us to another thing that a second opinion may provide: alternative techniques for a procedure. In plastic surgery there are often different approaches to achieving the desired outcome. As in many professions, you will find those who keep abreast of new trends that have proven to be effective, those that jump on any new fad that pops up and those who are resistant to any change or updated procedures. You as the patient need to be informed about the different methods and why one is deemed better than another. This will inevitably add to your comfort level about the selected surgery.  

Question:  I heard that the FDA has allowed silicone gel implants back on the market. Does that mean that anyone can get them now?

Answer: It is true that the FDA has recently approved the use of silicone gel implants for primary breast enlargement.  Previously, they could be used in restricted conditions: the patient had to be meet specific criteria and the physician doing the surgery had to be part of an ongoing national clinical study.  Now that all the data from this study has been reviewed and the implants were deemed safe, they have been made available to the public in general.

Both companies that manufacture and distribute silicone gel implants still have an ongoing clinical evaluation taking place in which you may or may not choose to participate in.  Presently, the only conditions set for women choosing to have breast enhancement with silicone gel implants are that the patient must be at least 22 years of age (an arbitrary age set by the FDA), cannot be pregnant or nursing at the time of surgery, cannot be treated for infectious diseases at the time of surgery, and cannot have an existing breast cancer that is untreated at the time of surgery.  This follows the common sense pre-surgical screening that most qualified surgeons would follow, with the exception of the subjective age qualification.

Your surgeon should discuss with you the differences between the silicone and saline implants as they apply to the various placement options available.  Your evaluation of which type of implant to use would also be based on your physical stature, the type of look that you want, and your lifestyle.  These are all factors that your surgeon should be willing to review with you, as well as the risks and complications associated with each type of implant and procedure.

Question:  My husband is a 43-year-old man who exercises regularly but is still very self conscious about his appearance because he has breasts. (if you call them that on a man?) He won't even go to the pool in the summer because he's uncomfortable being shirtless in public. No matter how much he works out, he's unable to lose the fat or tighten the skin in this area. Is there a surgery that could help him?

Answer: Your husband's problem is not uncommon and definitely makes a man very uncomfortable in many situations. He has a condition called gynecomastia (male breasts). True gynecomastia is caused by abnormally enlarged breast tissue whereas pseudo-gynecomastia is the result of an excessive amount of fatty tissue in the male breast area. The most common deformity is a combination of both, where there is a larger than normal amount of breast (fibrous) tissue in the chest, along with an abnormal amount of fatty tissue.

True gynecomastia can be a normal finding in a healthy male, but there are some medical conditions that can cause pathologic (disease related) gynecomastia. There are also a number of medications which can cause the development of male breasts. Men are also susceptible to breast cancer and this must be evaluated.

If your husband has the type of gynecomastia that is not related to disease or medications, then he would be a good candidate for surgery. Surgery is performed on an outpatient basis and requires an anesthetic.  The excess fatty tissue is removed around the chest area with liposuction, and then the breast tissue is removed surgically through an incision just under the nipple. This keeps scarring to a minimum.  When the breasts are extremely large, the skin may not shrink completely after the chest area is flattened with surgery. In that case, additional surgery may be required.

I believe that this surgery gives excellent results and certainly improves the patient's self esteem and self image.  I would recommend that you make a consultation with an experienced board-certified plastic surgeon who can evaluate your husband and discuss his options and the risks and complications associated with the procedures.

ASK THE PLASTIC SURGEON; JANUARY 2007

Question: On a frequent basis, I see advertisements for products that are "better than Botox", lunchtime laser liposuction, weekend facelifts, non-surgical tummy tucks, facial exercise equipment for jowls, and products that can thicken your hair and fill in balding areas in one treatment. Is there any truth to these claims; do they work even a little?

Answer:  If it sounds too good to be true• well, you know the rest.  The golden standard for treatment of these areas of the body cannot be found in a bottle or box but in the office of a reputable physician; that's why I am still in business.

Although taking a quicker or cheaper route can be very appealing and hard to resist, ultimately, you get what you pay for.

Many of the companies offering these products just want you to try them once, that's where they plan to make their money. Statistically, very few people will ask for a refund and fill out the necessary paperwork to get their money back.  Millions of dollars are made annually on unproven and false claims made by companies and there really is no government entity to oversee these goods. The products are not illegal, only unethical.

This is not to say that there are not exceptional products on the horizon that may sound too good to be true; those that will ultimately pass the test of extensive research and time.  I tell my patients that if they encounter such a product or procedure that my staff and I will be more than happy to discuss those that we are familiar with, and research those we are not.

ASK THE PLASTIC SURGEON: DECEMBER 2006

Question:  I am a 62-year-old woman and my youngest daughter is getting married in two months. I've had several consults from plastic surgeons for facelift surgery in the past few years, but I'm afraid that I have procrastinated too long. Is it too close to the wedding to have a facelift; if so, do you have any recommendations?

Answer: Your dilemma is not that uncommon. Facial rejuvenation surgery requires a lot of forethought, and you certainly have to be mentally prepared to undergo a procedure. You need to find a Surgeon that you are comfortable with and have an appropriate amount of time for healing. Even though most of my patients look great within an average of 2 weeks, there are things, which can occur that can't be predicted. For instance, some patients because of dietary supplements or aspirin use tend to bleed more during surgery, which can cause excessive bruising postoperatively, thus a longer recovery time. Smokers tend to take longer to heal and can be prone to complications due to poor circulation. The amount of postoperative swelling is also something that can't be foreseen. Most patients will see swelling resolve anywhere from 4 to 6 weeks.

  Probably the biggest hurdle for you at this point though, is the surgeon's schedule. Most surgeons with a great deal of experience in facelifts probably have their schedules booked ahead a few weeks at least and wouldn't be able to perform your operation within the week of your visit. So, you're actually looking at a much smaller window of time than 2 months.  As a general rule, I will not operate on anyone less than 2-3 months prior to an important event, just to be on the safe side.

  Even though the timing isn't right for you to have the procedure before this wedding, there are some great options that you can take advantage of that will have you looking more youthful for the event. Then you can plan your surgical procedure at a more optimal date.  There are injectable products requiring only an office visit at least three week prior to your scheduled event that can make you look significantly younger.

