October 2009

I was recently the featured interview for an online magazine for busy moms to talk about the mommy makeover.


I received a question today asking if there was a natural, nonsurgical way to lift the breast.  Ah… If only I were magic.

The breast is not a muscle.  Doing pectoral muscle exercises will not lift the breast.  You can be as toned as possible in your underlying muscle, but it won’t lift the breast tissue, firm the ligaments, or tighten the skin. (or make your breasts larger. sigh.)

Skin tone is like a bathing suit.  When your skin is new, it has great elasticity.  It bounces back well, and doesn’t stretch out, wrinkle, or sag.  As we age, our swimsuit ages as well; and the tone isn’t as good.  We all have different qualities of skin tone based on our age, ethnicity, sun damage, smoking, what we have put it through (major weight changes, pregnancy, etc) and genetics.

Once your skin is stretched out, it is stretched.  There is no proven skin cream, exercise, or laser to improve it.  Many products will claim they firm and lift.  But I think these products prey on our dreams- none of them really work.  I always ask them to show me the science.  Show me the improved skin biopsy; show me the photos of the lift.

Watch out for trickery.  Many cosmetic lasers will show only photos at 1-2 months out.  This is misleading. When you have a little bit of swelling, the skin looks prettier, plumper, and more youthful.  What does it look like at 6 months? A year?  Some of the lasers will take the first photo without flash (always shows more wrinkles and aging) and the second photo with flash.  Or they will take the photos from different angles.  Watch out for this.  I love marketing.  I had a woman who was going to do a “laser bra” in which the laser lifted the breast.  Trust me, I have breastfed three kids.  If there were a simple laser treatment which firmed and lifted, I would be the first to sign up.

So, alas, I am here to tell you there is no magic answer, no pot of gold at the end of the rainbow.

The only way to really lift and reshape the breast is with a surgery.

Where to cut?

When you choose to do a breast augmentation, we must get the breast implant inside. (Unfortuantely, it is not magic.)  This is the scar you will see when you are done.  There are pros and cons to each incision.

There are three basic common incisions:

  • Armpit (also known as axilla)
  • Periareolar (at the bottom of the areola, the colored portion of the breast skin)
  • Inframammary fold (also called IMF, the under part of your breast where an underwire goes)

There are other incisions  you hear about such as through the umbilicus (TUBA), through an abdominoplasty incision, and through the base of the  nipple. These are not as common (for real reasons).

IMF: This is the most common incision used.  The scar can go in the crease of the underwire or just above the crease on the bottom curve of the breast.  PROS: On the breast, so only someone seeing you naked will see it.  Preserves ability to breastfeed.  Can use as an open door- when you need a revision surgery due to deflation or capsular contracture, you can fix it through the old scar.  CONS: If you wear a bikini which doesn’t hug your underwire, you may see the scar.  For patients who don’t scar well (read: hyperpigment, keloid, hypertrophic scar) you can see the scar.

AXILLA: Scar goes into the armpit.  PROS: Preserves ability to breastfeed.  No scar on the breast.  CONS:  Scar in a place visible when you wear tank tops or bathing suits.  Usually more of the pocket is done by blunt dissection, so may get more bruise.  More difficult pocket dissection, may lead to implant malposition and upward migration of implant.  Difficult to place gel implants.  Usually need to make a second incision when you need revision surgery for implant replacement.  For patients who don’t scar well (read: hyperpigment, keloid, hypertrophic scar) you can see the scar.

PERIAREOLAR: Scar is at the transition between the areola and the breast skin.  It does NOT go all the way around the areola.  It is at the bottom of the semicircle.  If you see a scar going 360 around the areola, then a breast lift was done.  PROS: I find this incision hides the scar the best, particularly in my patients with darker skin tones: Asian, Phillipino,  Latina,  and Black.  If your scar turns darker / brown, then it tends to blend with the areola.  It is an open door- you can reuse the old scar for any revision surgery.  It does NOT interfere with sensation. (Will go into sensation details below.) The scar is on the breast, so only someone seeing you naked will see it.  It gives the best access to making an accurate pocket dissection, important for smaller implant sizes, which is important for my natural aesthetic in my Bay Area patients.  It allows access to have meticulous bleeding control, important to limit bruising and potentially capsular contracture.  This is my favorite incision as I find the scar fades in most patients to nothingness.  I like it particularly for women who are done with pregnancy and breastfeeding, women with constricted or tubular breasts, and women who may need a lift down the road, so you limit future scars.  CONS: It does cut through some of the breast ducts, so for women who have not had children yet and want to breastfeed, it may impair breastfeeding.

