Posted on March 9, 2010 in Body, Post Pregnancy Body, tummy tuck
I had a patient inquiry about her upper abdominal bulge after a mini tummy tuck. She was only a week out from surgery with another doctor, so she needs to wait to evaluate what is real and what is post surgery changes. But the better question is why?
Why would you get a bulge in your upper belly? And if it is real, what is the fix?
Mini tummy tucks are alluring. As I have said before, everything sounds better when it is mini. Mini M&Ms must not have as many calories. A mini skirt? Oh so alluring. And that mini car? Adorable!
Mini isn’t always better. Pregnancy affects the length of the belly muscles, from your rib cage to your pubic area. I don’t care if you carried high, or carried low, or carried to one side or the other. There will be differences, and when I tighten your muscles I can usually see how you carried. But you will be loosened to some degree throughout the length of your muscles.
I don’t tend to tighten the muscles when I do a mini tummy tuck. If I do tighten the muscles, I do so moderately. In English that means I am not going to tighten you so you can bounce a quarter off your belly. Why not? Trust me, I’d love to have all women after kids have rock hard abs. Heaven knows we deserve them. The issue is the belly button. When doing a limited incision (this includes the endoscopic approach) you can’t get great exposure of the muscles in the upper belly.
To retighten the muscles and let the skin redrape, you need to repair the length of the muscle, from your pubic area to your ribcage. You need big strong suture. I always do a two layer repair. My California girl patients are athletic (keeping them from exercising is tough). If you are active, you will be hard on my repair. Suture and scar are never as strong as your original tissue. So the muscle tightening is important.
You may think, “I carried low.” “My upper belly doesn’t look so bad.” “Why would I need to tighten the upper belly?” If you tighten the muscle only below the belly button, I expect you will bulge in the upper belly. If you tighten both above and below the belly button, but tighten the muscle below the belly button tighter, you will bulge. You must tighten them so there is even tension when you are done.
At one week, you can’t tell what is what. So you should wait. But if your upper belly is truly bulging, the fix? You may need a full tummy tuck to get your desired result.
Posted on February 26, 2010 in Breast, Mommy Makeover / Body post baby, Post Pregnancy Breast, breast reduction
The trend of the week this week: questions to me, the plastic surgeon, about “how can I avoid you?” How can I do what I want without surgery?
I get it.
Surgery is a big deal. It is scars, and surgery with its risks, and recovery, and paying money. So I get it.
So. Back to the question: Can I do a breast reduction without surgery? Breast size is related to a bunch of things. And breast size and composition (breast tissue versus fat) changes over time. Two things come to mind which will reduce your breast size without surgery:
1. Lose weight. Particularly if you are overweight, losing weight will reduce the size of your breast.
2. Breast feeding. It doesnt’ happen for everyone. Some women stay the same size, and some swear they are larger afterwards, but the general trend I see is loss of volume after breast feeding, particularly the longer and more children you have.
But size isn’t everything with the breast.
When women come to me with large breasts they have two issues. 1. size (obvious) 2. droop. The skin is an important factor. One of the issues we have with liposuction of the breast is the younger large breasted women who have good skin tone (who’s skin will shrink if the breast is made smalller) tend to have dense breast tissue with little fat, which is not amenable to liposuction. The older women with the softer, buttery fat who would liposuction easily are droopy, so when you remove the volume, they just droop more.
So, as breasts get smaller, they flatten and droop. I fix this constantly in women in their 40s seeking a mommy makeover. If you want to go smaller AND reshape, lift, and firm up the tissue, you need a surgery. Welcome to my short scar vertical breast lift.
So it is just the size you don’t like? Or do you also not like the bungy jump when you take off your bra? If you want to lift and firm, you need surgery. Sorry.
Posted on February 22, 2010 in Breast, Post Pregnancy Breast, breast augmentation, breast implant, interesting & new
This is the age old question.
How can we make breasts larger without a foreign object? They have tried all sorts of things in the past. The issue with many of them is:
1. Screening of the breast for cancer
2. Injury or hormonal stimulation to the breast- could it cause cancer or make a cancer which is there grow faster?
There are medications which claim to make the breast larger. Be careful of anything hormonally based. Many “herbals” are basic forms of hormones and are as potent as the prescription strength hormones you get.