Botox can be used to soften the lines of the forehead, crow's feet, and upper lip.  Restylane or Juvederm can soften the nasolabial creases (around the mouth) as well as just slightly plump the lips, which naturally thin with age.  Cosmoderm can be used to treat the fine wrinkles around the mouth and face. Bruising can occur slightly at the injection sites, that's why I recommend treatment 2-3 weeks prior to the event. A series of microdermabrasions ending one week prior to the wedding will also help to give your skin a radiant more rejuvenated glow. 

   The combination of all these products will give you wonderful results and get you some compliments along the way.  The longevity of the injectables vary from 4-6 months in duration or longer in some patients. The effect can be extraordinary and with little risk Over time, there is no substitute for facial rejuvenation surgery but these suggestions will help significantly in your situation.

November 2006

Ask the Plastic Surgeon

Question: Recently, I saw a news feature on a new product called Juvederm. I thought that it was used to give a person fuller lips. If that's true, how does it differ from other products already on the market?

Answer: Juvederm is a facial filler recently approved by the FDA for use in the U.S. and will be available to the general public in 2007. It is a hyaluronic acid or "HA", a complex sugar similar to Restylane. HAs are gels that absorb and retain water. This type of product has been used for years by orthopedic surgeons to improve lubrication in the joints. Restylane, which has been available for 3 years, has become the most commonly used filler for injecting the face to fill grooves or for plumping lips. Juvederm is in the same category of substance but the assertion is that because it has been enhanced biochemically it will absorb and retain the body's natural water better. Juvederm is currently undergoing a massive U.S. study by select physicians to determine its long-term efficacy compared to Restylane, which has been widely successful. As previously stated, Juvederm has been used in Europe and Canada for many years, and has been an effective product with an excellent safety record. In the past, facial fillers have been either Bovine (cow) collagen such as Zyplast and Zyderm, requiring skin testing for allergies, or human collagen such as Cosmoplast and Cosmoderm, which don't require skin testing. The collagens, which have been extremely successful and safe, lack longterm efficacy. This new wave of fillers, the HAs, (hyaluronic acids) are showing great promise to be easier to use and last much longer than the traditional collagen injections. These products are great to fill the nasolabial grooves around the mouth or creases in other areas, giving a person a more youthful appearance. Other uses are plumping thin lips and filling divots in the skin produced by scarring.

October 2006

Ask the Plastic Surgeon

Question:

I am a 34-year-old male and I am experiencing hereditary hair loss. My hairline is receding significantly and I have developed a bald spot in the back of my scalp. I am very self-conscious about it, and I feel that it makes me look older than I am. It is only getting worse. What can I do?

Answer: There are many types of hair loss, but the male pattern baldness you are experiencing is hereditary. Unfortunately, you received the short straw on the genes. There are several medications available to help you slow the loss and even regain some of the hair on the back of your scalp. Some are over-the-counter medications, while others require a prescription. You should visit a qualified physician for these options; it is a good place to start. Your surgical option is a hair grafting. Hair grafting today is a standard procedure in the hands of experienced surgeons. It is not the old "hair plugs" that everyone fears. The procedure has become refined and gives a natural hairline that you will not lose. The terminology used today is "single follicular grafting": this has replaced micro-hair transplantation to give the most natural appearance. The procedure can be performed in an afternoon under a local anesthetic. The grafted hair will take several months to begin growing, but it is well worth the effort to have natural-looking and permanent hair growth. More than one surgical session may be required. A consultation with an experienced, board-certified surgeon to discuss your options is recommended.

September 2006

Ask the Plastic Surgeon

Question: I've been thinking about getting breast implants and have no idea what size would be best for me. How would I determine that? What is your most commonly requested size?

Answer: There are many things to think about when deciding on an appropriate postoperative breast size. The first thing that you would want to consider is whether or not you want to go with a very natural look or a more "stand out" appearance. As we all know, breast enhancement can be a very subtle change or incredibly dramatic. With this in mind, you need to take into account your body frame. A 5' tall, size 4 petite person will look quite different with a small C cup breast versus a woman who is 5'9" and wears a size 12. This is simply a matter of proportion and balance. Another thing you will want to think about is your lifestyle. For instance, if you are a runner, a DD breast may not be the most comfortable option. However, women that prefer exercise with less impact may be perfectly happy with this size. Unfortunately, the bra industry, like the clothing industry in general, has not standardized its sizes; cup dimension varies from manufacturer to manufacturer, making size comparisons somewhat subjective and therefore challenging to determine. Taking all of this into account, the majority of women in the Midwest are choosing a full C cup, whereas women on the West Coast, are more likely to request the D to DD size. A cup size that is in proportion to the rest of the body will offer a woman more wardrobe options right off the rack, where a larger breast size and smaller frame will generally require tailoring. It is very helpful to see the before and after photos of your surgeon's work to help you determine which size would be appropriate for you. It is also important that you consult with an experienced and board-certified plastic surgeon that will listen to you and work with you to establish a size and surgical approach that is safe for you. As you can see, there are many things to consider.

August 2006

Ask the Plastic Surgeon

Question: I think that the "J.Lo" figure is very attractiveand I have a very flat bottom. I've heard that there are buttock implants that could give me a more rounded figure; are these an option that you would suggest?

Answer: I must say that as a practicing plastic surgeon for the past 17 years, I have only seen problems with buttock implants. I personally do not perform the surgery. Placing a silicone gel implant under the buttock muscle (gluteus) seems simple enough, and the technique is relatively straightforward but there are a number of problems that can occur with this procedure. The incisions are generally placed in the crease between the buttock

cheeks. Although most of the time the incision remains within the crease, a significant scar deformity can result and show outside of this area. The implants are placed beneath the buttock muscles (gluteus). This muscle can cause the implant to move and the pocket to enlarge. This can result in excessive drainage (seroma) to develop within the pocket. Seroma prevention requires drains, and if the seroma were persistent, draining them multiple times in the surgeon's office would be required. Infection would also become a concern. Another option to increase the shape of the bottom is a free fat transfer to the buttock region. Fat is harvested from one site of the body and injected into another part of the body for enhancement. Theoretically, it is a great idea but I have not seen lasting results and the multiple procedures required can be costly. My personal suggestion would be to visit a good personal trainer, and target building the gluteal muscles with weight training. This is certainly less risky, and you will be healthier in the long run. You will save a lot of money and possibly a significant amount of aggravation.

