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.

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?

1. KNOW YOU ARE DONE WITH KIDS.
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.

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

http://bizymoms.com/palo-alto/surgery/mommy-makeover-palo-alto.php

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.