The question is a big one, especially as we are now seeing teenagers considering things like breast surgery.  So I have some things for you to consider.

1. Are you done growing?  When did you have onset of puberty? Has your height changed at all?  Breasts and body are all about proportion.  You need to make sure your body isn’t still changing. 

2.  Is your weight stable?  Breasts can change with weight changes.  The breast is made up of breast tissue and fat.  The proportion of breast tissue to fat is different for every person.  For some, their breast size will go up and down with their weight.  For others, it won’t change at all.  Regardless, you seek a certain breast cup size to create an overall proportion with your body.  So make sure your weight is stable.  Especially when you go through life stage changes- college, new job, etc, it is common for your weight to change.  For example: you don’t want to put in implants which look proportionate to 150 pound body, which may look too large on a 135 pound body.  Another example: You don’t want to do a reduction and lift, and then lose weight, so then the lift loosens up and droops.

3. Babies? Anytime soon?  I know you are in your 20s, but pregnancy and babies change everything.  If you are on the cusp on babydom, wait to do surgery. 

4.  Think about the future.  Particularly for breast augmentation, consider future surgeries.  Fat grafting could potentially increase your breast size, and no future surgeries are needed, but there are issues with fat grafting (I am a fan, but it is not perfect- read my blogs) .  With implants, consider what size to do with the thought you will need to replace implants in the future and during pregnancies and breastfeeding your breasts will be bigger.  My general advice is don’t max out when you are young- leave yourself room to upsize down the road to tighten things up as you age.  With breast reduction, surgery can affect your ability to breastfeed. 

5. Why are you doing this?  Your body changes as you age.  There are things though which will not change with time- breast asymmetry, a funny shaped breast, no breast tissue at all.  These are usually good motivators.  Are you doing this for you? your self esteem? Or someone else?  If it is for a boyfriend, your implants will likely last longer than he will. If it is to get a boyfriend, wrong motivation.  Plastic surgery is not for others.  It really is for YOU.  Take this as a time to be introspective.  What are your expectations?

You can see my post on Quora as well: http://www.quora.com/What-should-I-consider-before-getting-a-boob-job

So what 5 things to do?

1.  SUNSCREEN.  Not going to go on and on about this one.   You know it is good.  SPF 15 or 30.  Daily.  I don’t care if you aren’t outside a lot.  If you live in the Bay Area, you get tons of sun.  Sun is one of the most damaging, aging things you can do to your skin.  It will make you look old and wrinkly.  Block it.

2. DON”T SMOKE.  I won’t go on and on about this one either.  Smoking damages your skin.  It has toxins, it reduces blood flow, it causes little lines around your mouth.  The effect of it won’t show for years, but when it does it hits like a brick wall.  You can never fully reverse the damage smoking does.  So don’t do it.  It will make you look old and wrinkly.

3.  EXFOLIATE.  Cleaning your skin well is a must.  It will keep your skin healthier, remove all those bad things in the environment, reduce your pore size, and help your products work better by penetrating more.  You can use a chemical exfoliant (like my lovely glycolic acid pads!) or a mechanical one (like the clarisonic). 

4.  ANTIOXIDANTS.  These are products which help repair the damage to your skin.  Think of them as little doctors running around your skin fixing the injured cells.  Don’t buy over the counter products.  They are not the same strength and tend to cost as much.  Buy from a MD.

5.  VITAMIN A products, like Retin A and retinol.  This is still the gold standard for reversing damage in the skin.  I have tons of information on the subject.  If you don’t tolerate full strength Retin A, retinol is a good alternative.  Don’t do over the counter products- they don’t have the same strength medical grade products do.  Also, if you are within six months of trying to have a baby, you need to stop these products.  They are NOT safe during pregnancy and breast feeding.   

So it is tough.  I was reminded of this today when I saw a patient who had liposuction and a tummy tuck a month ago.  She looks fantastic and is back to normal life, but still doesn’t feel quite back to her old self.  She gave me a beautiful card and present (thank you!!! So so lovely of you!).  What she said I think is particularly poignant and insightful:

“Dear Dr. Greenberg,

Thank you for everything.  It’s been a tough month, but well worth it.  Thank you for your care and support. It has been awesome.”

On the same day I got a card from another tummy tuck patient who is 3 months out.  Her card read,

“I wanted to show and say my appreciation for your services.  I feel like a million bucks and like that I can do just about anything.  Thank you for being such a great doctor.  And thank you for helping me look better than I did 10 years ago!.” 

