Plastic Surgery After Weight Loss

I am commonly asked about plastic surgery after weight loss. The post-bariatric surgery patients are a very common group of patients for us. There are several things that someone should know before considering doing this. I always recommend that patients have their weight stable for preferably 6 months following their weight loss prior to considering plastic surgery. During the rapid weight loss, particularly, the patient is nutritionally compromised in terms of needing to heal after surgery. We also want to give the skin time to contract as much as it will. It has not been my experience that the skin disappears after weight loss.

People who lose weight with diet and exercise run into similar problems. Due to the fact that the weight loss is typically a little slower we don’t run into the same nutritional problems. The most common things that people want to address are their abdomen, breasts, and arms. We also commonly do facelifts as well as inner/outer thigh lifts for weight loss patients.

These patients are some of my most gratifying patients to work with. It really does allow them to close a chapter of their life. A lot of people tell me that the extra skin is a reminder of where they used to be and they would really like to move on. The surgery is a lot of fun because it does help the patients achieve this. 

For more before and after photos, click here

Treatment of Veins

There are two basic types of veins that we treat in our office.

The first is spider veins. These are commonly treated on the thighs and legs as well as the face. For small veins I typically use a laser. The laser targets the hemoglobin inside the red blood cells. By doing this the red blood cells are lasered causing the veins to collapse. It is best if compression hose are worn after this. Depending on the number of veins multiple sessions are sometimes required.

For larger reticular veins we perform sclerotherapy using Asclera^®.

We don’t treat varicose veins. 

Gynecomastia (Male Breast Reduction)

Every year we treat a number of men that have gynecomastia. In my practice I have found that there are several groups of patients that have gynecomastia surgery.

One is the weight loss patients. A lot of men after losing a great deal of weight find themselves with a lot of loose saggy skin. There are surgeries that we can do to remove this extra skin and restore them to an aesthetically attractive shape. There are commonly longer scars for the weight loss patients as more skin is needed to be tailored.

The next group is the more common gynecomastia that arises with puberty.

There are several causes of gynecomastia including puberty as well as anabolic steroids and marijuana. I have certainly seen all these groups in my practice.

Treatment of this form of gynecomastia can range from liposuction to also requiring a small incision around the areola or possibly even a lift. Which one of those options is best depends on the degree of breasts tissue and extra skin that the patient has.

Anytime someone has gynecomastia it is important to consider endocrinological causes such as testicular tumors. As need we routinely order labs and evaluate patients to make sure there is no other cause of the gynecomastia. 

Laser Tattoo Removal

Tattoos are a common part of society today. These are often obtained by young people. When they enter the workforce or become parents they often experience a great deal of regret or sometimes shame. People very commonly come to me for laser tattoo removal. The advantage of laser tattoo removal is that it can fade a tattoo without scarring. There are several things that someone should know about laser tattoo removal.

1. It always  takes multiple treatments. It not uncommon to require 6-10 treatments depending on the darkness of the tattoo as well as the color. I liken it to removing paint from a wall. The limitation is that you can only scrape so many lasers of paint off at one time. To avoid scarring the laser energy has to be controlled thus the technique requires multiple treatments.
2. The treatments have to be spaced out. I usually favor 6-8 weeks between treatments. After lasering the tattoo we want to give the body time to remove the ink debris from the tattoo site so that the next laser treatment is only treating the remaining ink. Bright colors are a lot more difficult. Some of the bright and particularly florescent colors or pastels are very difficult to remove. This can either mean a great number of treatments or not being able to remove it at all. 

For more Before/After pictures click here

Hysterectomy or Bladder Suspension with Abdominoplasty (tummy tuck)

I am commonly asked whether a tummy tuck can be done at the same time as a hysterectomy or bladder suspension.

Performing a tummy tuck with either one of these procedures is safe. It allows ladies to combine two procedures into one recovery. People often have to take time off from work to have their bladder suspension or hysterectomy so there is an added benefit of also getting rid of a lot of unwanted skin. Combining these two is safe and effective. 

click here for more Before/After Photos

Laser Hair Removal

This is a common office procedure that we perform. The most common areas are the bikini, armpits, as well as the face. Other areas include the legs and back. Laser hair removal is an effective procedure. It always requires multiple sessions. Laser hair removal only works on growing hairs at any one time; not all the hair on a given part of your body is growing. This is why hair on our heads grows out unevenly. A mans beard has approximately 90% of the hairs growing at any time. Areas such as legs or back grow much more slowly. 

