One of the commonest reasons to see a plastic surgeon is for enhancement of the breasts. While each individual’s situation is unique, breast surgery boils down to making changes in size, shape or symmetry. Those are the key three components, and, if you asked anyone who had cosmetic breast surgery, she would have to say that she wanted to change something about her size, shape or balance. Plastic surgeons use these concepts for analyzing a patient’s situation and, as you better understand the way surgeons think, you will learn more about the procedures that are available.
As far as breast size is concerned, much of the media and certain societal trends have suggested that “bigger is better.” The plastic surgeon, on the other hand, sees two opposing aspects of the issue of breast size. On the one hand, we see women with small or average breast volume who are seeking increased size in order to create a more feminine body contour or more enhanced chest area. Many of them are patients who wore size A-cup bras, and always looked at themselves as “flat-chested.” Those women often express the feeling that they have too “masculine” of a figure. Breast enlargement can achieve the goals of creating an improved shape in the chest area as well as a greater curve toward the torso. Not only do patients appreciate the results of their breast enhancement when they look at their body, but also they enjoy the benefits of new choices in their attire and wardrobe.
On the other hand, we commonly see women who have been large-breasted all of their adult life, and feel that very large and heavy breasts have been a burden. They may complain of neck and back pain, they may have indents in the shoulders where the bra straps rest, and they may have had skin rashes underneath the breasts from friction. For them, their large breast size has created physical problems, and they are seeking a reduction in size and weight. And, because larger breasts often show more sag and droop, they seek a smaller breast size that is lifted and more youthful. The fact that there are excellent candidates for both breast augmentation as well as breast reduction indicates that there is no “correct” choice as to whether the female breast should be made larger or smaller. Like most things in life, it’s about what you like and how it makes you feel.
As far as breast shape is concerned, it may seem to many that it would be difficult to describe the qualities of an attractive breast shape in words, and that it is completely an arbitrary judgment. . . the “you-know-it-when-you-see-it” concept. Actually, there are specific characteristics associated with what most individuals consider attractive breast shape. First, there is the concept of how high or low the nipple is positioned relative to the breast fold (we call the fold under the breast where the underwire rests, the “inframammary fold” or IMF). You can refer to figure 1 to see this illustrated. If the nipple is below the IMF when a person is standing up, the breast will appear “droopy” and in need of lifting. If the nipple is above the fold, it will appear more youthful. Second, the skin between the nipple and the IMF, which is the skin of the bottom part of the breast, should have a nice convex curve similar to the curve of a part of a circle (see “A”). If it is indented or too straight, it will give a suboptimal shape. Third, the skin above the nipple and extending to the collarbone should ideally be either straight or slightly convex (see “B”). If this is indented, it is not as ideal, and may seem deflated. Finally, from the front view, the breast curve from side to side of each breast should have a smooth curve that approaches, but does not have to match, that of a portion of a circle (see figure 2).
Finally, there is the issue of symmetry. This can be somewhat difficult to assess in mild cases. As a general statement about living organisms, perfect symmetry is almost never found. The closest that we can find in nature are highly similar levels of symmetry. This imperfection in life is also seen in the plastic surgery practice, where degrees of asymmetry between the left and the right breasts are detectable in almost all exams. So, that raises the question: At what point does the degree of asymmetry become a problem that needs correction? This is really a judgment call, since the human eye is drawn to asymmetry, and correcting an imbalance can significantly improve overall attractiveness. More severe asymmetry can also have practical implications, such as difficulties with bra fit and the need for padding or other measures to look normal. As a rule of thumb, if a patient’s asymmetry appears to be correctable in a safe and predictable way, it would be worth discussing with your surgeon.
We will further explore details about cosmetic breast surgery in Part 2!
Rhinoplasty refers to surgery of the nose intended to change its appearance or structure, and is commonly used interchangeably with the term “nose job.” There are different plastic surgery techniques that have been developed for use in rhinoplasty, and each procedure is, ideally, customized for a patient’s specific needs or goals. People considering rhinoplasty usually wish to change specific features of the nose, such as size or shape in order to make it more attractive, although they may also have breathing issues that need to be corrected as well. Although your plastic surgeon will analyze your own situation and create a surgical plan that is best for you, it is helpful that you identify exactly what aspects of your nose you would like to improve before your consultation so that your surgeon understands your goals clearly.
Simplifying it, there are only several types of adjustments in rhinoplasty that can be used to achieve results. First, one can reduce parts of the nose by “shaving” down or removing, such as reducing bone or cartilage that causes the appearance of a large bump. Second, one can re-shape what is already there, such as narrowing a very wide or unattractive tip. Third, one can add more to the nose, such as when the tip needs to be enhanced because it is not well positioned. In this third category, there are options of adding tissue from the patient’s own body, tissue that has been obtained from a donor, or completely synthetic material manufactured specifically for implanting in the body.