There is a machine BRAVA that applies suction, causing the tissue to swell and get new blood supply to make the breast larger. It does seem to work, but it requires 11 hours a day for a median period of 18.5 weeks to go up about 100cc. It has been around for over a decade and never got traction in the cosmetic market. Why? To quote a plastic surgical colleague of mine, “The patients hated it. It required a lot of nursing time and assist because it was difficult to use, and the results were not impressive.” But now, BRAVA, the “machine looking for an indication” may have found it. It may help fat survive when transferred to the breast to do breast augmentation using fat.
Fat injections may be a promise in the future. Really thin women don’t have enough fat to harvest, so for them, this will not be an option. For others, it may. I went to a recent meeting (Feb 2010) in Miami with surgeons who are innovative in the field. The main issue still remains, how do you get the fat to survive reliably? How can you make sure it is safe? How much does it impair the ability to screen for breast cancer?
I will continue to blog about fat grafting to the breast, or as some believe, “stem cell breast augmentation.” I am just not sure yet I am ready to do it. My base question always with patients is would I recommend it to a family member? And as of now, I wouldn’t feel comfortable telling them I know it is safe. But with more research, time, and hard scientific data, I believe it may be.
(NOTE: This is a hot topic. Beware of untrained doctors who call themselves “plastic surgeons” who are doing fat grafting to the breast. We do know fat grafting when done poorly has poor survival, causing oil cyts, hard nodules, and calcifications. You can also easily get into the wrong plane and cause a pneumothorax, or the possible risk of fat emboli. This is only a technique which should be done by experienced board certified plastic surgeons. We do breast surgery, from breast reconstruction to lifts/ reductions/ augmentations, and we trained as general surgeons (doing mastectomies, etc) prior to plastic surgery.)
Posted on February 11, 2010 in Breast, Post Pregnancy Breast, breast augmentation, breast implant
Now there is a title which gets your attention.
Nipples aren’t symmetric. Breasts aren’t symmetric. We always aim for them to be close, but as a colleague once said “breasts are sisters, not twins.”
I got an email from a breast augmentation patient saying her nipples are asymmetric. Most are a little. I looked at her preop photos and hers were always asymmetric. She was happy after her surgery at all of her visits, including a couple months out.
But she is sending me an email now, about 2 years after her surgery, saying they are asymmetric. What changed? Why is she now noticing there is a difference?
The most likely culprit for seeing a progressing nipple asymmetry when you have breast implants is a mild capsular contracture on one side (if it happened on both, your nipple position would likely be changing equally). If you notice one breast is softer than the other, you might be forming a mild contracture. When this happens, it often causes the affected breast to become a little rounder in shape, firmer, and it lifts the breast up a little. You may notice your nipple position changes or you look like you have more cleavage in the upper breast on one side than the other.
See your surgeon when you see this. Sometimes there are habits which may make one side age differently than the other. Do you sleep on your tummy? Only on one side? Do you wear good supportive bras? Did you have a child? Did you breastfeed evenly?
You can try nonsurgical ways to loosen it up. Massage, lying on a stack of books, vitamin E, singulair have all been described. I haven’t seen tremendous success with these, but it is worth a shot. We don’t do closed capsulotomies like they did in the old days (turns out you could rupture the implant when you were trying to break open the capsule). So it frequently ends up being a surgery. (ug.)
When to operate? Hmmm. Tough question. If it bothers you. If it is a grade III or IV capsule. If it is painful. If it is visible in clothing. The bad part is we still don’t really know what causes capsular contracture. Bleeding, fluid, infection, gel implants, in front of the muscle placement- all are associated. But then there is dumb (bad) luck. To fix it you can open up the capsule, cut out the capsule, or create a neopocket. The issue is there is no guarantee it won’t recur.
So. See your surgeon. And think- how much does it bother you? are you willing to do the time/expense/recovery of another surgery? how will you feel if it recurs? There is no rush. Remember your nipples were likely never exactly symmetric.
Breasts are like sisters, not twins. (But is nice if the sisters look like they are from the same family.)
Posted on February 4, 2010 in Breast, Mommy Makeover / Body post baby, Post Pregnancy Breast, breast reduction, interesting & new
Ahhh. Marketing.