The laser hair removal works by concentrating laser energy on the hair shaft. This then heats up and burns the hair follicle. The hair follicle is where the hair is created. The ideal candidate has very pale skin and dark course hair. In this scenario all the laser energy will be absorbed by the hair shaft and none of it will be absorbed by the skin. Blonde or gray hair is essentially impossible to do successfully. Darker skinned patients are also more challenging. One has to be careful in those situations that there is no reduction in skin color or scarring. Overall it is a very satisfying procedure. I personally have had laser hair removal on my neck which I love! Now I barely have to shave my neck at all. 

Filler vs. Neurotoxin (Botox, Dysport)

A common question that I am faced with is which is better for a patient: fillers or Dysport. This is a little bit of a trick question. These are both simply just tools for facial rejuvenation. They accomplish different things and they have different indications for using them.

Fillers are for filling static wrinkles. One of the most common examples is the fold that goes from the side of your nose towards the corner of your mouth, the nasolabial fold. Fillers can also be used for volumizing the face. One of the signs of aging is a deflated appearance to the face. As people age their face changes from a more round shape to more triangular. Volumizing the face can help rejuvenate the face. A common filler that is used at the time of facelift is fat grafting. It can also be done independently from a facelift. The other use for fillers is for shaping the face. Fillers such as Radiesse have been, aside from its usual indication for the nasolabial folds and other uses around the face, has also been used to conceal nasal defects.

So while fillers are used to fill wrinkles that are there at rest neurotoxins such as Dysport or Botox are used to weaken the muscles that cause winkles. Wrinkles or facial lines are caused by animation of facial muscles. The wrinkles are usually perpendicular to the axis of the muscle. The muscles on your forehead run up and down thus the wrinkles run across the forehead. The wrinkles between your eyebrows are vertical. The muscles called the corrugator supercilii is perpendicular to this inline with the eyebrow.

Dysport is commonly used by me for the forehead, the glabellar (the 11 between the eyebrows), and around the crow’s feet. Another common use of it is around the mouth for softening lipstick lines.

To answer the question of which is better; fillers or neurotoxin, it just depends on whether you are trying to fill in a wrinkle that is there at rest or weaken a wrinkle that is caused by animation.

Tummy Tuck with Labor

I am occasionally asked to perform a tummy tuck at the same time as a lady gives birth. I certainly understand the desire to combine these two procedures. The lure is that “as long as we are there….”.

There are several very serious pitfalls that make this a very unwise decision in my opinion.

The first is the patient’s safety. Mothers at the time of delivery often have issues with blood clotting. They can either clot too easily or clot too much. There are various reasons for this but the reality is that mothers have an exaggerated tendency to bleed or clot. For safety sake combining this with a procedure that has a small but real risk of deep vein thrombosis or blood clots seems particularly unwise. The last thing I want to do is hurt a brand new mother. Pregnant women also have an altered immune system. This in theory could make them more prone to having wound healing problems or infections. A mother with a new born baby may want to breastfeed and would not want to be on antibiotics should that be needed.

The second reason is that you would get a suboptimal result. There are a couple reasons for this. One is that ladies tend to retain water so their tissue is quite edematous at the time of delivery. This is going to restrict how much skin you can get off and limit the success of the operation. Also, mothers should be given a chance to lose some of their baby weight. This will enhance their result that the surgeon can achieve for her.

Next is that the uterus is also swollen and taking up more space than it will after the lady has recovered from pregnancy. This is going to limit on how tight you can get the abdomen.

Overall I think doing a tummy tuck at the same time as delivering a baby is ill-advised. It compromises the safety of the mother while giving her a suboptimal result. 

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How To Choose A Plastic Surgeon

People often shop for a plastic surgeon. It is not uncommon that a patient will interview myself as well as other plastic surgeons trying to make their decision for surgery. There are several things that an educated patient should look for. There is no perfect filter for finding the right doctor. There are several things that one can look for.

1. Is the doctor a board certified plastic surgeon? There are a variety of doctors that try to pass themselves off as cosmetic surgeons that are not properly trained in plastic surgery. An easy place to check is the American Board of Plastic Surgery (www.ABPLSURG.org). Another place is the American Society of Plastic Surgery (www.plasticsurgery.org).
2. Find a plastic surgeon that you communicate well with. Plastic surgeons can perform a lot of procedures and achieve a variety of results. 

What is the recovery like after facial cosmetic surgery?

Facial cosmetic surgery, which can be done on an inpatient or outpatient basis, usually has about a two week recovery period.