Some people seeking a “nose job” do so primarily for reasons of breathing problems, and they may have what is referred to as a “deviated septum.” The septum is basically the dividing “wall” of tissue that separates the left and right sides of the nasal passage inside the nostrils. Usually the septum is a solid structure made of cartilage and tissue, but it may be weakened or have holes in it because of injury, surgery or cocaine abuse. Surgery of the septum, or “septoplasty,” is a procedure that helps correct any bends or abnormalities in the septum that block the airway and create difficulty breathing. This may have no effect on the appearance of the nose, or could improve appearance by straightening the profile or creating other cosmetic changes. While it is possible for patients to have their health insurance cover a septoplasty for breathing issues, the insurance companies do not provide coverage for cosmetic alterations of the nose.
I am often asked about the incisions used for rhinoplasty, as they are not always visible or obvious to many people. Plastic surgeons think about rhinoplasty incisions in two general categories. The “closed” rhinoplasty places incisions inside the nose and out of any significant visibility. The “open” rhinoplasty places an incision in the skin located between the nostrils which, if done properly, should have minimal or no visibility. For the surgeons who advocate an open approach, the rationale is that the use of the incision allows better access and visualization to make the necessary changes and improvements. Surgeons may have a preference as to which approach they prefer, and this is something that should be discussed as part of the consultation.
In the next article, we will review the process of the consultation and more details about the operation and healing process.
For so many people, scars evoke an emotional reaction. It may be simply because of the look, or it may bring to mind a past event, often unpleasant. Scars result from any kind of cut or injury to the skin that is deep enough to cause the process of repair and healing to leave permanently visible changes. Scars result from many causes, and they can occur both in body parts that are easy to conceal (like areas covered by clothing) and in parts that are exposed all of the time, such as the face. Common examples of the kinds of scars that I evaluate frequently include acne scars on the face, traumatic scars from accidents, dog bites of the face and arms, enlarging or growing scars called “keloids,” and scars from surgical procedures. Sometimes patients have scars after cosmetic surgery that they are not thrilled with, even with otherwise excellent results under the care of highly qualified plastic surgeons. This guide will help shed some light on scars, and also contains a unique summary of scar treatment options that you may find very helpful (see “A Simple Guide to Scar Therapies” section below).For so many people, scars evoke an emotional reaction. It may be simply because of the look, or it may bring to mind a past event, often unpleasant. Scars result from any kind of cut or injury to the skin that is deep enough to cause the process of repair and healing to leave permanently visible changes. Scars result from many causes, and they can occur both in body parts that are easy to conceal (like areas covered by clothing) and in parts that are exposed all of the time, such as the face. Common examples of the kinds of scars that I evaluate frequently include acne scars on the face, traumatic scars from accidents, dog bites of the face and arms, enlarging or growing scars called “keloids,” and scars from surgical procedures. Sometimes patients have scars after cosmetic surgery that they are not thrilled with, even with otherwise excellent results under the care of highly qualified plastic surgeons. This guide will help shed some light on scars, and also contains a unique summary of scar treatment options that you may find very helpful (see “A Simple Guide to Scar Therapies” section below).
Many people are unaware of the factors that affect how a scar ultimately looks. Some of the causes of scars are out of our control, such as in the case of an accidental injury or an emergency surgery to treat a serious condition (like appendicitis). In the case of cosmetic surgery, the common belief is that the scar result is completely related to the workmanship of the treating doctor. That is not usually the case, especially if that physician is a highly qualified specialist, such as a board-certified plastic surgeon. Here are four key factors that determine how visible or obvious your scar will ultimately be:
1. Your own genetics determine a lot about your healing characteristics. Some people heal with flat, pale, or softer scars, while others heal with thick, raised, or darker-colored scars solely on a genetic or hereditary basis.
2. The location of a scar on the body will often influence its appearance. Areas of greater skin tightness or increased motion can develop a more unsightly scar, and long scars can show differences in healing along different parts of the very same scar. Examples of troublesome areas include the central chest skin, the top of the shoulder, and directly over the knees, to name a few.
3. The original cause of the scar can significantly affect the scar result. For example, accidents that result in crushing, tearing, loss of tissue or dirt embedded in the skin will often cause an unfavorable result.
4. Surgical technique can influence the scar appearance, especially if the repair and closure are not provided by a properly trained specialist. Also, reactions to the stitches used, or the development of infection or separation of the stitches can also lead to “bad” scarring.