The biggest issue women bring up when discussing breast augmentation incisions, tends to be sensation.  Will my breast sensation change? What affects it?  There is a common perception that cutting at the areola will cause more sensory change.  This is not true.  Funny.  It seems like if you cut at the areola then the nipple sensation should change more than if you cut at the armpit, eh?  A study published in our white journal (the plastic and reconstructive surgery journal- a big deal in my world) showed there was no difference in sensation based on where you cut, but there was a difference based on how big you go.  The sensory nerves come up from the sides.  As you stretch the skin the nerves stretch.  This is what causes the sensory change.  Think about how your breasts feel when you are pregnant- or better yet -when your milk comes in.  That tingly, numb, or hypersensitive-don’t-touch-my-breasts sensation.  Many women report right after augmentation feeling like they did when their milk came in.  This feeling goes away, though your final sensation may be the same, less, or more than prior to surgery. I tend to find sensory change is less for women after having kids, and my thought is they have essentially “prestretched” their breast skin.

SO. Bottom line on sensation? The bigger you go, particularly if you are stretching the skin, the more sensory change you will get.

For photos, check out my gallery.  Most of the incisions you see are periareolar, and most photos are 6 weeks out.

Oh my.  How confusing all this liposuction stuff is, even for me, a Board Certified Plastic Surgeon. If it confuses me, I can only imagine how it must confuse others. So here is a quick and dirty breakdown of what is out there, and my opinion of what it does…

UAL, ultrasonic, Vaser liposuction

  • UAL is ultrasonic liposuction.  It uses ultrasonic energy to help fat cavitate, or liquefy/break up.  It has been around since the mid 1990s.  It is wonderful at breaking up fibrous fat, and is thought to potentially tighten the skin a bit.  It never caught on as much as some other methods. Why if it is so good did it not catch on?  The machine was expensive.  They marketed mostly to true plastic surgeons (there aren’t many of us), so they didn’t sell many machines.  Some people who didn’t know how to use it well would get skin burns and issues with seromas, so they would bad mouth it.  After all this time, I am still a huge fan.  I find it is a good caliber, it really breaks up fibrous fat (which all you athletic people have, and you men, and anyone with any prior surgery and internal scar), and it helps create a smooth even result.  I still love it.
  • Vaser is ultrasonic liposuction.  A slightly smaller caliber, not quite as strong an energy as UAL.  Still effective at breaking up fat.  Good.

Laser liposuction, Slim lipo, Smart lipo

  • Laser liposuction uses laser energy to break up the fat.  Again, just like ultrasonic liposuction, the energy can potentially cause burns.  If you liquefy the fat and don’t remove it with traditional liposuction, you will get seromas.  My biggest issue with laser liposuction is the marketing.  They purposefully lead patients to believe there is no anesthesia needed, it retracts the skin well, no traditional liposuction is needed, and you will be back at normal life in a day or two.  ANY TIME YOU DO A SMALL AREA THESE THINGS ARE TRUE.  When you do any larger area, which even here with my uber atheletic Palo Alto patient population most of my patients need, they still use ultrasonic liposuction FIRST and then the laser second.  For normal sized cases where they only use the laser, it takes forever.  Because the laser is such a small caliber, it is like painting a room with a small paintbrush, not a roller.  Time on the operating room table is a risk factor for complications.  Smoothness of fat removal is important as well, and painting a room with a small brush doesn’t give that smooth airbrushed quality which a roller can.  Again, I think energy to break up fat is a good thing for most liposuction patients.  When I went to the seminar where they tried to sell me these machines, the instructors admitted for most cases they used ultrasonic first and finished the patients with the laser.  I don’t think lasers are bad.  My issue is with their misleading marketing.  Also these companies are focused on selling machines.  I am concerned about their integrity because they specifically target nonplastic surgeons to do the procedure.
  • Smart lipo. Brand of laser liposuction
  • Slim lipo. Another brand.  They argue they are faster than Smart Lipo. ??