July 2006

Ask the Plastic Surgeon

Question: I've heard horror stories about people who had extensive liposuction surgery that took hours and nearly died. How does something like this happen and how much fat can be safely removed in one liposuction surgery?

Answer: We've all heard the kind of stories that you mentioned, they are very tragic and extremely avoidable! A number of factors could lead to such a scenario but there are three main things for a prospective patient to be concerned with if interested in liposuction these are: their overall general health, the credentials and experience of their surgeon and the facilities in which the procedure is to take place. The first and most important issue prior to liposuction or any other elective surgery is the health of the patient. A concerned and credible physician will always ask extensive questions about a patient's health history and have a medical clearance done prior to operating on someone, to ensure that they can tolerate the planned surgery. It really is the responsibility of the patient to do research into the credentials and experience of the surgeon that they are choosing for the procedure. Patients will go to a physician based on the cost of the procedure assuming that a cheaper surgery will turn out the same. This is often a red flag to the eventual outcome. The reality is that a more experienced surgeon in a safe surgical environment is always going to cost more than a less experienced surgeon doing surgery in an environment that will lower his overall prices for a procedure. Thus, the old adage; "You get, what you pay for!" A hospital or an accredited surgery center are truly the ONLY places that are safe for an extensive liposuction procedure. An office setting is all right for a small refinement technique but not for a large area procedure. Regarding the question about the amount of fat being removed in one procedure, there is no way for me to give a set amount because each case is different. Such a decision is based upon several factors, some of these would include: the size of the patient, their general health, the amount of tumescent solution required, the color of the fat and saline (aspirate) coming out during the procedure; this indicates blood loss, and the elasticity of the patients skin. These factors, along with continuous interoperative monitoring, (vital signs, etc.) dictate the amount of fat that can be safely removed from a patient during a procedure. All of these things are inherently important. An experienced surgeon will know when it is safe to remove a lot of fat and when to stop the procedure if necessary. Also, keep in mind that he amount of fat removed does not equate to pounds lost, as in dieting. Liposuction effects the inches lost in the areas that are treated.

June 2006

Ask the Plastic Surgeon

Question: I'm 44 years old and have developed wrinkles around my eyes and lines around my mouth. I've read ads for both Botox and Restylane but am confused about which would work best for me. Are there significant differences between the two products?

Answer: Botox and Restylane are excellent products that function in completely different ways. In fact, I use both products together on a very regular basis because they complement one another so well. Botox paralyzes the muscles beneath the skin that cause grooves and wrinkles. It is injected in a very precise manner in terms of the location on the face and the number of injections needed to treat an area. Common treatment sites include the grooves between the eyebrows, crow's feet, and forehead lines. Once these muscles that create the lines are paralyzed, the skin lines soften, and may sometimes disappear all together. Restylane, on the other hand, does not affect the muscles beneath these lines and grooves; rather it functions as a filler, similar to a putty, which elevates the depression in the skin, giving it a smooth appearance. This product is also injected into the skin in a very precise manner. Restylane is used most commonly to "plump" thin lips but often to correct lines and folds around the mouth and the grooves between the eyebrows. These products, used together, can make a significant difference in the overall appearance of a person with fine lines, wrinkles and folds on the face, due to age. They offer a very non-invasive alternative to surgery for someone who wants to look years younger. As always, it is important to find a physician with significant experience and training in the use of these products.

May 2006

Ask the Plastic Surgeon

Question: I have been considering having breast enlargement surgery and recently saw a news report that silicone implants may soon get FDA approval for use again. Are silicone implants safer now than in the '90s when they were banned and are they better than saline?

Answer: The reality is that silicone gel implants were never the threat to women's health that the media and some attorneys portrayed them to be. Although they were partially banned in the 1990s, plastic surgeons were still authorized to use them for reconstructive purposes such as reconstruction after mastectomy, or if a breast lift (mastopexy) was performed. Silicone gel implants were banned for breast enlargement surgery only.

The initial concern was the thickness (viscosity) of the silicone gel inside the implant. The older implants, if they broke, would be runny and leak. The new implants are more cohesive and will stay together even if they rupture. Many large studies by reputable institutions and endorsed by major medical colleges have confirmed the safety of silicone gel implants. The FDA studies by the manufacturers of silicone gel implants have also confirmed the safety of the implants. The pending FDA approval would permit the use of the silicone gel implants in breast augmentation (enlargement) once again. However, this approval could be months or years away. Whether to use silicone gel implants or saline implants is truly a matter of personal preference and is often dependent on a woman's physical structure. Saline implants may offer a more natural appearance in some instances whereas silicone gel may be better on other occasions. Both silicone and saline implants are manufactured by the same companies and therefore considered equally safe. When the approval of silicone gel implants for enlargement does take place, a discussion of which would be appropriate for you should take place with your surgeon. Be certain that your surgeon has had significant experience using both types of implants and is Board Certified in Plastic Surgery.

April 2006

Ask the Plastic Surgeon

Question: Over the last several months, plastic surgery has been highlighted a lot on daytime talk shows, specifically the "lunchtime procedures" that have patients in and out and back to work with little, if any, downtime. Some of the advances seem too good to be true, but when the show has a credible host and you see the results of a procedure performed live, it seems very impressive. Have a lot of your patients been asking you about these afternoon procedures and what is your opinion of them?

Answer: It seems that a month doesn't go by without a new product or procedure being highlighted on a talk show or newscast. Sensationalism gets viewers, viewers increase ratings, and ratings bring in money. It is disappointing to me that these programs do not investigate the long-term result of these products and procedures better. Instead of giving a snapshot of immediate success, they should show the final product months later. The injectable medications, whether proven effective longer term such as Botox or Restylane or more recently introduced products like the new volumizer touted as a "liquid face lift" can not be realistically assessed when performed for an audience. Once a needle is used to penetrate the skin or lips, swelling occurs immediately. The clinician does not even need to inject any substance other than saline to get an immediate result that would impress viewers. The reality is, all injectables are not created equal, nor are the clinicians injecting them. This also holds true with the minimally invasive procedures that are promoted to have immediate improvement without requiring healing time. I reviewed my thoughts on the thread lift and feather lift in a previous article (July 2005) and still consider them to be a questionable course of action with noteworthy risks involved. Benefits have to substantially outweigh the risks with any procedure, and the results should have a reasonable duration given the cost. Many physicians use these new and unproven treatments to attract patients to their practices but offer no guarantee of the longevity of the end product. Remember the old adage: If it's too good to be true, think again. I suggest that you do research about the product or procedure that you're contemplating, look for a physician with good credentials or referrals and ask about these products before you put yourself and your pocketbook at risk.