Patients will have a variable amount of bruising and swelling following surgery. I have found that this is often related to general health status and other medical issues, such as high blood pressure, that patients may have. I generally recommend that for the first two weeks after facial cosmetic surgery, such as facelift, eyelid lift, or brow lift, the patient sleep in a recliner with their head elevated. Immediately following facial cosmetic surgery, I also recommend that patients keep the area of surgery cool with ice, cold compresses, which may be accomplished by way of gel packs or coolers that circulate ice, cold water. Nonetheless, each system seems to have its drawbacks. One method that has been very reliable and simple is keeping a basin of ice water at your bedside. A wash cloth can, also, be dipped in ice water and then rung out to achieve whatever temperature is most comfortable for each patient. Patients generally find this to be a soothing comfort for the first 2-3 days immediately following surgery.

While some patients will have very little bruising and could return to work quite quickly, other patients may take as long as two weeks before the bruising and swelling can be camouflaged by makeup.

Dysport Day in the Office

Join us for a special Dysport Day, February 8th. Call our office for scheduling as well as any questions.

Breast Augmentation Recovery

What is the recovery like after breast augmentation?

The recovery after a breast augmentation is usually considered relatively easy. Surgery is done on an outpatient basis. We allow our patients to shower starting the day after surgery. We recommend that they do not have the water spray directly on any incisions but rather let soapy water gently run over their incisions. There are no drains left in after a breast augmentation. Most patients are able to return to work in 2-3 days. The patient starts implant massages typically three or four days post op. These massages are done several times per day for several weeks.

I ask my patients to restrain from a lot of physical activity for the first couple of weeks. We then very gradually increase their level of physical activity from week 2 to week 6 at which point they have no restrictions. There is an upper extremity ten pound lifting restriction for six weeks. Certainly at all times during the recovery we remind our patients that if an activity hurts then to please not do it. Also, it is not uncommon to have transient changes in nipple sensation where there is either hypersensitivity or decreased sensitivity in the first few weeks after surgery. Should either case arise it usually resolves on its own. Some ladies after surgery even notice some swelling around their abdomen. This is most likely fluid from irrigation at the time of surgery. This resolves in a few days.

Ladies generally inquire about what they can wear soon after surgery. We recommend wearing a comfortable loose fitting shirt that buttons or zips up the front on the day of surgery. This is also a comfortable item to wear over a cami which we recommend after surgery until the first office visit. We transition ladies to sports bras after that and then over time they are back to wearing underwire bras. Many women choose a less structured bra with no wire during this period due to sports bras limiting clothing options.

**Actual Patient. For Before and After Breast Augmentation Photos click here for Silicone and here for Saline**

What is the recovery from an abdominoplasty (tummy tuck)?

A significant concern for any lady considering a tummy tuck is how long the recovery is.

Abdominoplasty is a procedure that can be safely and comfortably performed as an outpatient procedure, meaning that you can have the surgery and leave the hospital the same day. Performing an outpatient abdominoplasty is a change in my practice since I started using pain pumps. The pain pumps have made the recovery significantly more comfortable.

I usually advise ladies to take two weeks off of work. This advice is based on estimation of the standard desk job. A small percentage of ladies could get back quicker than that but two weeks is generally a very safe number. During this recovery I expect ladies to be able to move around at home fairly easily. By the end of two weeks their activity level usually can afford them to get back to work, depending on how rigorous the job is. The pain pumps usually are removed at day three. Drains left in at surgery will come out usually around day four or five.

As far as cosmetic recovery, a patient could have a significant amount of swelling that takes several weeks to months to completely resolve. A scar will actually take one year to fully mature though the progress is barely noticeable in the last several months. It is normal for ladies to feel a little swollen particularly at the end of the day even for a few months.

**Actual patient**

For more Before/After photos of abdominoplasty click here.

Which is better: dermal fillers or Botox?

Patients often ask me which is better for them, a dermal filler or Botox. This is a little bit of a trick question in that these are very different tools. Dermal fillers can rejuvenate by filling in lines such as the ones at the junction of the cheek and lip called the nasolabial folds. Botox is not very good for helping this. Conversely Botox is very good for smoothing some of the dynamic wrinkles between ones eyebrows that are caused by frowning. There are times where both modalities are effective, fillers and Botox. Some wrinkles occur not only when the patient animates but also at rest. I will frequently use Botox or Dysport to help paralyze the muscle and then use a filler such as Juvederm or Radiesse to fill in any residual wrinkle after the Botox has helped soften the active wrinkling.

Whether it is Botox, Juvederm, lasers, or surgery; all of these things are simply just tools to aide in facial rejuvenation.

Which one is the best depends completely on what the patient is trying to correct and what magnitude of procedure they are looking to undergo. All of these decisions are highly individualized and can be accessed during a consultation.