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.

The goal? In addition to the pigmentation, its goal is to

1. help brighten

2. even skin tone

3. help reduce appearance of fine lines and wrinkles

with visible results seen in just 8 weeks. “Restorative, antioxidant-rich cream works to help even out skin tone without hydroquinone.”

Key ingredients:

GLX Technology^TM, superoxide dismutase, methyl dihydroxybenzoate (reduces pigmentation), licorice root extract, mulberry fruit extract, grape extract, green tea extract, lycopene, olive leaf extract, fennel seed extract, vitamin C, vitamin E, retinol, soy isoflavones.  Contains 15% glycolic compound.

To be used once or twice daily. For daytime use, apply after you have cleansed your skin.

1. McDaniel DH, Wu J. Efficacy of a natural-based bleaching cream versus hydroquinone 4% bleaching gel in the treatment of hyperpigmentation. Cosmet Dermatol. 2008;21(11):596-602.

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.

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.)

I was saddened by the recent Heidi Montag feature on People magazine.  Here is a beautiful young girl who underwent a lot of surgery and procedures to change herself.  Overlooking my opinion she aged herself by a decade and looks more masculine, the real issue is why? what motivated her? and why didn’t someone stop her?

I know many of you will read this with a grain of salt.  How can a plastic surgeon not be about promoting plastic surgery?  But there are different types of surgeons.  I don’t like the culture now, where it seems people are becoming distortions and caricatures (just see the women on one of those reality shows, some don’t look human anymore); where everyone calls themselves plastic surgeons when they are not; where plastic surgeons spend more time marketing than taking care of patients and doing what we were trained to do; where people start to think about surgery when they barely hit 20.  People are being encouraged to dislike themselves.   Is it the old “girls with straight hair want curly hair, and those with curly want straight”? Or is it something different?

I am a plastic surgeon.  I do surgery. But I talk women out of surgery.  A lot of what I do is more “restoration” than “change.”   I like natural.  I like subtle.  I like people to still look like themselves. 

I want you to still be you when you are done.  

Be happy with yourself.  No surgery or change in your appearance will make you more popular, get a husband, or be more successful.  (though it can get your breasts off your waistline and your eyelids out of hanging into your eyes.) Happiness comes from within, and we can’t do surgery for that.

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.)

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.

Juvederm is offering a free Vivite lip plumper ($45 value) when you use a syringe.

Restalyne and Perlane are offering $50 back for every syringe you use.

Woo hoo! Call the office for an appointment.  These are great fillers for the tear trough, cheek, nasolabial fold (the parenthesis around your mouth) and your lips (yes,don’t worry, you don’t have to look overplumped and ducky when it is done well.)

Anesthesia is an important part of having a surgery.  For some of my patients, it is likely the only uninterrupted sleep they have had for a while.  I respect the anesthesia risk.  My patients have elective (ie they choose to do it), scheduled surgery.  For many it is cosmetic.  Most of my patients are moms.  The safety bar for me is high.  It should be high.  I only operate in accredited centers, and for general anesthesia I always use a board certified anesthesia doctor.

The anesthesiologists use a combination of IV medication and gases to put you to sleep. They change the dosages based on your weight, length of surgery, etc.  Herbal medications can affect the medications they use, by changing the heart and blood pressure dynamics, the liver metabolism of the drug, and other effects. BAD.

EPHEDRA (MA HUANG)

This is an ancient Chinese medication.  It is a known stimulant, which constricts blood vessels, increases heart rate, increases blood pressure, and is “thermogenic” (increases metabolism).  This was a common weight loss drug.  It has also been used for asthma, hay fever, and to increase general “energy.” There are many known severe reactions to this drug.  The New England Journal of Medicine in 2000 had a study showing sudden heart attack and severe disability in young people who were taking the drug within the recommended dose. (!!!!) Side effects are many: nausea, dizziness, seizures, heart attack, stroke, and heatstroke (see Steve Belcher and Korey Stringer, both pro athletes who died from heatstroke, likely after using ephedra for its “performance enhancement.”)