February 2006

Ask the Plastic Surgeon

Question: I am a 53-year-old woman and I am beginning to see loose skin around my neck and jawline. My mother began to have sagging skin at the same age. Am I too young for a facelift? I am concerned about starting to get plastic surgery too soon. Should I wait until it gets worse?

Answer: The question you asked is a very common one. The loose skin is not only hereditary, but influenced by your sun exposure, cigarette smoking and yo-yo dieting history. The loose neck skin (turkey gobbler) and jaw area (jowls) can be corrected with a facelift/necklift procedure. I am operating on younger patients today. The younger and healthier you are, the faster your recovery and the more natural your post-op appearance. The advantage to having surgery sooner is that most people will not recognize that you had a cosmetic procedure performed. The facelift/necklift procedure will enhance the appearance of the face and neck up to the browline. Eyelid and forehead lifts are entirely different procedures from the facelift. It is not uncommon to perform eyelid and forehead surgery at the same time as the facelift/necklift. Cosmetic surgery is not without risk, but the benefit should outweigh the risk. The right time for you to have surgery is when you look in the mirror and want an improvement, and you are willing to accept some potential risk. A consultation with an experienced, board-certified plastic surgeon who performs facial cosmetic surgery should help you to make a decision.

January 2006

Ask the Plastic Surgeon

Question: I am a 34-year-old male and I am experiencing hereditary hair loss. My hairline is receding significantly and I have developed a bald spot in the back of my scalp. I am very self-conscious about it, and I feel that it makes me look older than I am. It is only getting worse. What can I do?

Answer: There are many types of hair loss, but the male pattern baldness you are experiencing is hereditary. Unfortunately, you received the short straw on the genes. There are several medications available to help you slow the loss and even regain some of the hair on the back of your scalp. Some are over-the-counter medications,

while others require a prescription. You should visit a qualified physician for these options; it is a good place to start. Your surgical option is a hair grafting. Hair grafting today is a standard procedure in the hands of experienced surgeons. It is not the old "hair plugs" that everyone fears. The procedure has become refined and gives a natural hairline that you will not lose. The terminology used today is "single follicular grafting": this has replaced micro-hair transplantation to give the most natural appearance. The procedure can be performed in an afternoon under a local anesthetic. The grafted hair will take several months to begin growing, but it is well worth the effort to have natural-looking and permanent hair growth. More than one surgical session may be required. A consultation with an experienced, board-certified surgeon to discuss your options is recommended.

December 2005

Ask the Plastic Surgeon

Question: I developed cellulite in the thighs and bottom; even at my best weight it is still visible. What is the cause of cellulite and do the treatments that are available really work?

Answer: The dimpled or cottage-cheese appearance is caused by the structural difference between cellulite fat and normal fat. Both cellulite fat and normal fat cells are the same consistency. The difference is due to the architecture of the cellulite fat cells just under the skin's surface. Bands (septa) separate the fat cells into pockets. In cellulite fat, the septa are thicker than the septa of a normal fat cell. When the cellulite fat cells enlarge (weight gain), the septa act as anchors to the skin, then the skin becomes dimpled. Cellulite is also more evident when the skin loosens (loss of elasticity) with age, which is probably what you are experiencing. Many treatments have been offered, with several new treatments every few years. The general public as well as many physicians have been exploited by manufacturers of these products because of society's desire to look as young as possible. Among the many methods to treat cellulite are endermologie, massage, creams, ultrasonic liposuction, superficial liposuction, and now laser treatment. Although some treatments can offer temporary and moderately improved appearance of cellulite, there is currently no treatment with medically recognized accomplishment. Unfortunately, all fall short of giving significant and sustained results. Probably the least successful of the products mentioned above are the superficial creams that claim to "smooth and tighten the skin"; this is physiologically impossible.

November 2005

Ask the Plastic Surgeon

Question: My husband is a 43-year-old man who exercises regularly but is still very self conscious about his appearance because he has breasts. (if you call them that on a man?) He won't even go to the pool in the summer because he's uncomfortable being shirtless in public. No matter how much he works out, he's unable to lose the fat or tighten the skin in this area. Is there a surgery that could help him?

Answer: Your husband's problem is not uncommon and definitely makes a man very uncomfortable in many situations. He has a condition called gynecomastia (male breasts). True gynecomastia is caused by abnormally enlarged breast tissue whereas pseudo-gynecomastia is the result of an excessive amount of fatty tissue in the male breast area. The most common deformity is a combination of both, where there is a larger than normal amount of breast (fibrous) tissue in the chest, along with an abnormal amount of fatty tissue. True gynecomastia can be a normal finding in a healthy male, but there are some medical conditions that can cause pathologic (disease related) gynecomastia. There are also a number of medications which can cause the development of male breasts. Men are also susceptible to breast cancer and this must be evaluated. If your husband has the type of gynecomastia that is not related to disease or medications, then he would be a good candidate for surgery. Surgery is performed on an outpatient basis and requires an anesthetic. The excess fatty tissue is removed around the chest area with liposuction, and then the breast tissue is removed surgically through an incision just under the nipple. This keeps scarring to a minimum. When the breasts are extremely large, the skin may not shrink completely after the chest area is flattened with surgery. In that case, additional surgery may be required. I believe that this surgery gives excellent results and certainly improves the patient's self esteem and self image. I would recommend that you make a consultation with an experienced board-certified plastic surgeon who can evaluate your husband and discuss his options and the risks and complications associated with the procedures.

October 2005

Ask the Plastic Surgeon

Question: After nursing three children, my breasts are sagging and significantly smaller. I've been thinking about having a breast lift, but I'm concerned about ending up with really small breasts and also about the scars that result from the surgery. Do the scars fade eventually or will they always be visible?