Do I sound like a broken record or what? I am just so dismayed by all of the hype and spin out there. It seems like everyone is trying to make a catchy new phrase for their surgery which will change the world, defy gravity, have no scars, and no downtime.
Bottom line still is when it sounds “too good to be true” it is.
I recently got an inquiry about the laser bra. Why don’t I do it, it only takes one hour to do, it keeps its lift better, etc etc. In general, good plastic surgery techniques get accepted by the general board certified plastic surgeon population over time. The hype and marketing things do not.
Lasers sound cool. They sound more modern, high tech, and less invasive. But there is a great deal of deception about lasers. When I was in residency and the CO2 laser came out, we all jumped on board. Now 15 years into plastic surgery, with a gazillion different lasers out there, I don’t use lasers at all. There are many types of lasers. Some address redness, some pigment, some promote collagen in the skin, some sandblast off the top layers. The one used in the laser bra is the CO2.
The CO2 laser does tighten the skin. I used to use it for resurfacing facial skin. I stopped using it due to issues with depigmentation, redness, and potential for scar. If you are using it on skin which subsequently is buried, those are not problems. The biggest thing with lasers is the amount of “tightening” is not much. Some people imagine lasers are like putting a wool sweater in the dryer. Oh. If that were only the case. We 40 somethings would jump in and laser every inch of us. But alas, lasers are more like an “iron”- they help remove fine light wrinkles only.
The laser bra involves lasering the top layer of skin, and then using that skin, tacked down to underlying tissue, as an internal “bra.” Sounds fantastic. Who wouldn’t want an internal bra to lift you?
But the laser bra will not “hold” the lift any better over time than traditional surgery. Traditional breast lifts already use the skin as an internal bra- we just deepithelialize it, not laser it. Regardless of what you do, skin stretches. Skin droops. This is deceptive marketing. I am saddened by the claims.
- “The Laser Bra surgeon can keep the breasts lifted in a natural, beautiful position.” Nothing can “keep” breasts lifted. They will droop again over time.
- The time claims of surgery are skewed. Normal breast reductions do NOT take 5 hours- in most hands it takes 2 1/2 to 3 hours.
- Finally, many of the photos involve augmentations. Implants will always help “lift” the breasts and give fullness in the cleavage area- and that has nothing to do with what reduction or lift technique you use.
I have done many different kinds of lifts over the years. The breast is made up of breast tissue and fat. In general
- the more breast tissue, less fat
- the smaller the breast
- the better you support the breast (ie good bras)
- the less you stress the breast (pregnancy, breastfeeding, jogging)
the better and longer your lift will last.
I find in my hands the best lift is the vertical lift. I do a lot of internal suturing. Why? It takes tension off the skin and shapes the breast better. Hmmm. Maybe I should make a catchy new term. “The hammock”? “The cone”? “The anti-gravity-little-scar-secret-special-exclusive-breast reduction-by-Dr. Greenberg” technique?
I think I will stick with being a good surgeon and leave marketing to others. There are many good breast surgeons to choose from. Meet a few. Look at photos. And beware of the gimmicks. When someone sounds like they are selling you a rainbow, they usually are.
Posted on January 8, 2010 in Breast, Mommy Makeover / Body post baby, Post Pregnancy Breast, breast augmentation, breast implant
Americans love to supersize. 
Big cars, Supersized fries, the super big gulp. But bigger is not better when it comes to breast implants.
I answered a question from a patient who had been an AA her whole life. She was teased and felt self conscious. So she decided to do breast augmentation. Her surgeon (not me, but easily could have been) told her he would not do a breast augmentation to make her a DD or larger. She was “shocked.” “Lots of women get breast implants WAY bigger than a DD, so why am I being told me request is unreasonable?”
Hmmm. I can understand her frustration. Implants cost the same, regardless of size…. If I get a 500cc implant instead of a 300cc one, I got 200 cc more for the same cost. Woo hoo, eh? This is my body, and if I want a DD, then I will get one! Hmmm. She can go to another surgeon. I’m sure she’ll find someone who will do it. But I think she is bothered by this because the surgeon she saw seems principled and experienced. She knows he is right.
Why would a doctor talk her out of a big size?