Based on these four factors, here are my key tips to help you minimize scarring:
✔ If you are planning for elective (non-emergency) surgery, find out if there are scarless or scar-minimizing approaches available for your procedure. Many years ago, for example, all patients requiring removal of their gall bladder received a rather large and unsightly tummy scar that was painful. Now, patients can undergo removal of the gall bladder through laparoscopic incisions of less than an inch and go home faster with less pain.
✔ Do your best to control or avoid those things that cause scars in the first place, before they spin out of control. For example, aggressive control of acne, especially cystic acne, will reduce the frequency of inflamed areas that can result in scars that are hard to improve.
✔ For areas that are prone to bad scarring, and especially if you have a personal history of poor scarring, you may want to avoid optional treatments that are not medically necessary. For example, think carefully before asking a doctor to remove that mole from the top of your shoulder that you have had “forever.”
✔ Be sure to seek treatment with a skilled practitioner, such as a board-certified plastic surgeon, since surgical technique and planning are so important in the result.
✔ Follow post-treatment care guidelines carefully so as to reduce the risk of an infection or complication, which can worsen the result. Remember, guidelines generally include avoiding sun exposure on new scars.
✔ Use products that may help reduce or minimize unfavorable scars (see below).
A SIMPLE GUIDE TO SCAR THERAPIES
Here is my summary of the “winners” and “losers” available for scar treatment. The guide is based on scientific studies designed to study the effect of various treatments on scars. If the treatment listed must be provided by a doctor, there is an ” * ” next to it. Always remember: It is very important to check with your own doctor before beginning any scar therapy to make sure you are using a safe and effective approach:
• Onion Extract (ex. Mederma) – studies show mixed results for effectiveness, but some studies show improvement in color and sometimes height. WEAK WINNER
• Vitamin E – most studies show no benefit. LOSER
• Silicone – studies show reduced scar color and height. WINNER
• Steroids* – studies show good response. WINNER
• Fat Grafting* – studies show improvement in appearance and softness. WINNER
• Radiation and certain prescription medications* – studies show improvement with keloids or severe scars. WINNER
• Cocoa Butter – no effect. LOSER
• Olive Oil – no effect. LOSER
• Infrared Energy treatment* – no effect. LOSER
• Retin-A* – marginal effect. LOSER
• Scar massage – helpful in burns. WINNER
• CO2 laser* – helpful for acne scars. WINNER
• Pressure garments – can reduce scar thickness. WINNER
• Pulsed dye laser* – most studies show it is effective. WINNER
In summary, things you can do on your own to reduce scarring include:
1. Use sun block for scars located in exposed areas of the body, especially if the scar is still new.
2. Use a silicone-based topical scar treatment. Some premium silicone scar treatments also have a sun-block built in.
3. Consider using an onion extract topical treatment, though it seems less effective than silicone.
4. Consider scar massage (definitely check with your own doctor before massaging).
5. Avoid activities that could stress a new incision and possibly cause it to open up or separate.
Things that may be helpful for scars but must be provided by a doctor include:
1. Injecting medication into the thickened scar (many medications are available for this purpose, and your doctor must guide you).
2. Use of laser or light therapy.
3. Fat grafting.
4. Custom pressure garments.
5. Surgical removal of the scar with a new closure (“scar revision”).
6. Use of radiation therapy for severe problem scars, such as keloids (see an example at http://www.drberger.com/gallery/scarcorrection1.html ).
Saul R. Berger, MD, FACS
With an ever-increasing number of options for looking better, younger and healthier, it’s no wonder people think about having plastic surgery and non-surgical cosmetic treatments. If you are considering this for yourself, have you thought about the BEST way to go about it? In other words, aside from booking an appointment at the doctor’s office, have you thought about the process itself, and how to get the best results? Here is your essential guide to getting the best results from your cosmetic surgery:
1) ESTABLISH CLEAR GOALS. Before you jump in, it is best to establish clear goals of what you want to achieve before having a consultation. The more specific your goals are, the more likely your doctor can create an effective plan to meet your needs and the less likely you will fall short of your ideal results. Try to be as specific in your goals as possible! Examples of very specific goals are wanting a straighter nose profile, wanting to remove “bags” from under your eyes, or wanting your tummy to look flatter and tighter. Nonspecific goals, such as wanting your tummy or eyes to “look better,” leave too much open for interpretation, and are less helpful in designing the best treatment plan. Only if your doctor can understand precisely what you are seeking, can he/she determine if the result is realistic and the best way to get there.