I warn all patients regardless of how fantastic they may look in the future to expect buyers remorse the first week after abdominoplasty.  Why?  Even if they look great and their friends and family can see a significant change, it is a big surgery and a tough recovery for the first few days in particular.  You are bent over, you have drains, you are wearing a garment, your skin is likely numb, and it hurts.  It is common for you to not “feel” like you look better.  It is common for you to feel weird, puffy, pudgy. 

So what to do?

• know it is normal to have mixed feelings the first week after surgery.  It is a tough recovery, big surgery, and unlike some other big surgeries, it is elective- you chose to do it. 
• know it is going to hurt.  To help with this, I use the pain pump which I implant during surgery, which drips numbing medication along your muscles to minimize the pain.  Also pain pills and muscle relaxants help.
• know you won’t feel “normal” until at least 4-6 weeks out.  At 3 months you will feel even better.
• look at your preop photos.   It is easy to forget what you looked like which drove you to seek help.  Our minds are gentle, and I think the mind freeze frames us at age 29, pre kids and other life tolls. So look at the preop photos to remind yourself.

Talk to your doctor.  If there are things which are bothering you, let them know.  Anxiety of what is normal or not, what is going to stay versus what is normal post op stuff is all important to address.

This is a tough question.  “Normal” healing after surgery varies a lot.  Some people have a little swelling and almost no pain, while others have a lot.  Both are normal, so how do you know? 

I talk to and see my patients a lot.  I do this because after being a surgeon now for almost 18 years, I have seen a lot.  The best tool I have for making sure there is nothing to worry about is to see you.  When I see my patients for follow ups, they likely think I am just chit chatting.  But I am noticing everything.  How do you move? Your pain level? Are you swollen? Bruised? How much?  How do your incisions look? Do you have a drain? If so, what color and how much is coming out?  I look at your skin.  Is there any redness? Discharge?  and overall, how are you?

I read a book recently by Atul Gawande called “Complications”  (It was assigned for my book club–it was a fascinating read and threw me back into residency while I read it.) One vignette which struck me in his book was a story about when he saw a patient and everything seemed not so bad with her, but something tickled his mind.  This tickle made him keep coming back to a different, unusual, but bad diagnosis.  It was a story of a woman with a skin infection in the ER.  He knew she didn’t have a fever….she didn’t look so sick…. her story wasn’t so bad….. she was young,  BUT something tickled his mind–something seemed off, worse, different.  And it was.  His little tickle caused him to push further, and it saved her leg and maybe her life.

So, you the patient.  When do YOU know?  Clearly you haven’t had years and thousands of surgeries.  When should you call the doctor?

• PAIN.  Pain is a good indicator of hurt.  Your doctor should be blunt and clear with you of how much pain to expect and how to treat it.  If your pain cannot be controlled by the normal medication, it is a reason to call the doctor.  Sometimes pain indicates something else going on- bleeding, infection, abnormal swelling.  This is a place where we get a feel for patients and for their surgeries.  How complex was your surgery? Did everything go well? Is there anything we are worried about?  How high or low is your pain threshold? 
• BLEEDING.  Bruising is normal after surgery.  A true bleed is not.  If there is a drain in, how much and what color is coming out?  If you have a bilateral surgery like a breast surgery or facelift, do the two sides look like each other?  If one side is a lot larger and painful than the other, it could signify a bleed.  You increase your risk of bleed if you have been on medications which thin your blood like aspirin, advil, vitamin E, fish oil, and many others- for many of my surgeries, my patients have to stop these 2 weeks before surgery and until their bruise is gone after surgery.  Before your surgery, consult with your doctors about what medications you can take. 
• INFECTION. This could be a skin infection, a urinary tract infection, a lung infection (take those deep breaths after surgery).  One general sign of infection is fever (greater than 101.5 in my practice).  Then it goes by area.  For urine, it is pain with urination, frequent urination, did you get a catheter during or following surgery?  For skin, you look at it.  Is it red, warm, tender? Is there discharge?
  • Bad smell. 
  • Discharge.  A little bloody discharge along your incision is normal usually for the first 24 hours.  If it is more, smelly, painful, looks like pus- call your doctor.
• DIFFICULTY BREATHING.  This may be shortness of breath or pain when you breathe deeply.  It could be a sign of a blood clot which started in your leg but ended up in your lung, called a “PE” or pulmonary embolus.  If you have any signs of this, go to an ER immediately.  They are not common.  They require urgent treatment.
• ANYTHING WHICH TICKLES YOUR GUT.  Just like we get a tickly feeling as doctors something is amiss, you get the same tickly feeling.  Call and see your doctor.  If you are really concerned, make sure you talk directly to the doctor.  Be a little pushy.  I do not have any nurses or assistants to handle my calls, but I have a secretary who answers the phone.  If you are worried, make sure you talk directly to me.