Many of us see our long term results years down the road. It does change the way we do things, and how we advise our patients
1. When you are thin, you have thin tissue cover over the breast implant. My skinny athletic Northern California women don’t have much padding. Whatever padding you start with gets thinner over time, as the weight and width of the breast implant thins it more. What does this mean in English? It means as your soft tissue padding thins, you will droop, potentially bottom out, and see wrinkling and other implant abnormalities.
2. If you go to a super large size, even if I put you in the narrowest implant, a high profile, it will be too wide for your chest. What does this mean? It means you will hit your breast when doing any movements along your side, like golf and tennis (what is the handicap for that?). It means your tissue on the side of your breast thins, and you will look round, shiny skinned, and again will see wrinkling.
3. The weight of the implant will cause you to droop. The implants come as cc measurements. The cc’s tells you the number of grams the implant weighs. Simple science: The heavier the implant, the more it weighs, the more you will droop with time. (Unless you live on the moon.)
4. The weight of the implant can cause back and neck pain, shoulder notching (where your bra straps go), and poor posture. See the issues large breasted women get, and why women who are a D, DD, on up come in droves to get lifts and reductions.
5. They will look bad. Unnatural. Round. Fake. Not pretty at all.
6. If you think you want it that large, wear it around for a while. This is more girlfriend’s advice, not a plastic surgeon’s, but do you want that kind of attention? Always? Try to jog. Try on shirts which button up. Try to have a conversation with eye contact.
I am not a Pam Anderson kind of doctor. My patients like people to look them in the face, and listen to what they say when they talk. (Oooh. Those ladies with thoughts and ideas…) I know. That was a horrible generalization. But I don’t see many women like this who want to be a DD or larger.
At least not at this point.
I do see many of these oversized implants down the road. Large, thin skinned, brassy, round. Droopy. Back pain. And NOW they want to downsize. This is now a much harder problem. Lifts are difficult when the tissue is too thin. Scars from a lift are much larger than a simple augmentation. And I can’t get the skin to “thicken” again.
So. Take a long term view. Bigger is not always better, particularly in my thin Bay Area patients. Go for a medium size. It’s bigger than what you’ve got. Go for natural, pretty. Go for breasts you can still jog with. And when you wish you were a little fuller on a Saturday night, wear a push up bra, and think how much better your breasts will look at age 60 than if you had blown them out at age 30.
Posted on December 28, 2009 in Breast, Mommy Makeover / Body post baby, Post Pregnancy Breast, breast reduction
Ah. The chicken and egg dilemma. 
Many women with large breasts are overweight.
Many overweight women have large breasts.
When you are overweight insurance will tell you your breasts are large because you are fat. Lose the weight and your breasts will get smaller. This is true. Especially as you age, breasts get fattier. Even women who when younger had “breasts which did not change with weight,” will see breast size change with weight change when they are older.
So. You are overweight and have large breasts. What to do?
Back to the chicken and egg dilemma…
If you are overweight you need to work out to lose weight. If you have large breasts, it is difficult to do the aforementioned exercise to lose weight because you can’t run, do aerobics, or do anything else which is bouncy. (Who can find a bra? Must you wear two bras?) Yes, yes. It is not impossible. You can work out with less bouncy things like swimming and biking. And yes, you can lose weight by watching what you eat. But it is more difficult.
Why try to lose weight before breast reduction?
The reasons are multiple:
1. Breasts are about proportion to your body. I don’t know what size to make you if I don’t know what size your body will be.
2. A breast reduction lifts the breast. If you lose weight after your reduction you will loosen up your lift. (This is not good. It will make you droop.)
3. If I make your breasts a perfect size and you lose weight, your breasts will get smaller. Again, it is all about proportion to your body.
4. If you are healthier, you will heal better and faster. There are higher surgical risk and complication rates when overweight, especially if your BMI puts you in the obese category.
So. Get working out. Double bra it and get moving. I love breast reductions and lifts. I think they can be life (and back pain) changing surgery.
Posted on November 23, 2009 in Body, Breast, Mommy Makeover / Body post baby, Skin / Nonsurgical, interesting & new
The government has gone mad.
I get why they would want to tax elective medical procedures. They need money. They have gone wild on spending, and they need new revenue. This new tax is proposed to go into effect January 1, 2010 (!!!).
5%.