2) CONSULT WITH A REAL EXPERT. Plastic surgery and cosmetic treatments require having knowledge of the procedures as well as the skills to provide them safely. Because of the local laws that apply in your state, it is technically possible for health professionals who are not specifically trained in cosmetic surgery or therapies to perform these treatments while remaining within legal boundaries. In the state of California where I practice, for example, any licensed physician can legally perform a facelift or breast augmentation even if he/she was never trained in plastic surgery at all! Yes . . . this is a scary thought. Thankfully, there are ways in which you can methodically go about the process of finding a great doctor. One of the best and most popular criteria to consider is board certification in plastic surgery. Certificates hanging on office walls claiming that the doctor is certified by some “cosmetic” board can fool many people. In truth, there is only ONE legitimate certifying board for plastic surgeons: The American Board of Plastic Surgery. So, be sure to know that the board certification is legitimate. Beyond board certification, membership in the ASPS (American Society of Plastic Surgeons) signifies both board certification as well as other additional characteristics. If you seek more selective “status” in your plastic surgeon, look for a physician who is a member of ASAPS (American Society for Aesthetic Plastic Surgery). ASAPS doctors are automatically screened for board certification while also demonstrating a focus on cosmetic procedures along with ethical integrity and other parameters. These following web sites can assist you in locating practitioners and verifying their board certification: www.surgery.org (American Society for Aesthetic Plastic Surgery – arguably the most “elite” society of cosmetic plastic surgeons), www.plasticsurgery.org (American Society of Plastic surgeons), and www.abplasticsurgery.org (The American Board of Plastic Surgery – you can check whether your doctor is board certified here). Once you find a doctor, recognize that there are varying policies as to how offices handle fees for a consultation. Some doctors offer complimentary consultations, others charge a fee, and yet others charge a fee initially and subsequently credit the amount back to upon booking a procedure. While you may have your own opinion about consultation fees, always remember that treatments and surgeries are far more important than the issue of a consultation fee in most cases. Consequently, I encourage people to avoid putting too much emphasis on the consultation fee. Often, the best-qualified doctors charge a consultation fee because of the time and expertise that they bring to the table for patients. So, in the long run, if you look for quality over these smaller financial issues, you will have access to a wider selection of potential doctors.
3) FIND THE RIGHT FIT. Ensure that you have a comfortable fit with the treating doctor and office, and have confidence that you will be able to communicate with them as well as obtain the information you need. As with any process, it is important to have excellent communication with your treating team, and always recognize that doctors vary in their work style and personality. If you are comfortable that your doctor understands your goals and can formulate a plan that seems to be a good fit, you increase the odds of having a great experience. As with any situation that offers you a choice as to where you receive your care, getting a second opinion may help clarify where you feel the most comfortable. Any doctor who has his/her own surgery center would be among an elite group of physicians who have dedicated the energy and resources to managing the surgical process with a “hands on” approach. I have a policy of providing a tour of my surgery center to all new patients so that they have an immersive and thorough experience before they undergo surgery. Most patients are intuitive and savvy enough to recognize top-tier quality when they tour an office and surgery center.
4) LEARN. Learn as much as you can about the procedure(s) as part of the process called “informed consent.” It is wise to be aware of the options available for your situation, the way in which the treatment will be given, and the risks or side effects associated with treatment. In spite of the remarkable capabilities of the Internet these days, it can be counter-productive to simply use Google to randomly search for information. In fact, I have seen patients become overwhelmed and even “stressed out” about information that they read on the Internet from questionable sources. This almost always occurs as a result of reading about bad complications that someone (often a celebrity) had suffered. Always remember that the “horror” stories get most of the media attention, even if they are based on avoidable or rare problems. I have found that my patients get much more reliable information from well-designed brochures, such as those from ASAPS, or by navigating to web sites of high integrity. You can refer to the web sites listed above for the ASAPS and ASPS resources.
5) PLAN A BUDGET. Consider your budget and the costs, so that you are prepared. Most patients either pay directly for their procedure (with credit card, for example) or use a special line of credit, such as CareCredit (www.carecredit.com) and Alphaeon (www.alphaeon.com). Many offices are familiar with these companies, and can assist you in applying for a medical line of credit. With the help of these companies, it is possible for you to undergo treatment today and pay for it over time.
