November 2009

The Senate, at the 11th hour, on a Saturday night while no one was watching tacked on a cosmetic procedure tax.


On every cosmetic surgery, botox injection, filler injection, and ??? what else.

The issues are multiple:
1. Never has the government taxed a patient for a medical procedure.
2. 90% of all “cosmetic” procedures are done by women.
3. This tax applies to procedures paid for by insurance, as well as by the patient. So if your insurance considers your breast reduction “medically necessary” (no small hurdle- see my blog on getting insurance to cover a breast reduction. It is as difficult as getting a child to eat broccoli over ice cream), the government will still consider it “cosmetic” and walah! You get to pay 5% more.  On a breast reduction surgery, this could amount to an additional $400-500.

4. The majority of plastic surgery patients are not the rich and famous.  They are, as I see in my practice, the soccer mom and the working mom.

This tax is effectively a “Soccer Mom” tax that will adversely impact mainstream American wives and mothers, who are the majority of plastic surgery patients,” said Renato Saltz, MD, President of ASAPS. “As doctors, we understand and appreciate the need for health care reform, but taxing physicians and cosmetic surgery procedures to pay for the reform is not realistic or beneficial,”

In a 2005 ASPS survey of people planning to have cosmetic surgery within the next two years, 60% of respondents reported an annual household income of $30,000-$90,000 a year. Most importantly, 40% of those reported a household income of only $30,000-$60,000. Only 10% of respondents reported a household income of over $90,000, which clearly refutes the suggestion that elective surgery taxes are “luxury” or”sin” taxes affecting a privileged few.

eeeek! I have on my website gone through the specific issues: breast reduction, diastasis after babies, botox.  And my biggest issue is why women.  WHY?  Let’s look at pure botox for wrinkles, pure elective cosmetic botox.  Why is my desire for botox as a 40 year old woman taxed, but a man’s desire for medications for his “erectile dysfunction” not taxed? Are there too few women making laws on Capitol Hill? Is it that doctors and women have poorer lobbies than men and pharmaceutical companies?

This is a broadly worded way for the government to try to get revenue.  If you think this is not a slippery slope to taxing more medical procedures and medications, think again.  Their definition is :

COSMETIC SURGERY AND MEDICAL PROCEDURE-  ”1. is performed by a licensed medical professional and 2. is not necessary to ameliorate a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or disfiguring disease.”

Many many surgeries are not congenital, related to injury from accident or trauma (though can I argue having an 8 pound baby constitutes trauma?), or disfiguring disease.  Mole removal? Hernia repair? Breast cancer reconstruction? Breast reduction? Under this broad definition, who determines what is “necessary”?

A tax was done on cosmetic procedures in New Jersey.  It has proved arbitrary and difficult to administer.  And the “projected revenue” was 59% lower than expected.  Eight other states have looked at taxing these procedures, and all did not do it.

As I said before, EEEEK.

If you would like to know what to do, go to my website. Why can’t medicine be about medicine? I am not a politician, nor a tax collector.  I really love being what I do best- a surgeon and doctor to my patients.

Mini. I love that word. Mini connotes cute. Mini skirts, the mini car, mini M&Ms. Adorable.

So who doesn’t want mini facelifts and mini tummy tucks?

A mini tummy tuck is not a tummy tuck. There is a place for it, but the application is limited. A mini tummy tuck involves removing skin and fat below the belly button only. If you have no issue with loose skin above the belly button and have tight muscles, then the mini is a good way to get rid of the extra little pooch of skin from the lower belly.

I find most of my mini patients come from two categories:
1. skinny women who get the muffin top when they wear tight lowrider jeans.
2. more overweight women who have thicker fat who need aggressive liposuction, but will end up with some loose skin in the lower belly if we don’t tighten it up a bit.

A benefit is you can position the scar as low as you want, and there is no scar at the belly button. But there is a scar, and the more skin you remove, the longer the scar will be. Sometimes the “mini” scar is not much smaller than a true tummy tuck scar.

Recovery from a mini tummy tuck is as expected- It is mini too. It is not very painful (woo hoo! Those real tummy tucks can hurt. So you Bay Area girls can get back to working out faster), because mini tummy tucks do not tighten the muscles.

So, are you a candidate for the mini? If your skin is only loose below the belly button, you don’t have much diastasis (separation of the muscles), and you scar well, it may be a good option for you.

But sometimes mini isn’t better to get what you want.

We have established it isn’t a good thing to do the tummy tuck with C section.  I know. I know.  I’d love it too.  But it just isn’t a good idea.  So when can you do it?

When is good timing? Here you will get varied answers.  Most plastic surgeons will advise 6 months or more.  Most will advise trying to get to your pre pregnancy weight.

My advice?

  2. Wait at least 3 months: you lose blood during delivery and need to give your body time to rebuild up its blood stores.
  3. Get back to prepregnancy weight.
  4. Work out and focus on your core.
  5. Be done with breastfeeding.  I would wait a couple months after breastfeeding so you can build up your nutrition again.
  6. See a Plastic Surgeon.  Make sure you don’t see someone who can only do liposuction– you need someone to evaluate you who actually can do a tummy tuck or liposuction.
  7. Know the “price” you are willing to pay for surgery.  (For this please see my blog on the grey zone for tummy tucks at bodypostbaby on wordpress.)