They are going to tax every “cosmetic” procedure by 5%. What is truly scary is their definition of cosmetic procedure is broad, and includes whether paid by insurance or otherwise (!!!) Their definition:
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.”
I understand many of the surgeries I do are not going to save the world. So government thinks “Hmmmmm…. we need money. Cosmetic procedures are a growing business. Let’s tax it.” But taxing cosmetic procedures is a slippery slope. When I do a breast reduction and insurance actually covers it as “medically necessary” (which is tough to get covered these days), will this be taxed? When I do a tummy tuck and repair the muscles, so my patient no longer has back pain, is it cosmetic? One of my general surgery colleagues calls the diastasis a “ventral hernia” and insurance covers it. Am I being discriminated against because I call it what it is- a diastasis, not a hernia? Will my patients pay the tax, but his won’t? Oh but wait. They said they will tax it even if insurance does cover it. So maybe they will tax me AND the general surgeon.
WHAT IS COSMETIC? Is having twins which blow out your belly so you look 5 months pregnant every day of your life a cosmetic repair? or is it reconstruction to get you back to where you were, so you won’t have chronic back pain? Do we just need more women in Congress who have had kids, so they can understand us better?
What is cosmetic? Botox patients who do botox injections to treat migraine headaches- cosmetic or not? Instead of living for months headache free, will they, must they go back to medications which they take after they already have the headache?
1. women are the majority of plastic surgery procedures and patients.
2. this tax won’t affect the wealthy. they’ll do things anyway. this tax will affect much of my patient base- my moms, who are in the middle class.
3.Will this create artificial distinctions between specialties? Looking at botox injections- if it is done to treat wrinkles will you be taxed, but to treat headaches it won’t? Will it only be taxed if I do it, a plastic surgeon for their headaches, and not if done by a neurologist?
4. The bill specifically states if done by a medical professional. Will this spur nonmedical people doing injections (an already scary trend)?
This is a horrifying step. Why should my 40 year old woman’s desire for botox be taxed, and a 50 year old man’s desire for medications for his “erectile dysfunction” not be?
Ahhh. the slippery slope. Once they tax cosmetic procedures, do you think others are not steps behind?
Is a hernia repair cosmetic? If a man has a bulge in his groin from a hernia which reduces easily (means it isn’t stuck, and therefore not a medical emergency) is that a cosmetic repair? It is not a congenital deformity, it isn’t an injury from an accident or trauma, and it isn’t disfiguring. I would argue a hernia is no more disfiguring than breasts which touch your waist and cause you incredible back pain, neck pain, tingling in the fingers, and a hunched posture. Oh. But women asked for that when we had kids and breastfed them to make them healthier.
Forget the removal of that mole. Or sebaceous cyst on your cheek. Those are not disfiguring, congenital, or a result of injury.
Do not tax procedures. It will create a slippery slope, it disproportionately and unfairly affects women, and it will cause weird practices and loopholes which have no business in medicine.
Posted on November 16, 2009 in Body, Mommy Makeover / Body post baby, Post Pregnancy Body, liposuction, tummy tuck
The belly.
How much does it suck to still look pregnant after your baby is out? I wore my baby like a necklace, always in the baby bjorn, so no one would make the horrid mistake of asking me, “When are you due again?” It is totally unjust, unfair, unreasonable our bellies look like they do after children.
So to fix it you can do liposuction or a tummy tuck. Liposuction only fixes the fat- not the loose skin, stretch marks, loose muscles, or hanging skin. Tummy tucks tighten the skin and muscles, but can’t thin the fat so much (see my blog on why you can’t do both at the same time). Frequently you need one more than the other, so you should do that surgery and avoid the other one.
But what if you need both?
Ah. If you need to tighten the skin, muscles, AND remove thicker fat… which surgery do you do first? Plastic surgeons disagree on this one. Some surgeons advocate liposuction first, stating you will “debulk” (fancy way for saying to thin the area) to allow for better tummy tucking.
I disagree. When you liposuction you create scar under the skin surface. This is not visible or palpable, but it is there. During a tummy tuck your abdominal skin needs to stretch to allow for the removal of the extra skin, ideally putting the scar as low and inconspicuously as possible. If your skin does not stretch well, the scar will end up too high. Imagine trying to stretch a bathing suit (belly with no prior lipo) versus leather (a belly with scar under the skin from prior lipo.) Give me the bathing suit every time. Also the scar under the skin from liposuction affects the blood supply to the skin, causing increased risk of wound healing and infection along the tummy tuck incision.