Answer: It is very common for the breast size to diminish and the skin to sag after having children or losing significant weight. Each pregnancy can result in less breast tissue and more sagging (ptosis). A breast lift tightens the skin of the breast and raises the nipple to its appropriate position. When the skin is tightened around the breast, the breast tissue is compressed, thus resulting in a smaller cup size after surgery. In order to return to the original breast size and give more fullness, most patients elect to have breast implants inserted at the time of the lift. Any time that skin is tightened on the body, i.e.) breast lift (mastopexy), facelift, tummy tuck; scars will result. As a plastic surgeon, I try to place the scars in areas that are more easily concealed. The skin is sewn together utilizing specific techniques and a specialized suture material to facilitate optimal healing. Your body's healing properties then take over, and the scar will vary in appearance from a very fine line to a more thickened scar; this will differ from one person to the next. Fortunately, there are medications and treatments (laser) that can greatly improve the appearance of thickened scars. There are a number of techniques used to perform a breast lift: the standard keyhole technique, the vertical technique (lollipop), and the periareolar technique (around the nipple). Your surgeon should be able to discuss the option most suitable for your needs. As always, it is important to find a board-certified surgeon with significant experience and training in these procedures.

September 2005

Ask the Plastic Surgeon

Question: Do breast implants interfere with mammography and can a mammogram injure the implants?

Answer: This is a question that I address with all of my breast implant patients. The answer depends upon whether the implant is surgically placed above or below the pectoralis (chest) muscle. Most of the time in very small- or medium-sized candidates for breast augmentation (A and B cups), the implants are placed beneath the chest muscles. This actually allows the patient's breast to be more easily mammogramed. The implant pushes the natural breast away from the ribs, allowing the mammographer to get better compression and view of the breast. Many small- breasted women (A cups) are virtually impossible to mammogram because the tissue cannot be compressed between the x-ray plates. Occasionally, a patient will opt for an implant above the chest muscles but beneath the breast gland (subglandular). This placement is generally used for patients who have slight sagging of the breasts (ptosis) and do not want to have a breast lift (mastopexy).In this case, the implant obscures a percentage of the breast. Breast implants are radiopaue, which means the mammogram rays cannot see through them. In this case, a maneuver called an Ekland is performed, to push the implant away from the breast tissue so that it obscures less tissue. Even with this maneuver though, some tissue will not be seen. This is important information for a patient to understand prior to surgery and it is valuable for a patient to understand the placement of their implants for future reference. Although I have never seen or heard of an implant being damaged during routine mammography, saline implants do have a leakage rate of less than 1%, so it cannot be ruled out entirely as a possibility. As always, it is important to find a physician with significant experience and training in cosmetic surgery with whom to discuss all options.

August 2005

Ask the Plastic Surgeon

Question: Can an actress like Angelina Jolie have lip augmentation that looks natural and lasts in definitely?

Answer: I am not certain that Angelina Jolie has had lip augmentation. I have seen photos of her at a young age and she had very full lips. Voluptuous lips are definitely the trend today and have been in vogue for some time. Luckily, there are a number of enhancement alternatives available to people who weren't fortunate enough to be born with full lips. Some of these options are as follows:

• Surgical elevation of the lip line.

• Surgical placement of enhancement material such as Alloderm.

• Free-fat transfer.

• The use of fillers, such as Restylane, Zyplast (collagen), and Hylaform.

None of these procedures is considered permanent innature, except for surgical elevation of the lip line. However, this method results in a permanent scar of the lip line that may be aesthetically unappealing. The surgical placement of a graft material, such as Alloderm, in the lips diminishes within 8-12 months and is a relatively expensive procedure.Free-fat transfer, where fat is harvested from a small area in the belly or buttocks and then injected into the lips has been an option for many years but is an involved procedure. The lips require over-injection so that some of the fat will remain and not be absorbed, therefore the lips can look distorted for weeks after the procedure. I believe that the injectable products are a fast and economical method of lip enhancement and my personal experience has been best with the Restylane product. When a dental block is performed prior to the Restylane injection, it is a relatively painless technique and the results will last around 6 months. There are no guarantees that the aforementioned procedures will last indefinitely, including the free-fat injections. That is why I recommend a straight-forward method such as Restylane injections. As always, it is important to find a physician with significant experience and training in the use of these products.

July 2005

Ask the Plastic Surgeon

Question: My friend was telling me about a new procedure she saw being done on TV called a thread lift or feather lift; what is it and how is it performed?

Answer: The thread lift and a variation called the feather lift have both received an enormous amount of media attention lately. They are procedures that elevate the facial skin without performing a facelift but unlike a facelift, have no effect on the neck and jowl regions. It is performed as follows: a cannula (tube) is passed under the skin from the temple to the corner of the mouth. The tube contains a thread with hooks (barbs) on it. The tube is withdrawn, leaving the thread with hooks under the skin. When the thread is pulled upward, the hooks grab the undersurface of the skin, pulling the skin upward. The thread is then fixed to the undersurface of the scalp with tension. This lifts the facial skin. Minimal incisions are required and there is minimal recovery time if the procedure goes without problems. However, there are concerns regarding the thread or feather lift. If one of the threads loosens, the facial skin can drop on one side or the other, requiring additional surgery to tighten them evenly. These threads can loosen with time. In addition, there have been reports of the hooks causing irregularities on or under the skin's surface. If there are problems and the thread needs to be removed, it is nowhere near as simple a procedure as the initial placement. In my opinion, a face/neck lift is the golden standard; when performed by a qualified and experienced surgeon, a face lift will only take 2-3 hours, not much more time than the thread lift procedure, but with a greater degree of accuracy that will insure exceptional and lasting results. The healing time for the average patient is only 10-14 days with a face/neck lift, well worth the additional time, considering the superior outcome. The consequences of a bad facial surgery can be devastating. In my judgment, this is not something worth cutting corners on.

June 2005

Ask the Plastic Surgeon

Question: I'm 44 years old and have developed wrinkles around my eyes and lines around my mouth. I've read ads for both Botox and Restylane but am confused about which would work best for me. Are there significant differences between the two products?