Life isn’t always black and white.

In fact, as we get older, I find little is black or white.  Women come in to see me after having children to look at their belly, and many expect  answer.  “You should do _______. Let’s sign you up for surgery next week.”  I’m not that kind of doctor.  Some women come in and are a clear tummy tuck candidate.  Others come and are clearly not.  And then… dum ta dum dum… there are those who fall in between.  The dreaded grey zone.

I’ve had three kids.  I know the grey zone. I’m in the dreaded grey zone. My belly used to be beautiful- not take photos of it and put them on a magazine beautiful, but flat and strong beautiful….though of course I didn’t appreciate it until I lost it. (Is there a country western song about this?)  I look at my belly, and I don’t love it, but I also don’t mind it.  There are those days where I think it looks pretty good, and those days it doesn’t.  But then I look at my kids and I know it was worth it.

So if you aren’t thrilled with your tummy, should you try to improve it?  As a woman surgeon, I think a lot about the scar of a tummy tuck.  Will you think about it? Let’s say we do the tummy tuck and the scar fades to nothingness, which is what I expect for most of my fair skinned patients.  So you have a teeny tiny line of scar across your belly and around your belly button.  Now you get dressed.  Are you going to think about the scar? Will you be concerned it shows? Will you reposition your underwear? With all of our tiny underwear and low rider jeans and running around all summer in a bathing suit chasing kids.  I think about the scar with every patient.

Many women I see fall into a grey zone- They aren’t what they were before kids (sigh.) but they aren’t bad.  If you stand up really super straight the belly skin looks okay. (don’t slouch!)  So should these women do a tummy tuck?

My advice for women waffling in the grey zone?  Wait.  Wait a couple years. Work out.  Do core training.  See what you can do.  Then evaluate if a tummy tuck is the right surgery for you.  When these patients come in for a consultation, I take out my very sophisticated advanced medical tool: a black sharpie pen.  And I draw (shhhh. don’t tell my kids) on your skin where I think your scar will go.  Then you go home and try on your clothes and stare at yourself in the mirror.  Imagine your skin is tighter; your belly flatter; and ohmy you have a waist again.  How do you feel about the scar?

Tummy tucks are big surgeries with a high “price”- they are painful, have bigger scars, and longer recoveries.  Don’t do it unless you need to.  Some women are just plain blown out after babies- hanging skin, stretch marks, or they look 5 months pregnant all the time.  These women really benefit from a tummy tuck.  But these women are not in the grey zone.

I get asked this question a lot.  “Why can’t I do a tummy tuck when I get a Csection?” Sounds good. Some people look at me like, duh, why haven’t you thought of this?

Anyone who has been pregnant knows their body is not normal at the end of pregnancy. During pregnancy your blood volume grows by 50%. If you labor hard, everything down south is swollen. Your body has been dedicated to creating a healthy baby, depleting your body of some nutrition. If you breastfeed, that continues. Your weight is not normal. Most of us have not worked out for months, and even for you uber Bay area athletes- admit it: you can’t really get a good core workout with a giant baby in your belly.

We plastic surgeons have thought about it. You are in surgery, anesthesia, everything is stretched out….. But a true tummy tuck is a big surgery. It is two layers- the bottom layer tightens your muscles at the midline where you formed the diastasis. The second layer is the excess skin. When we mobilize the skin, we undermine it from the pubic bone all the way up to the ribcage.

Many Csections are after laboring and failing vaginal delivery. The patients are exhausted and swollen, and so is their tissue. You have significant blood loss during delivery. There have been studies in the past which linked combined surgery to higher complications. Please reread paragraph one again.

Elective cosmetic surgery is that. Elective. Cosmetic. It must be SAFE. You need to be well, healthy, energetic. You have a newborn to feed and care for and lift. Blood loss, poor wound healing, opening of your incision, bleeding, inability to lift heavy objects, staying bent at the waist, drains, liquids only for the first few days- it is too much.

What about the people who advertise “Tummy tuck with C section, Get a 2 for 1!” Those are not true tummy tucks. That is usually a little wedge of extra skin off the lower belly. A small skin wedge is akin to a miniabdominoplasty and adds little extra risk. This is not a tummy tuck. During this procedure they are not tightening the underlying muscles, nor are they addressing any of the loose skin or muscle above the belly button.  But if you have to have the C section, why not take a little extra skin? I am not against it.  Removing a wedge of skin will lengthen your C section scar, but it may be worth it.

As for the real tummy tuck with the C section…. I get it.  I would love the two for one.  I would love to have been done with my third kid and come out looking like a movie star.  But it is surgery.  A big surgery.  And to do it right, your body needs to be normal.  You need to be healthy.  You need to have normal blood levels and nutrition.  And you need to be able to focus on YOU.

You just gave birth.  You are lucky.  Focus on your beautiful baby.  Trust me, your baby isn’t looking at your belly….  They have other parts of you they want.