I had 40 year old breast implants that were ruptured and Dr. Greenberg removed them and gave me a lift too.  My breasts have never looked so wonderful and I know that if others were to see my before and after pictures her already busy office would be over flowing.

Dr. Greenberg is so focused on her patients getting the very best results that I am telling all my friends about her.  I live in Mill Valley but I am so glad that I made the drive to Palo Alto.  

I have 2 woman coming to my home tomorrow because they are considering a breast reduction and a lift.  My friend told them about my surgery and that I was thrilled with the results.  I hope that I can refer her business because I want other woman to be as satisfied and get the best care possible like I did by Dr. Greenberg.

SR, breast reduction patient, Mill Valley

———————

8/28/2011

I had the most wonderful experience with Dr. Greenberg.  I had a breast reduction and a lift and I am so happy with the results.  I tell everyone to go to Dr. Greenberg.  She is a perfectionist. She puts her patients first and she arrived at the hospital early to make sure that all was in place for my procedure.  If you are seeking a compassionate professional that will produce the best results possible, there is no other plastic surgeon to consider.  I met with 3 other plastic surgeons before I made the right decision to go with Dr. Greenberg.

S.B, San Carlos, Breast reduction patient

——————————–

i wanted to write a review about Dr. Greenberg because she is a woman for whom I have enormous respect. She runs her own small office and isn’t affiliated with any of the large practices. I think seeing a woman doctor on her own is inspiring. When you meet her you know that she is a person of integrity who truly cares about the procedures that her patients are choosing. She is good at what she does and honestly provides feedback about what is and what isn’t necessary. I would recommend her to anyone who asks for an experienced talented plastic surgeon.

SS, Santa Clara, CA

—————-

I saw Dr Greenberg for a skin consultation as I have a lot of sun damage due to years of sun worshipping.  As I have aged I find that moisturizers have become a necessity and that there are way too many products out there which do little more than look good on you bathroom counter.  She has a personal line of products that not only repair your skin but reverse the damage.  Used with the exfoliate and the moisturizer I have seen a real improvement and am feeling much better about my appearance. These products are awesome and very affordable—I will never buy anything else.

MF, Redwood City, CA, skin cancer removal and skin care products

—————————-

I’m so happy I found Dr. Greenberg!  She did my tummy tuck two years ago.  After two large babies, my stomach muscles had separated to an awful degree.  I looked six months pregnant – and it wasn’t because I was fat.  I also had constant back pain and so little abdominal control I couldn’t do a sit-up.  But even after my primary care physician urged me to get a tummy tuck as soon as possible, I was hesitant to sign up for major surgery.  So, I interviewed five different doctors – I think this is an important step for anyone considering a major procedure of any kind.  

Dr. Greenberg really stood out.  In the first place, her scar book – the photo album the doctors have in their office to show exactly what you can expect to look like afterwards – was incredible.  Her scars didn’t have the “pulled” look I saw in so many other albums.  She was also happy to meet with me several times when I had more questions.  And she gave me a very honest assessment of what I could expect to achieve.  She was warm and sympathetic, but also not afraid to tell the truth!   After the procedure, she responded promptly when I had concerns – either over e-mail or by phone.  

My results are incredible.  My scar has faded to a thin white line that’s perfectly placed to not show when I’m wearing a bathing suit – even a bikini.  Since having the procedure, I’ve seen other people’s scars from other doctors, and I’ve been happily surprised at how much better mine is.  Most importantly, I’m STRONG again.  I can do headstands in my yoga class!  Thanks, Dr. Greenberg.

SL, Los Gatos, CA, abdominoplasty

——————-

My introduction to Dr. Lauren Greenberg was in the beautiful work she did in giving me breasts.  Breasts that look real and natural, and that fit my build.  If you didn’t know they weren’t real, you’d never guess.  That was nearly five years ago now, and I appreciate daily what she has done for me.  Given me a figure where once there was none.  But in the years that have followed this transformation, I’ve embarked upon other transformations as well, seeking now to combat the effects of time on the face and hands, and on the skin overall.  I have a figure finally, now I want to forestall the aging process just a little.  Slow it down, and enjoy life.