Answer: Botox and Restylane are excellent products that function in completely different ways. In fact, I use both products together on a very regular basis because they complement one another so well. Botox paralyzes the muscles beneath the skin that cause grooves and wrinkles. It is injected in a very precise manner in terms of the location on the face and the number of injections needed to treat an area. Common treatment sites include the grooves between the eyebrows, crow's feet, and forehead lines. Once these muscles that create the lines are paralyzed, the skin lines soften, and may sometimes disappear all together. Restylane, on the other hand, does not affect the muscles beneath these lines and grooves; rather it functions as a filler, similar to a putty, which elevates the depression in the skin, giving it a smooth appearance. This product is also injected into the skin in a very precise manner. Restylane is used most commonly to "plump" thin lips but often to correct lines and folds around the mouth and the grooves between the eyebrows. These products, used together, can make a significant difference in the overall appearance of a person with fine lines, wrinkles and folds on the face, due to age. They offer a very non-invasive alternative to surgery for someone who wants to look years younger. As always, it is important to find a physician with significant experience and training in the use of these products.

Question: I have been considering having breast enlargement surgery and recently saw a news report that silicone implants may soon get FDA approval for use again. Are silicone implants safer now than in the '90s when they were banned and are they better than saline?

Answer: The reality is that silicone gel implants were never the threat to women's health that the media and some attorneys portrayed them to be. Although they were partially banned in the 1990s, plastic surgeons were still authorized to use them for reconstructive purposes such as reconstruction after mastectomy, or if a breast lift (mastopexy) was performed. Silicone gel implants were banned for breast-enlargement surgery only.

The initial concern was the thickness (viscosity) of the silicone gel inside the implant. The older implants, if they broke, would be runny and leak. The new implants are more cohesive and will stay together even if they rupture.

Many large studies by reputable institutions and endorsed by major medical colleges have confirmed the safety of silicone gel implants. The FDA studies by the manufacturers of silicone gel implants have also confirmed the safety of the implants. The pending FDA approval would permit the use of the silicone gel implants in breast augmentation (enlargement) once again. However, this approval could be months or years away.

Whether to use silicone gel implants or saline implants is truly a matter of personal preference and is often dependent on a woman's physical structure. Saline implants may offer a more natural appearance in some instances whereas silicone gel my be better on other occasions. Both silicone and saline implants are manufactured by the same companies and therefore considered equally safe. When the approval of silicone gel implants for enlargement does take place, a discussion of which would be appropriate for you should take place with your surgeon. Be certain that your surgeon has had significant experience using both types of implants and is Board Certified in Plastic Surgery.

Submit your questions to "Ask the Plastic Surgeon" at allnewu@AOL.com. Questions may be condensed and reformatted for the column.

Questions are answered by Dr. Mark A. Foglietti, a nationally recognized board-certified plastic surgeon and author.

Question: I am 42 years old and have sagging eyebrows. I cannot see my upper eyelids and it is worthless for me to attempt wearing eye shadow. This runs in my family. Will Botox lift my eyebrows or will I need surgery? Sincerely, J.D.

Answer: Your question is important because it addresses two different types of treatment to the forehead region. Brow ptosis (sagging eyebrows) is a common concern for many people. Lowering of the brow is one of the first signs of aging in the upper face, along with wrinkles in the forehead. This can dramatically affect the appearance of both men and women.

The appropriate treatment for brow ptosis is a brow lift. The most common technique today is the endoscopic brow lift, which is minimally invasive. This procedure takes about 60 to 90 minutes to perform on an outpatient basis. It involves several small cuts behind the hairline, where specialized instruments are used to release and lift the eyebrows. The brow is then secured in the new position. The grooves between the eyebrows (glabella) are also treated at the same time. This results in a more pleasing look in the upper third of the face and eyes. The expertise of the surgeon is important so that the patient isn't given a "surprised" appearance.

Botox can be used to treat the grooving between the eyebrows, but can actually accentuate brow ptosis when injected just above the eyebrows to treat wrinkles of the forehead. A brow lift can result in a more youthful appearance to the face. This procedure can be performed alone or in combination with eyelid surgery (blepharoplasty) and facelift surgery when indicated.

Submit your questions to "Ask the Plastic Surgeon" at allnewu@AOL.com. Questions may be condensed and reformatted for the column.

Questions are answered by Dr. Mark A. Foglietti, a nationally recognized board-certified plastic surgeon and author.

The Experience

You Trust and the

Skill You Desire.

Question: I am 34 years old and have three children. I have a C-section scar and loose skin around my belly button. Even though I am the weight I was prior to having children and work out at least twice a week, I can't seem to tighten my tummy. I'm not going to have any more children and would really like to get my figure back. I've thought about having a tummy tuck, but my husband thinks that if I exercise more I should be able to return to my pre-baby shape. Is surgery a good option for me?

 Answer: Pregnancies, and the weight gain and loss associated with them, can cause several problems in the appearance of a woman's tummy. The stomach muscles that you most often see in body builders, known as the rectus abdominus muscles or "six pack," can separate during pregnancy. This condition, known as diastasis, can worsen with each pregnancy and will not tighten to the pre-pregnancy state with exercise. The size of the baby/babies as well as the amount of weight gain during the pregnancy can result in stretch marks, or stria. These are merely visible damage to the elastic properties of the skin and cannot be reversed with the use of creams or topical treatments.

A flat, tight stomach requires tight muscles as well as taut skin. A tummy tuck procedure, or abdominoplasty, can achieve both of these. The muscles are returned to their pre-stretched position and the skin is tightened through a bikini-line incision. The belly button is also returned to the smaller pre-pregnancy shape as well.  

I believe that surgery may be a good option for you, but a consultation is necessary to determine whether or not you would be a good candidate for this procedure. I recommend that you and your husband make an appointment with a qualified plastic surgeon who can take the time to explain in detail all options, benefits and risks involved with this surgery.

Submit your questions to "Ask the Plastic Surgeon" at allnewu@AOL.com. Questions may be condensed and reformatted for the column.

Questions are answered by Dr. Mark A. Foglietti, a nationally recognized board-certified plastic surgeon and author.

The Experience

You Trust and the

Skill You Desire.

QUESTION: I am a 53-year-old woman and I am beginning to see loose skin around my neck and jawline. My mother began to have sagging skin at the same age. Am I too young for a facelift? I am concerned about starting to get plastic surgery too soon. Should I wait until it gets worse?

ANSWER: The question you asked is a very common one. The loose skin is not only hereditary, but influenced by your sun exposure, cigarette smoking and yo-yo dieting history. The loose neck skin (turkey gobbler) and jaw area (jowls) can be corrected with a facelift/necklift procedure.

