bodypostbaby's blog

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

5%.

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.

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.