Dr. Greenberg works magic with the needle.  She does Botox, and you don’t look like you have Botox.  You look smoother, younger, the perpetual frown is gone, and, if you’re lucky, there will be a slight lift to your brows, which helps open up the area around your eyes.  They’ll look a little bigger, a little brighter.  But you won’t look like you’ve had anything done.  You will look like you, and you will have the full range of expression.  Dr. Greenberg works with fillers as well, and, again, the results are beautiful.  Those pesky lines around your eyes and mouth will smooth out and melt away.  It’s you, it’s all you, just with the clock cranked back a bit.  And people will stop asking you whether you’re getting enough sleep.

But aging is relentless.  Came the day, about three years ago, when I could no longer bear how hollow my face had become.  I had the look about me of starvation.  The standard fillers won’t do much for such large hollowed out areas.  Dr. Greenberg suggested Sculptra.  Sculptra doesn’t just fill in lines, it adds volume.  And it lasts, for up to two years or more.  But it means, perhaps more so than with anything else, you must have absolute confidence in your surgeon.  Me, I didn’t have to think twice.

Three years later, and I look better than I could have ever imagined.  No one knows I’m having “work” done.  People tell me I look healthy.

I wouldn’t let anyone else near my face.  My doc’s touch is sure, her eye unerring.  She’s simply the best.

I highly recommend her. She is a knowledgeable very intelligent will train upfront courtesy surgeon and honest. I know this from experience.

CF, Los Banos, CA, Abdominplasty and liposuction patient

1. Smoking.  You knew this one was coming.  Do not have your eyes glaze over.  Smoking is bad for your body and particularly bad for healing.  Infection rates, wound breakdown (your incision doesn’t heal well), and tissue loss are clearly correlated.  There are some surgeries (tummy tucks, facelifts, and breast lifts and reductions) we won’t do on smokers.  Period.  I am not your mom.  I am not making judgements on you.  I am trying to make sure you heal uneventfully.

• Tell your doctor if you were a smoker in the past.  Even if it was a little bit in college, smoking is smoking and your doctor needs to know.  We can adjust what we do a bit to help make sure things heal well when we know you are an ex smoker.
• If you “smoke just a little bit on weekends when you have a drink” you are a smoker.  Yes, it isn’t as bad as chain smoking a pack a day, but you are still a smoker.
• If you smoke something other than cigarettes you are still a smoker.  Tell your doctor.

2.  Medications, vitamins, herbals, fancy power protein shakes, chinese medications, etc etc.  It is important your doctor knows everything you take.  Many medications make you bleed (aspirin, NSAID, vitamin E, fish oil, are among the common ones.)  ADHD medications should be stopped two weeks before surgery.  Birth control pills.  Diet pills should be stopped.  Many herbals have a lot of stuff in them you may not know.  What exactly is in your “hair and nail health” formula? 

• Medications can make you bleed, affect your anesthesia, interact with other medications.  Tell you doctor.  It doesn’t have to be a prescription- tell them of everything you take. 
• Medications also help us know what your medical issues are.  If your cholesterol or blood pressure is normal while you are on medications, it doesn’t change the fact you have an medical problem:  high cholesterol, blood pressure, thyroid issue, etc.

3.  Any history of blood clots.  Do you or anyone in your family have a history of blood clots?  A blood clot is a “DVT” (deep vein thrombosis) or PE (pulmonary embolism).  You may have had one or had a relative who had one, particularly after a surgery, long plane flight/car trip, immobilization, or during pregnancy.  See my blog on the subject for a questionaire.

• Why does this matter?  One of the biggest risks after surgery is a DVT.  Blood clot.  If you hear of a patient dropping dead a week after surgery, this is a comon reason why.

4.  Bleeding issues.  Just like clotting too easily is an issue, bleeding too much is an issue as well.  If you have a genetic issue, blood disorder, “bruise easily” or just know that when you cut yourself you don’t stop the bleeding for a while, please tell your doctor. 

5.  Your goal and expectations.  This is particularly important in my field of plastic surgery.  When you come into surgery, you have in your mind what you think will happen with surgery.  When I do surgery on my ….. I will look like ….. when I am done.  It is important for your surgeon to know what your expectations are. 

• Have realistic expectations
• Meet with a few board certified plastic surgeons to get different opinions of your options
• Make a wish list.  Review it with your doctor.
• If you have seen photos of what you don’t want, bring those in as well

You and your doctor need to be on the same page.  There are things which are easy to fix, and things which are unfixable.  Your doctor can help you navigate and explain what can be done.