6) PREPARE. Once you have a treatment plan, prepare thoroughly for your procedure(s). For cosmetic surgeries, such as breast augmentation or tummy tuck, you will typically need up-to-date blood tests and a physical exam to ensure you are ready for any anesthesia required. Also, there are a number of additional steps to prepare for surgery that can reduce your risk of side effects or complications. Of course, you should always get specific instructions from your own doctor, and some of the list that follows may not apply to you. Examples of advice often recommended before surgery include (1) Avoid pills that may increase your bleeding risk, such as aspirin, ibuprofen, etc., (2) Avoid most herbal products or supplements as well as vitamin pills unless cleared by your doctor, (3) Avoid unnecessary extreme exertion just prior to your procedure so that you are not dehydrated, (4) Obtain as much of the materials you will need after surgery in advance, such as compressive garments for liposuction, post-operative bras, healing creams, etc., (5) Prepare your home for your return after the procedure by making sure you are well stocked with food, have clean clothes ready, and have your pets’ needs accounted for. If you require medications after your procedure, be sure to pick them up in advance whenever possible. Prescriptions may include pain medications, antibiotics, sleep aids as well as others. It is common to need ice to apply to surgical sites, for which many people use frozen peas, (6) Be sure not to drink any fluids or eat anything by mouth for at least the 8 hours prior to a general anesthesia you may be having (or as advised by your doctor), (7) Be sure to wear comfortable and loose-fitting clothes that are very easy to remove and put back on after surgery. A zip-up top, for example, is better than one that requires you to stretch over your head. Also, be sure to leave all of your jewelry and valuables at home, (8) Make sure your transportation is set up with someone reliable, such as a relative or good friend. If you receive any anesthesia or sedation, you will only be discharged in the custody of a reliable adult who can drive, (9) Make sure your driver receives all of the instructions from the medical staff, as you may not remember the details right after you awaken from anesthesia.
7) FOLLOW INSTRUCTIONS. Follow all of your post-procedure instructions carefully, and ask any questions of the staff for clarification. The results of a procedure can depend on both the surgery as well as the aftercare at home. Some instructions, such as taking a pill, can be quite straightforward, while other instructions, such as recording fluid output in a drain, require more detailed information so that it is done properly. I provide all of my surgery patients with a specific form that they take home and use as a reference for aftercare. It includes just about anything that they would need to know. I have also found it helpful to use specific instruction guides for non-surgical treatments when a procedure requires any detailed home care.
8) KEEP YOUR APPOINTMENTS. Every surgery or procedure has its own aftercare regimen. Surgeries generally have a longer list of aftercare instructions when compared with non-surgical treatments, although laser treatments and some injections need extra post-treatment care. There may be a need to remove stitches, and the timing for stitch removal will vary with the procedure and the kind of suturing. A drain may be used with certain plastic surgery operations, and the decision for the timing of drain removal must be made by the doctor. In the case of a rhinoplasty, (“nose job”), for example, there may be a splint placed over the nose or special material inserted in the nose that must be removed. Although most of these aftercare visits are short, they allow your doctor to monitor you closely for any problems and keep you on track.
9) BE PATIENT! Believe it or not, complete healing after surgery can take over 12 months! Of course, returning to work or activities occurs much sooner, while the softening of scar tissue and the reduction in scar visibility takes many months. So, patience is a virtue under these circumstances.
In summary, it is helpful to know what to expect if you want to consider cosmetic surgery, and, with the proper knowledge, you can stack the odds in favor of success. The key success elements are:
- ✓ Establish clear and specific goals of what you want
- ✓ Consult an expert, such as a plastic surgeon member of ASAPS
- ✓ Ensure you have a comfortable fit with the doctor and office
- ✓ Learn about the procedure and associated risks and alternatives
- ✓ Consider your budget and the costs
- ✓ Prepare thoroughly in advance so there are no surprises or problems
- ✓ Follow the post-procedure instructions faithfully
- ✓ Follow up with your doctor
- ✓ Be patient!
Saul R. Berger, MD, FACS
For many years, liposuction was associated with body contouring and fat removal, and was mainly in the domain of plastic surgeons. Although the technique has been refined in some ways, fundamentally it still involves the removal of fat using small, often insignificant incisions, to reduce areas that have accumulated fat deposits. We use the term “cannula” to describe the metal tube that is passed to extract the fat. While the details of each surgeon’s technique may vary, most agree that nowadays it is appropriate to place fluid (“tumescent fluid”) into the area first, in order to best prepare the site for fat extraction and to minimize blood loss and discomfort. The ideal patient who is a candidate for liposuction has traditionally been the patient who is close to ideal body weight and has focal areas of excess or prominent fat. Often, these patients note that, however hard they may work to keep their weight at their best, certain areas “just don’t go away.”
Some of the ways that liposuction has evolved include the development of new kinds of cannulas, the use of different ways of aspirating the fat, and the use of different forms of energy to break up the fat for removal. Energy forms that have been applied to fat tissues include lasers, ultrasound and radiofrequency. The use of radiofrequency has even been used without any incisions or cannulas, and has been passed directly through the skin with no incisions. In my opinion, the results achieved with that technique have been minimal or disappointing. It is always worth considering the fact that, whenever the surgeon delivers any thermal energy to the tissues, the risk of scarring or burning the tissues is a real potential danger.