Noninvasive liposuction.

  • No incisions. Not a surgery.  External machines which “melt” the fat, which is then absorbed into your body.   Sonosculpt, Zerona, Cryolipolysis, Ultrashape are some of the machines touted.  There is also mesotherapy and lipodissolve, where you inject fluids under the skin to melt the fat.  I was on the board of directors for a fledgling company which was trying to address noninvasive liposuction.  I think it is a fantastic idea, but has many issues still.  Most of the companies which show true reduction in fat volume could not control the smoothness and amount of fat removal.  And it was painful.
  • The goal with liposuction is not just the amount of fat removed.  You want the contour to look smooth.  I had a patient who came to me from Wyoming who had mesotherapy.  It has never really taken off for a reason.  There is no “standard” solution.  For my patient, the solution injected caused her to go into liver failure, and she was taken by emergency helicopter to Salt Lake City and was in the ICU for a week.

When fat is liquefied, it gets absorbed into your bloodstream, so safety and health issues to consider:

  • ?Change in blood triglyceride and cholesterol levels?  I recently went to a talk for a noninvasive liposuction machine.  They said the triglyceride and cholesterol levels were fine after the procedure.  When I asked for more detail (I was curious), they had only taken a single blood test six weeks after the procedure to look at levels.  That does not tell me the safety at all!  What was the level in the blood during the procedure? An hour after? 6 hours after? 24 hours?  I need to know my patients who are doing elective procedures for cosmetic reasons are safe.  If your blood stream is flooded with fat, can it cause organ damage? etc etc.
  • ?How much fat can you safely remove at a time?
  • ?Smoothness and evenness of fat removal?
  • ?Fat emboli in your blood stream?
  • ?Is the size reduction long lasting?  We all have seen massage and body wraps “take off inches” which we know will come right back after a few days.

So. I have gone into this on my website with liposuction pitfalls: I and II.  I may repeat myself a bit, but I hope to educate you and demystify the madness a little.  I like to think of myself as a girlfriend’s guide to plastic surgery.

Tell a friend.  I am always so sad when I meet a patient after they have been snookered into surgery by promises of a rainbow: no pain, no surgery, no scars, no downtime.  And some things I can’t fix.

Some plastic surgeons seem more focused on marketing than on their patients.

I guess I am an old fashioned girl. I like honest and real.  I don’t try to sell my patients a rainbow.  I don’t try to lure them into my office with promises of scarless surgeries, only to tell them it isn’t possible for them.  (Kind of reminds me of those teaser car lease rates.  In the fine fine print you’ll see only one is available at the special advertised rate, and oh yes, we forgot to mention the thousands of dollars down for registration and drive off…)

Anyhow, I recently saw an article by two young plastic surgeons advocating a single incision, single scar mommy makeover. (Forgetting all tummy tucks have two scars, so the name is misleading from the start…) But love it. Sign me up! What is it?

It basically is for women who need

  1. Breast augmentation, in front of the muscle.
  2. Tummy tuck.

Now I have many patients who benefit from a tummy tuck and breast augmentation.  It is a common combination for mommy makeover.  I find these dual surgeries safe in most of my Bay Area healthy patients. Most of my Palo Alto moms don’t have time to do two surgeries, the cost is lower, and it is one recovery. And I am all for reducing the number of scars.  Plastic surgery is about innovation.  What I do today is not what I did a decade ago.  And with new advances and refinements, I expect what I do in the future will be different as well.

My issue is with this procedure is it  has been tried before, with some poor results.  It is tough to position the implant well when going from the abdomen.  You create an opening which connects the breast pocket with the abdominal pocket.  There are many many issues with placing the implant in front of the muscle, particularly in thin women.  (Please see my page on breast augmentation for more information.)  And with implants my greatest concern is always what happens down the road.  Does it move? infection? hardening? And if you put it through the abdominal incision how are these addressed?

This is being spearheaded by two young guys just out of residency.  I don’t know how many they have done, what they look like (no photos were shown in the article, or on their website), or what the technique really is.

But it is a great marketing play.  It has gotten them an article written about them which I read, and I am sure it will attract patients to their new practice.  They have many sayings which could apply here: Buyer beware.  If it seems too good to be true, it usually is.  Show me, don’t tell me.