We plastic surgeons are not your mom (except for my three kids.  For you guys, I am your mom.)  I don’t want to know these things for any reason except for your safe, good outcome surgery.

Breast reductions are a surgery I commonly perform.  It is great –not just from the lift and cosmetic perspective– it is great from a health perspective.  I have seen dramatic changes in neck pain, back pain, posture, and better body image.  Any woman who takes off her bra and watches her breasts plummet to her waist, can’t jog because of the bounce, or has deep digs in her shoulders from her bra knows of what I speak.

This study is out of Maryland, led by Dr. Shermak at Johns Hopkins.  In the introduction it states, “Despite the fact that complications after breast reduction surgery occur at a relatively high rate of 14-52%, breast reduction is one of the more commonly performed procedures in plastic surgery. ” 

She goes on to state, well known factors impair outcomes in breast reduction surgery:

• BMI (obese or greater)
• resection of 1000g
• smoking

But what about age?  So they did a study of 2156 breast reductions.  They looked at the different types of reductions: inferior pedicle / Wise pattern, superior pedicle with nipple graft, vertical lift (the one I do), and liposuction alone. 

What is considered a complication?  They included symptomatic scars, minor wounds requiring dressings, fat necrosis, infection, and seroma. 

Age groups were younger than 40, 40-50, and older than 50. 

So.  What did they find? 

•  Age over 50 is a “significant factor” impairing outcome, particularly with regard to infection and wound healing problems.
• Even 40-50 showed a trend toward complications

Why?

• They postulate due to lower estrogen levels.  They found women on hormone replacement therapy or birth control pills fared better, and those with ovaries removed did worse with regard to reoperation for postoperative wounds.
• Other theories include: decreased growth factors, diminished cell proliferation.

Of note: This conflicts with a study of Roehl et al who found complications were more common in the 30-39 year old group.  This paper postulates maybe the younger women in that study were different- high BMI, larger reductions- which made them get a breast reduction at a younger age.  They said in this study they controlled for factors affecting the outcome, so they could single out age alone.

So take home message?

Don’t wait to do the reduction.  If you are done with kids and breast feeding, and still have those hormones going, this study indicates it is better to do the surgery now. 

Thank you, for my patient’s choice award.  “Your patients have selected you again for the Patients’ Choice Award in 2011.  More than 200,000 patient reviews and ratings are gathered each month.  This top rating has only been awarded to you and a select few of the nation’s most beloved doctors.  Congratulations!  Your patients have taken the time to compliment you in areas such as: your bedside manner, the amount of time you spend with them, the courtesy of your staff, appropriate follow up, and their overall opinion of you as a physician.  Quite simply, you are one of the best!”

Thank you to all of my patients for your words of kindness, your happiness, your hugs, your friendships, and your gifts.  I am so blessed to love what I do, and I get to meet such amazing women on a daily basis.  My life is fuller because of you.

Thank you for your support.  I will continue to try to be the best doctor I can.  Please enjoy your holiday. 

Thanksgiving.  I give you thanks.

Yes, yes, I know for many of my large breasted patients they want them off. Gone.  You are done with the whole breast thing.  I get that.  But there are two basic reasons you can’t or shouldn’t go super small.

1. Technically, the breast reduction is usually done with a breast pedicle.  In English, this means the blood supply to your nipple areola is coming from a chunk of breast tissue.  You don’t fully cut off the nipple and areola (phew!).  It stays attached to the underlying breast tissue. 

The droopier you are, the bigger and longer the pedicle.  You can’t make the pedicle too small- you need to keep the blood supply adequate, so your nipple and areola live. 

2. Aesthetically.  I find cup sizes are hard to talk about.  Getting slightly deep here (we are in California …) What is a B cup? A C cup?  When you say “B” and I say “B” are we picturing the same thing?  We know a 36 C versus a 34 C is not the same amount of breast tissue.  In fact, a 32D can look quite normal.

When you talk about size, it is hard to distinguish exactly what size you are currently and what size you want to get to.  A B cup is a pretty small breast.  I think the basic consideration is to think about proportion.  When you have been large breasted your entire life, you are used to the proportion it gives.  Your belly never has looked large because your breasts are larger. 

You may really want to be small in the chest.  I am happy to get you as close to where you want as safely possible.  Things to help you think:

• Find photos of the “ideal” size you like. 
• Look at your body.  Imagine your breasts are small. 
• Strap down your breasts in a really tight bra and imagine they are gone.  Do you like how you look? 

My advice is always to err too large, not too small.  We can always remove a little with lipo after.  It is hard to add some back.