Over time, interest has grown in using fat for valuable purposes rather than discarding it as medical waste. Although fat has been harvested and reinjected for many years, the process has hardly been standardized and the results have been extremely variable. Some of the best “minds” in plastic surgery have had legitimate disagreements on whether transfer of fat really works, and even more disagreement on the best method(s) to use for fat transfer. Evidence increasingly shows that fat can be transferred by injection techniques and survive, and that fat can also be used as a source of delivering other cells, such as stem cells, to different regions of the body. I have personally experienced very gratifying results with fat transfer, provided certain principles were followed. Here are some guidelines that I follow in my own practice:
1) The technique of harvesting the fat is very important, and this includes the selection of the instruments used, the pressure used to extract it, and the manner in which it is separated from unnecessary fluid. This concept would suggest that the use of newer laser-assisted or thermal systems of fat removal may be very unappealing because they can destroy these valuable cells.
2) The technique of delivery of the fat is equally critical, as the fat must be able to thrive in its new location and receive adequate blood flow and nutrition.
3) Patients who are thin may be very good candidates for specific types of fat grafting; they do not have to be overweight or carrying pockets of donor fat.
4) Areas that are prone to constant movement, such as the lips, are less likely to retain the volume injected when compared to areas that do not move as frequently.
5) If you assume that some percent of the fat will be lost over time, while the rest has a good chance of retention, you are embracing a more realistic approach and will likely be pleased with the results.
6) Fat grafting can be a great addition to other surgeries that you may already be considering, such as face or neck lifting.
7) Fat has the possibility to provide long-term volume enhancement; off-the-shelf fillers usually do not. For large areas of fat grafting, such as the buttock area, fillers are not even a reasonable option given those that are FDA approved in the U.S.
Fat grafting and transfer is a growing area of interest, and you will likely see more advances on the horizon. I will keep you posted . . .
To your health!
Saul R. Berger, MD, FACS
Over the past couple of years, I have seen more women seeking consultation for labiaplasty than ever before. Many people have speculated as to why there is increasing interest in these procedures, and explanations include social trends toward greater hair removal in the genital region thereby exposing the area more, as well as greater societal exposure to nudity. Patients seek out treatment for a variety of reasons and come from all walks of life. Some women feel self-conscious about the way they appear even if no one else sees the area. Others develop irritation and physical symptoms related to pressure from excessive or protrusive tissues. Specific reasons that women seek consultation include:
1) The desire to reduce the size or improve the shape of the labia minora or labia majora for cosmetic purposes. Many view the excessive and protrusive tissues as appearing “stretched” or excessive, and not youthful. As with other aesthetic procedures, correction can improve self-confidence.
2) The desire to reduce the labia minora size because of irritation, pressure, or pinching during sports, exercise or certain activities. There are also circumstances in which such individuals are uncomfortable during sexual relations secondary to traction and irritation.
3) Many women have an imbalance in size or an irregular shape that gives the appearance of an “abnomality” and can cause patients to feel self-conscious.
Although labiaplasty is offered by a variety of medical professionals, I believe that the well-trained plastic surgeon is ideally suited to handle this kind of operation with skill and finesse. While historically, many surgeons simply “cut off” the extra tissue and “sew it up,” such procedures can leave a lengthier scar at the edge of the labia and could result in increased sensitivity in that area. My own philosophy, on the other hand, is to bring the principles of plastic surgery to this arena and use smaller scars and avoid placing them along the labial edge when feasible. These techniques have proved very worthwhile.
I feel very privileged to be able to offer two options to patients at my center in Encino/Los Angeles, California. One option is the full labiaplasty procedure performed without the need for general anesthesia. Patients remain completely comfortable and pain-free while the correction is performed, but are able to be discharged in a short time, alert and awake, and without having the after-effects of anesthesia or the need to have bloodwork checked in advance. The total cost for this option is also lower, with fees that are some of the most affordable in plastic surgery. The other option is the use of general anesthesia, which provides the ultimate in ease for the patient experience. Patients who undergo labiaplasty under general anesthesia tell me that the procedure seemed to have taken “only a few minutes.”
Many patients begin their journey toward this procedure by reading reviews such as this one and gaining awareness of what is involved. The next step for interested patients is the scheduling of a consultation to assess each patient’s specific needs. At the first visit, I typically give my patients the information they need to understand the procedure and the risks, discuss the option of having it done with or without general anesthesia, and provide a copy of the aftercare instructions so that each individual is well-prepared in advance. The recovery is not very difficult, and often requires only a few days off work if one’s job is office-based.