I am operating on younger patients today. The younger and healthier you are, the faster your recovery and the more natural your post-op appearance. The advantage to having surgery sooner is that most people will not recognize that you had a cosmetic procedure performed. The facelift/necklift procedure will enhance the appearance of the face and neck up to the browline. Eyelid and forehead lifts are entirely different procedures from the facelift. It is not uncommon to perform eyelid and forehead surgery at the same time as the facelift/necklift.

Cosmetic surgery is not without risk, but the benefit should outweigh the risk. The right time for you to have surgery is when you look in the mirror and want an improvement, and you are willing to accept some potential risk.A consultation with an experienced, board-certified plastic surgeon who performs facial cosmetic surgery should help you to make a decision.

Submit your questions to "Ask the Plastic Surgeon" at

allnewu@AOL.com. Questions may be condensed and reformatted for the column.

Questions are answered by Dr. Mark A. Foglietti, a nationally recognized board-certified plastic surgeon and author.

The Experience

You Trust and the

Skill You Desire.

January 2005

Ask the Plastic Surgeon

Question: I am a 34-year-old male and I am experiencing hereditary hair loss.My hairline is receding significantly and I have developed a bald spot in the back of my scalp. I am very self-conscious about it, and I feel that it makes me look older than I am. It is only getting worse. What can I do?

Answer: There are many types of hair loss, but the male pattern baldness you are experiencing is hereditary. Unfortunately, you received the short straw on the genes. There are several medications available to help you slow the loss and even regain some of the hair on the back of your scalp. Some are over-the-counter medications, while others require a prescription. You should visit a qualified physician for these options; it is a good place to start. Your surgical option is a hair grafting. Hair grafting today is a standard procedure in the hands of experienced surgeons. It is not the old "hair plugs" that everyone fears. The procedure has become refined and gives a natural hairline that you will not lose. The terminology used today is "single follicular grafting," this has replaced micro-hair transplantation to give the most natural appearance. The procedure can be performed in an afternoon under a local anesthetic. The grafted hair will take several months to begin growing, but it is well worth the effort to have natural-looking and permanent hair growth.More than one surgical session may be required. A consultation with an experienced, board-certified surgeon to discuss your options is recommended.

QUESTION: I am considering a breast-enlargement

surgery. I am 35 years old and have had three children. Before

my children, I was a 34C-cup bra size. After three pregnancies and breastfeeding, I am barely a B cup and my breasts are sagging. I just want the breast appearance that I had before children. Am I a candidate or is this foolish to consider?

ANSWER: Your question is a good one. This is a

common concern among women who were very happy with their breast size prior to children. It is not unusual for the breast tissue to shrink and the skin to become loose after breastfeeding, and it can worsen with each pregnancy.

A breast enlargement or augmentation will definitely help you, but the sagging skin has to be addressed. Sagging skin (medically known as ptosis; the "p" is silent) varies in degrees from 1 to 4. It is graded according to the position of the nipple in relationship to the crease beneath the breast. Grade 1 has the nipple well above the crease and grade 4 has the nipple completely below the crease and pointing to the feet.

Grade 2 may or may not require a breast lift at the time of breast enlargement. Grade 3 and 4 most always require the additional surgery of a breast lift or mastopexy. These are standard procedures in breast surgery, and there are options as to the type of lift that may be required.

The combination of a breast enlargement with a breast lift will give you the full and perky look of youth prior

to pregnancy. Whether you would require a breast enlargement, or a breast enlargement with a breast lift, can be determined by an experienced plastic surgeon, who should discuss all of the surgical options available to you.

Submit your questions to "Ask the Plastic Surgeon" at

allnewu@AOL.com. Your questions may be condensed and reformatted for the column.

Questions are answered by Dr. Mark A. Foglietti, a nationally recognized, board-certified plastic surgeon

and author.

The Experience

You Trust and the

Skill You Desire.

QUESTION: I have inherited my father's eyes! I am 42 years old with heavy upper eyelids and bags under my eyes. I am concerned that eyelid surgery will change the shape of my eyes and make me look like a different person. Is this possible?

ANSWER: Eyelid surgery (Blepharoplasty) does not change the shape of the eyes but will change their appearance. People who have excessive skin and

puffiness prior to surgery will appear to have larger eyes after the procedure because the eyes are returned to their younger state. Whether your eyes are round, oval or oblong, the shape will remain the same.

Blepharoplasty is performed on both the upper and lower eyelids. They can be done together or independently, based on an individual patient's needs. The

heaviness on the upper eyelids and the bags on the lower eyelids can cause a person to look fatigued and older than they are; this is caused by fatty pockets around the eye and loose skin. Blepharoplasty reduces the fatty pockets around the eyes and will tighten the skin of the upper and lower eyelids. The incisions made are hidden in the natural creases of the eye and other inconspicuous places. The surgery is usually

performed on an outpatient basis. Some bruising can occur and will generally fade within 7-10 days.

There are medical conditions that can cause puffiness and bagging of the eyelids. Therefore, a thorough

history and physical is an important part of your

evaluation. I recommend that you consult with a

qualified board-certified plastic surgeon, oculoplastic surgeon or facial plastic surgeon with experience in eyelid surgery.

Submit your questions to "Ask the Plastic Surgeon" at

allnewu@AOL.com. Questions may be condensed and reformatted for the column.

Questions are answered by Dr. Mark A. Foglietti, a nationally recognized board-certified plastic surgeon

and author.

The Experience

You Trust and the

Skill You Desire.

QUESTION: I had bariatric surgery for obesity 18 months ago. I have lost 125 pounds and now weigh 150 pounds. My weight has remained the same for the last 8 months. Everyone tells me how wonderful I look but I have a tremendous amount

of sagging skin that I have to cover with my clothes. My face looks fine, but the skin on my arms, breasts, stomach and thighs look like deflated balloons. What can I do?

ANSWER: This is a common problem after any kind of extreme weight loss. Once your weight has stabilized for a year, you are eligible for cosmetic surgery. All of these target areas should not be treated at one time because it is too much surgery for the body to handle. An evaluation of your physical health and nutritional status must be completed prior to any surgical procedures.