I know this from personal experience. I had two patients with prior liposuction who did not tell me they had it done. I could see the scar plane during the tummy tuck procedure, and both of them had little healing issues along their scar and did not stretch to where they should. Their liposuction clearly affected their results. Some doctors advocate doing the liposuction and waiting a long time to let the blood supply reestablish. These patients had liposuction years before, and their blood supply was still not that of normal tissue.
Some people are in the grey zone. If you are borderline needing a tummy tuck and your biggest issue is fat, I like to liposuction first. But I recommend this in patients I expect will never need the tummy tuck. For those patients I know need liposuction and a tummy tuck, I like to do a two stage procedure:
1. the tummy tuck (with liposuction to the back/flank/and thighs) at the first stage, and then
2. liposuction of the abdomen at a second surgery.
I focus on your final result. I want your scar as low and hairline as possible. To best achieve that, I need to tuck first, lipo second.
Posted on November 11, 2009 in Body, Post Pregnancy Body, liposuction, tummy tuck
Many women need liposuction and a tummy tuck. The issue for the belly is you can’t beat it up with both at the same time.
Medical definition of flap: (American heritage medical dictionary)
noun
“Tissue used in surgical grafting that is only partially detached from its donor site so that it continues to be nourished during transfer to the recipient site.”
Advancement flap (Merriam Webster dictionary)
“A flap of tissue stretched and sutured into place to cover up a defect in a nearby position.”
Blah blah blah. What does this all mean in English?
A tummy tuck is based on something called a flap, a fancy medical term (we do like these fancy terms) to indicate the blood supply to the skin isn’t coming from all directions anymore. When we make our incision, we interrupt the blood flow.
Imagine blood cells are like cars; your arteries are streets; and the incision / scar is where your house is. You need to get your car to your house- in your car you have all the food and supplies to keep your house alive. (Bear with me; this is liberal arts education at work.) Instead of being able to drive straight there, when I cut through the skin those streets are now all dead ends. Hmmm. It’s harder to get home now. And you need to get there to bring in the food and supplies. You need it more than ever. Your house is injured.
When you do a tummy tuck, you cut where a c section scar is and you lift up the fat and skin like a giant apron. (Sorry for the graphic vision, but it is what we do.) This is the flap. We then pull this apron down and cut away the extra. Walah. Tighter belly skin.
This flap needs blood to get to its edge to heal the scar. We don’t want anything which will hurt the blood flow to the edge. Using our nifty example of cars and streets, we need to get as many cars to our house as we can. We need supplies!
But by making the incision, we already blocked many streets. By pulling on the skin to stretch it, we narrow those streets. We need those streets which remain to stay open. And we don’t want anything more to hurt the streets: no making the streets one lane instead of two, no putting road blocks or traffic jams. This is why we don’t do tummy tucks in smokers, and there are increased risks in people with poor blood flow like diabetics, ex smokers, and those with high cholesterol. Their streets are narrow and slow. Not enough cars get through.
If you liposuction this flap at the time of tummy tuck, all those blood vessels carrying oxygen and nutrients to the edge of the flap to heal the large incision would be hurt. Because we made a flap, we really need all the blood flow we can get, so we don’t have problems healing: infection, wound breakdown and opening, or potentially skin loss. (where the skin turns black and dies. eek!)
Some surgeons are cavalier and will liposuction the abdomen at the time of tummy tuck. I am not. There are good studies in our Plastic Surgery literature which studied where it was safe to liposuction at the time of tummy tuck. These zones are consistent. You can safely liposuction your back and love handles, your thighs, your chin…. I am happy to combine these areas with a tummy tuck. But if you need liposuction on the front part of your belly, you need to wait and stage it at a second surgery.
The key to a pretty abdominoplasty is the best scar you can get. Pretty scars come from good solid closures, and no issues with wound healing. We have all seen photos of dead abdominal skin from someone who pushed the limit too far. Remember this is elective, cosmetic surgery. Safe surgery and pretty results are what we need.
So get as many cars to your house as you can.