For greater detail and real case analyses, you can find more detail at my web site: www.drberger.com.
We are frequently exposed to ads for surgery purported to rejuvenate the face in seemingly remarkable ways. “In as little as one hour . . . with miraculous results . . . with no scars or down time . . . over your lunch break . . . ” and so on. Usually there are accompanying photos which show dramatic results that appear almost “too good to be true.” Is it all true?
It is important for individuals seeking facial rejuvenation to have both a careful evaluation by a professional who performs reliable procedures and an understanding of the various options available. A successful treatment plan usually considers the recovery and down time involved, the possible risks of the treatment as well as the patient’s medical status, and the pros and cons of the choices (and there are many choices nowadays). Did you know that some of these heavily advertised procedures are offered by “franchised” operations that involve non-physicians for patient screening and evaluation? Did you know that some of the procedures that are speedier than others may be a poor match for certain patients and can increase the risk of side effects or the amount of down time? Did you know that some of the photos which appear in ads represent results achieved only weeks after surgery (and may not hold up over time)? Did you ever think that an effective procedure performed over lunch would allow the average individual to return to work “business as usual?”
For most of us, applying common sense would raise suspicions and doubts about many of these claims. The aging process in the face is quite complex, and involves many factors including loss of skin tone, changes in fat volume and location, and changes in the skeleton itself. Each of us ages in our own way based upon factors such as genetics, environmental influences, diet, and lifestyle (and there are other factors). Surely, common sense would suggest that we are not all candidates for the identical treatment!
More than twenty years of plastic surgery practice have allowed me to make some observations:
(1) Good results are generally based on a skilled assessment of the aging changes for a specific individual, rather than a “cookie cutter” approach;
(2) Often, the best results require a larger procedure that may involve longer healing and recovery instead of a “quickie” approach;
(3) A non-physician or non-expert evaluating a patient in order to devise a treatment plan that is implemented by a physician creates a “disconnect” or fragmentation of care that may compromise the results; and
(4) While some “quickie” procedures are completed in a short time, they may create unnatural results.
As with many things in life, if it looks “too good to be true,” it often is. Quick and easy works great for online shopping . . . just don’t shop that way when it comes to your looks!
To your health!
With the incidence of breast cancer at nearly one in eight females, I see patients with this diagnosis almost every day in Encino and the Los Angeles, California areas. The patients that I treat are in various phases of care, ranging from newly diagnosed to survivors beyond five years. Nowadays, many are receiving chemotherapy and radiation, and many are undergoing mastectomy rather than breast-conserving lumpectomy. As one member of a team of specialists, the plastic surgeon tries to focus on the restorative aspect of breast cancer care.
Patients with new cancer diagnoses are faced with an early decision of lumpectomy and radiation versus mastectomy. While conserving the breast is an appealing idea, it does not work well for many women, and can result in a deformed breast that is difficult to improve. I have also seen a number of cases that developed cancer in the remaining breast tissue left behind after lumpectomy in spite of radiation treatment. Nevertheless, I tend to advise the option of breast preservation if it is likely to give a good cosmetic result. If not, the mastectomy, which removes almost all of the breast tissue from the cancer site, may be the better option.
Patients who are potential candidates for mastectomy should, ideally, see the plastic surgeon early on in the workup process to ascertain the role of plastic surgery for them. There is no substitute for a detailed and thorough examination, assessing each patient for options involving both implant approaches as well as body tissue reconstructions. I have heard so many women say, “I wish I knew that before . . .,” as they had never seen a plastic surgeon until they were already healing from the mastectomy. As a general rule, use of implants and expanders are shorter procedures involving less hospitalization. Implants are limited in how they can be placed and used to shape a breast, do not fare well in areas that have had or will have radiation, and can be difficult to match to an opposite “natural” breast. Because of these limitations, they often work better in cases of double mastectomies.
Tissue reconstructions can require longer operative and hospitalization times, but offer advantages in shaping and in radiated areas. Their success relies on adequate blood flow into the tissues, a factor that the plastic surgeon is attentive to throughout the surgery and post-operative period. The two most common sources of body tissue are the tummy and the back areas. Not everyone is a good candidate for this approach; your plastic surgeon can guide you.
Some words of advice if you are facing breast cancer or know someone who is . . .
1) Take a deep breath, and try to stay focused to make the best choices you can. Experienced plastic surgeons know that you are sometimes under short time constraints to make decisions about your care, and they will try to give you as much information as possible. Meet with them as early as possible.
2) With the current state of chemotherapy and additional treatments, survival with this diagnosis has made great progress in the last few decades.