I ask patients to prioritize their problem areas and then consider operating on a few at a time. I request that patients heal from each surgery for at least 6 months prior to undergoing the next stage. Surgical combinations often performed are: breast lift and tummy tuck, tummy tuck and arm lift, tummy tuck and liposuction of the legs, or a combination of whatever surgery is needed. Liposuction is often required prior to lifting the thighs

or tightening the tummy because the remaining fat can weigh down the skin, which will result in sagging.

A discussion with your plastic surgeon will help you decide which areas you can couple, and how much

surgery is safe for you personally, as this varies with each patient. It may be recommended that only one

area be treated at a time. You will need to have realistic expectations about your procedure.

I recommend that you consult with an experienced and board certified plastic surgeon to discuss your options, and review the risks, complications, and benefits associated with each of the procedures.

Submit your questions to "Ask the Plastic Surgeon" at

allnewu@AOL.com. Questions may be condensed and reformatted for the column.

Questions are answered by Dr. Mark A. Foglietti, a nationally recognized board-certified plastic surgeon

and author.

The Experience

You Trust and the

Skill You Desire.

Question: I am 47 years old and I am starting to get fullness under my chin, prominent creases around my mouth and crow's feet around my eyes. I know that one day I will probably have a facelift, but I'm just not ready for the jump to major surgery yet. Is there anything that I can do now that will buy me some time?

Answer: It is not unusual for me to begin performing facial rejuvenation surgery on patients in their forties. When you are younger, your healing time is shorter, and the fact that you have had facial surgery is much less obvious. However, patients who are just not ready for the standard facelift surgeries can benefit from a number of less invasive procedures. The fullness under the chin, submental lipodystrophy, (also known as the wattle) can easily be treated in the office with a minimal liposuction procedure. The wattle is removed and the recovery time is only a few days. The creases around your mouth can be treated with a variety of fillers such as Restylane, Cosmoplast, or Collagen, depending upon which suits you the best. Crow's feet and lines in the forehead are treated very well with Botox. Also, a more permanent filler such as Radiance can be used to enhance the cheek bones and chin shape. These non-invasive procedures can all be performed during an office visit, resulting in a greatly enhanced appearance with minimal down time. All require a plastic surgeon with experience in such cosmetic procedures. I strongly recommend a consultation with a board-certified plastic surgeon who specializes in cosmetic surgery.

Submit your questions to "Ask the Plastic Surgeon" at

allnewu@AOL.com. Questions may be condensed and reformatted for the column.

Questions are answered by Dr. Mark A. Foglietti, a nationally recognized board-certified plastic surgeon

and author.

The Experience

You Trust and the

Skill You Desire.

Question: I am 23 years old and have always been teased about the shape of my legs. My brother says that my legs look like stovepipes. I work out three times a week and am not overweight. I have used the Stairmaster and the gym's leg machines religiously for years without attaining any definition to my legs. Is there a surgery procedure that could improve their shape?

Question: I recently saw the product Restylane has been approved by the FDA for lines and wrinkles. Is this product superior to collagen and Botox because it lasts longer?

Answer: Your question has been frequently asked by many patients. You are confused as to the indications for these products. Restylane, which is hyaluronic acid, a naturally occurring substance in the body, is a new compound for filling in deeper lines, such as those around the mouth (nasolabial) creases and enlarging (augmenting) the lips. This is a new generation of filler that has been used in Europe for many years and has excellent reviews. It should last longer than collagen in the face, but not necessarily longer in the lips. Collagens (Zyplast, Zyderm) have been the standard by which all other products are judged. They have been around for many years and have clinical success, but they are of limited duration. These fillers act as a human putty to fill in creases and lines of the face and augment the lips.

Botox, which is a purified protein, is not a filler. This substance relaxes the muscles so that the skin wrinkles soften, and in many cases, disappear. It does not treat the skin, it treats the underlying muscle. Examples are the creases between the eyebrows (glabella), the forehead lines and crows feet around the eyes. It is not uncommon to use Botox to treat the underlying muscle and soften the skin creases, and then treat the remaining creases with a filler such as Restylane or collagen.

I am hopeful that Restylane will live up to its PR, but only time will tell as we compare it to collagen products.

I recommend that you consult with a board-certified plastic surgeon or board-certified dermatologist regarding these products and whether they would benefit you.

Submit your questions to "Ask the Plastic Surgeon" at

allnewu@AOL.com. Questions may be condensed and reformatted for the column.

Questions are answered by Dr. Mark A. Foglietti, a nationally recognized board-certified plastic surgeon

and author.

The Experience

You Trust and the

Skill You Desire.

Question: My 14-year-old daughter has inherited my family's nose. It is a large nose with a bump. She is very attractive but feels that her face is overwhelmed by her nose. This has bothered her for several years. Her father and I have decided that if she would like to have nasal surgery, we would support her decision. At what age do you recommend nasal surgery?

Question: I have been considering having breast enlargement surgery and recently saw a news report that silicone implants may soon get FDA approval for use again. Are
silicone implants safer now than in the 90s when they were banned and are they better than saline?

Question: I am 42 years old and have sagging eyebrows. I cannot see my upper eyelids and it is worthless for me to attempt wearing eye shadow. This runs in my family. Will Botox lift my eyebrows or will I need surgery? Sincerely, J.D.

Question: I am 34 years old and have three children.
I have a C-section scar and loose skin around my belly
button. Even though I am the weight I was prior to having children and work out at least twice a week, I can't seem
to tighten my tummy. I'm not going to have any more
children and would really like to get my figure back. I've thought about having a tummy tuck, but my husband thinks that if I exercise more I should be able to return to my pre-baby shape. Is surgery a good option for me?

Question: I am a 53-year-old woman and I am beginning to see loose skin around my neck and jawline. My mother began to have sagging skin at the same age. Am I too young for a facelift? I am concerned about starting to get plastic surgery too soon. Should I wait until it gets worse?

Question: I have been considering liposuction for several years now. I am 34 years old and have two children. I try to stay in relatively good shape, but my lower abdomen and hips will not slim down to where I feel good about myself. My tummy skin is a little loose from my pregnancies, and exercising doesn't seem to help tighten it. Will liposuction benefit me?

Question: I am considering a breast-enlargement surgery.
I am 35 years old and have had three children. Before my children, I was a 34C-cup bra size. After three pregnancies and breastfeeding, I am barely a B cup and my breasts are sagging. I just want the breast appearance that I had before children. Am I a candidate, or is this foolish to consider?