Until then, I will continue to keep my breast implants separate from my abdominal incision.  The breast augmentation scar at the areola on most of my patients fades to nothingness, I like the submuscular placement of the implant, and I like knowing I did everything I could to insure they have a beautiful, natural, soft result.  Unfortunately for me, good solid plastic surgery technique isn’t catchy.  Alas, no splashy article about me today.

Is plastic surgery a right choice for you?

As I said earlier, there is a price you pay for plastic surgery.  The price is scar, time off work and exercise, healing, getting someone to watch your kids for a week so you can do this, and the risks of surgery.  What price are you willing to pay? How much are you bothered? How easy is it to fix?

Some people scar well.  For these women, when they have a scar, it will start as a red scar, then turn purple, and then fade away into nothingness.  I have seen some of my patients come back, and I can’t find their scar.  I know where it is, but it faded away.  They pay a lower price than someone who may hyperpigment  (fancy way of saying scar turns darker, black, or brown) or keloid (fancy term for a condition where you form an elevated, itchy, ropey scar).

Some surgeries have small scars and potentially large changes.  Breast augmentation, eyelifts, and liposuction tend to have big changes with small scars.   Small price.  But now let’s say you come in, you were a 34D prior to kids and now you are more like a B, and your breasts droop.  Hmmmm. Tougher choice.  Breast lift with an implant is a bigger surgery, more scar, more potential for sensory change, etc etc.  What price are you willing to pay?  Would you rather have a small scar and the ideal sized breast implant for you, but still be a little droopy? Would you rather go to a larger volume breast implant if it meant you could be perkier and avoid doing a lift? How much larger? If you think, “no way! If I am going to go through surgery and get a breast implant, I want them to look perky and fantastic. I need the breasts up!”, then you might need a breast augmentation with a lift, with the larger length of surgery, recovery, and scar it entails.

Most of my photos I show are women 6 to 8 weeks after surgery.  I am reprimanded for it a lot.  Why do you show red scars? Why don’t you show scars when they are farther out? Why don’t you put underwear on your tummy tuck patients so we don’t see the scar?

I have photos of patients a year out with beautiful scars.  Most have beautiful scars. I don’t think that is helpful. You will see the scar the photos hide under the underwear. Anyone can look at a photo of a wrinkled, strech marked, hanging belly and think “of course they should do a tummy tuck.”  But you, the patient, will need to do the surgery.   You will feel the changes. You will see the scar while you heal.

So, find an honest surgeon.  I don’t candy coat.  I show my large surgery scars on purpose when they are new. Red. Raw. Visible.  New.  I discuss the risks and complications in detail.  When you do surgery there are elements we can’t control as plastic surgeons.  How will you heal? How will you scar?  When we say there is a 1% chance of something, will you be that person?  Education can be scary.  When choosing to do elective cosmetic surgery, you need to know what you are choosing.  I do hundreds of surgeries a year.  For these women, the “price” of surgery was worth it.  Only you can make the decision of what is right for you.

There is a price for plastic surgery.   (yes. yes. I am a plastic surgeon who will not give you a hard sell to do surgery do surgery do surgery.)  Because plastic surgery, the yummy mummy, mommy makeover is not for everyone.

When you get done having your beautiful babies, you wait a bit.  I strongly recommend you wait a bit.  What will your post baby body be like? Will your breasts stay full or will they deflate? Will they be anywhere near your neck or will they touch your waist? Will your belly look like you are permanently 4 months pregnant or will it get back into an okay territory?  How bad does it look when you sit down? And most importantly, does it bother you?

We all have these thoughts.  No woman goes through labor and gets done and doesn’t think UGGH when they see their belly skin flop over when they lie on their side that first day. Thank heavens we are ramped up on adrenaline looking at the beautiful new baby next to us, and then sleep deprived and can’t see straight for the next few months.  When women show up in my office, they have thought about doing surgery for months, sometimes years.  They are not happy.  On a frequent basis some thought haunts them.  “I can’t buy a bathing suit.”  “I was dancing and my bra padding migrated down my dress.”  “I look like a boy.”  “I look four months pregnant all the time.”  “I can’t do sit ups.”  “I have to always take in my jeans at the waist, because when I buy pants to fit my thighs the waist is too big.”  “I look like I hopped out of National Geographic.”