3) The changes in your body tissue that result from a course of radiation may never go away. They may have a major impact on your reconstruction in the future.
4) If a lumpectomy will likely deform your breast in a way that could disappoint you, think carefully about whether the mastectomy option would be a better choice.
5) All other factors being equal, the body tissue reconstruction frequently offers the best long-term result.
6) If you need reconstruction after mastectomy, good integration of your plastic surgeon with the other members of the team is a strong advantage.
To your health,
Saul R. Berger, MD, FACS
A couple consulted with me some time ago about a number of cosmetic issues. Both had traveled to a Central American country for cosmetic surgery. Both individuals had multiple procedures to the face and body, including facelift, brow lift, breast surgery, tummy tuck and more. Frankly, it was difficult for them to know where to begin describing the problems that resulted, including sutures that still needed to be removed more than one year after surgery, scars that left them looking “strange,” and residual cosmetic issues that were never corrected. In actuality, they began the consultation acknowledging that they had made a “big mistake” in traveling for surgery, but were trying to maintain a positive attitude in moving forward. What was their prime motivation for surgery in another country? Cost. They spent about 50% of the cost of similar surgery in the U.S. Some of their problems were correctable, and some were not. Ultimately, they never underwent additional surgery — they were not able to budget for the corrective work. How did they find and “screen” the cosmetic surgeon who treated them? The internet.
The desire to look one’s best and the benefits of improved appearance on both a personal and professional level have been recognized for many years. Interestingly, there are many studies in the field of sociology that have documented measurable advantages, on a societal level, to possessing beauty and attractiveness. Studies have even documented this fact across cultures and geographical boundaries. The wild popularity of such relatively “simple” procedures such as Botox Cosmetic and the billions of dollars spent on skin care attest to our desire to “look our best” as much as possible. Despite the current state of the domestic and world economies, individuals are still seeking aesthetic treatments and surgeries. In order to reduce costs, some people have traveled to other destinations for their treatments. Is it worthwhile to travel abroad for cosmetic surgery, and what are the risks? What is involved in “surgical tourism?”
Some years ago, medical tourism described upper social class individuals traveling to countries for specialized skin care, spa therapies, mineral baths, or other unique treatments in pampering settings such as cities in the Mediterranean. In more recent times, it has become commonplace for foreigners to travel to the U.S. for treatments that were either unavailable or associated with major delays in their native country. The escalation in health care costs in the U.S. along with advances in aviation travel have increased the volume of Americans seeking medical care outside the U.S. for everything from organ transplants to cardiac surgery. Specifically in the area of cosmetic surgery, people have traveled for procedures such as liposuction, facial cosmetic surgery, tummy tucks and much more. In almost all cases, the motivation for travel is a lower price. The obvious question is: are those savings justified?
While there is no definitive answer to this question, and there are certainly skilled and competent surgeons practicing around the world, what risks do patients face when traveling abroad for surgery? The risks fall into several general categories:
Competency risk – does the physician have the necessary training to perform the procedure(s) safely and to achieve desirable results? It can be very difficult for Americans to ascertain the quality of training and certification outside of the U.S. Satisfactory results in a friend or family member may not translate to your results.
Facility risk – does the facility follow the safest protocols to ensure sterilization of instruments and proper function of equipment? Are there contingency plans for emergencies? Do they have the latest equipment should something untoward occur? As medical director for an ambulatory surgery center in Encino, California, I can tell you that we use many safety systems about which most patients are unaware. Did you know that we confirm the reliability of every sterilization cycle by using a separate biological test? Did you know that we maintain a completely autonomous power backup system that automatically activates in the case of regional power loss so that surgery is not interrupted? Did you know that an independent technician performs regular site visits and checks every piece of electronic and anesthesia equipment for proper function and maintenance? These are just a few examples of many.
Follow-up risk – how does a patient propose to get the follow up care and information that they may require? Most surgeries require a full healing period of at least 12 months. Once returning to the U.S., patients no longer have the chance for direct “hands on” evaluation of their surgery by the practitioner. What if they experience a problem or require some minor adjustment, such as a scar revision?
Complication risk – how do patients handle complications, such as infections or keloid scars? What if their medical insurance does not cover the complications of such elective cosmetic procedures? Are complication risks higher because of travel itself? For example, prolonged airplane travel could increase the risk of a clot in a leg vein, with the risk of a life-threatening clot moving to the lungs.
So, is it worthwhile to travel for surgery? Of course, price has to be figured into any assessment for cosmetic surgery. But I advise my patients to make sure that cost is not their prime motivating factor. Remember, surgical tourism can result in medical problems, and any savings could be easily wiped out. Caveat emptor!
To your health,
Saul R. Berger, MD, FACS
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