If you are happy with your body, don’t do anything.

Seeking advice from a plastic surgeon is the next step.  You have thought about it, talked to your friends perhaps, and read too much on the internet.  You need a doctor to evaluate you.  Please here take my advice:

  • See a Board Certified Plastic Surgeon.  Anyone can call themselves a plastic surgeon.  True plastic surgeons are trained as general surgeons first.  We are well trained to do all breast and body surgery.  I keep seeing women who have the wrong surgery done (especially liposuction when they needed a tummy tuck) because the doctor is not a real plastic surgeon.
  • See more than one doctor.  I joke if you see three plastic surgeons, you’ll get at least two different answers on how to do something.  Many patients fall into what I call a grey area: no surgery is perfect, but all will improve the situation.  An example:  You have lost breast volume and are mildly droopy.  Do you do a breast implant alone? Do you do an implant with a lift?  Do you just do a breast lift? Every woman is unique in what they look like and what they want to look like.  My Palo Alto patients are smart women.  They know their body, they know what amount of scar is okay, they know what look is okay.  I educate them, so they can make the right choice for them.

So, getting back to my original point, you pay a price for surgery. The price is not actual money (though yes, you do need to pay actual money too).  There are some procedures where the “price” is low: the surgery is easy, short, fast recovery, little downtime, small scar, scars heal well.  There are other surgeries where the price is higher: longer, bigger surgery, longer recovery, larger scar, higher chance of other things.

So you decided you will do implants.  Now where to put them? (Yes, yes. other than the obvious “on the chest” or “one on each side” answer).

You will see doctors put breast implants in front of the muscle OR behind the muscle.  The muscle we are talking about is your pectoralis major muscle.  It is the one you do push ups with (or for you moms out there, the one you use to hold your baby while you try to cook dinner).  The muscle inserts along your sternum (the middle part) and along where your underwire goes (the inferior part).

The traditional teaching is putting the implant in front of the muscle gives more lift.  So when you have kids, breastfed, etc etc and your breasts appear deflated, you will get more lift and perkiness from the implant if you go in front of the muscle.  There is also less pain (bonus), and your breast implant won’t sometimes do a funny jump when you use your muscle (great!).  The issue I find with putting breast implants in front of the muscle is rippling and wrinkling in the upper part of the breast and cleavage area.  This is icky and tough to fix.  It tends to happen slowly over time, as your tissue thins. 

You are looking on this site because you don’t have much breast tissue, hence your need for implants. 

Nothing substitutes for soft tissue coverage over the implant to get a good result.

That soft tissue is skin, breast tissue (you don’t have much), and fat (again, you likely don’t have much of that either).  The only other cover is muscle.  I like going under the muscle for many reasons. 

1. Lower rate of capsular contracture / turning hard. 

2. More tissue covering your implant in the cleavage and upper area.  So when you wear a low cut dress or strapless top, you don’t worry about wrinkles, ripples, or implant edges.

3. Easier to do a mammogram.  Behind the muscle lets you see more of the breast on mammogram than in front of the muscle.  Very important, especially with a family history of breast cancer.

4.  I think a more natural look.

Putting a breast implant behind the muscle does not lift as much as in front of the muscle.  To get around this, many doctors do what is called a biplanar approach.  Sounds fancy.  What it means is we keep the implant under the muscle up top, and the implant is on top of the muscle on the bottom.  For women in that droopy-i-might-need-a-lift category, I like to do this technique.  I also use more release along the inferior border of the muscle for women with tubular and constricted breasts.

Personally, I never release the muscle along the sternum (the medial, cleavage area).  I hate how it looks- I think it gives a fake, round look.  Sometimes the breasts get too close or too far apart with this as well.  Overall, I tend to favor more muscle coverage.  It gives better soft tissue coverage over the implant. (Remember: soft tissue over implant=makes look pretty.)  And I think it helps keep the breast from bottoming out.

So, what should you take away from this?

I favor under the muscle.  All doctors do not do “under the muscle” the same way.  Some cut the muscle more than others. 

So how do you choose?

Look at the photos. And talk to your doctor about what technique is best for you and why.