SO. This herbal medication is NOT benign.  Surgery is a stress.  I liken it to running a marathon.  In healthy people who are not having surgery, ephedra causes issues.  This herbal is well documented to cause heart attack, stroke, heartbeat irregularities, blood pressure issues, and body temperature issues.  Supposedly the effects wear off quickly, but this is an herbal proven to be deadly when taken as prescribed.  Not worth it.

KAVA

This is a drug from the root of a pepper plant, known to reduce anxiety and cause sedation.  Issue? During surgery anesthesiologists use drugs to help patients relax, like Valium, Xanax, and others.  Kava augments the action of these other drugs, and it sticks in your system for a while.  You may think sedation during surgery is good, why not have more? The issue with oversedation is primarily breathing.  If you are too sedated, you don’t breathe.

VALERIAN

Many herbal sleep aids contain valerian.  It is also used as an anti-convulsant, migraine, and pain reliever treatment.  It acts just like Valium.  If you have used it for a while, you can withdrawal if you stop it.  It also interferes with sedatives used during anesthesia.

I can’t repeat it enough- herbals, diet pills, and supplements are medication. You need to treat them as such.  Please tell your doctor about them before your surgery.  And for most, I strongly recommend stopping them 2 weeks ahead of surgery.

Herbals are medications.  In general, ones which are “heart healthy” and help you with atherosclerotic disease, peripheral vascular disease, impotence, or have anticoagulation properties = MAKE YOU BLEED. Seems obvious, but sometimes it is hard to think herbals are medications, and you may be taking an herbal for a different effect, like depression, and not know it is also an anticoagulant. 

Common ones:

GARLIC

No, if you eat garlic bread at dinner you aren’t going to bleed to death if you get a cut (even if you go to the Stinking Rose in San Francisco).  Garlic has been used as a medical remedy for thousands of years.  It lowers cholesterol, reduces blood pressure, and inhibits thrombus formation (it inhibits platelets which help blood clot).  The risk is dose dependent.  Again, the amount in food is low.  You are at risk if you take a specific supplement. 

GINGKO BILOBA

Gingko comes from a unique species of tree located in China.  It was thought to be extinct, but preserved by cultivation by Chinese monks for 1000 years.  Gingko is used for a grab bag of indications, including improving memory and concentration, vertigo, dementia / Alzheimers, MS, and blood flow / microcirculation.  Some of its effect is due to improving microcirculation and its antioxidant properties.  Again, like garlic, it impedes platelet formation of clots. 

GINSENG

Yes. The G herbals make you bleed.  Ginseng is a staple of Chinese and Native American medicine.  It is supposed to help the body fight stress and increase energy.  It is also thought to help with libido and other hormonal and reproductive issues. 

Issues for surgery? It has been said to increase coagulation time.  Also, it may decrease blood glucose, which can be an issue for surgery patients who are not allowed to eat prior to surgery, particularly in diabetics.  It can also interact with other drugs, including insulin, NSAIDs, anticoagulation drugs, blood pressure medications, and MAO inhibitors.

GINGER:

Thought to help with digestion and as a stimulant.  It prolongs the action of some anticoagulation medications, and is supposed to have blood thinning capabilities.

ST. JOHN’S WORT

This drug is commonly used to treat depression.  In some countries it is a prescription.  ?It is thought to have anticoagulation properties.  It is well known to cause increased metabolism of drugs and increased liver activity.  This can lead to medications used in surgery not being at the appropriate level, as they are metabolized too quickly  (and for you younger women out there, this includes birth control pills! women experience breakthrough bleeding because the blood levels of the birth control pill are too low).  And in some medications like Plavix (a blood thinner) it amplifies the medication, causing an increase in bleeding time.

OTHERS
Alfalfa, capsicum, celery, chamomile, Chinese herbs, fenugreek, feverfew, fish oil, ginger, ginseng, horseradish, kava, licorice, passionflower, red clover and Vitamin E, meadowsweet, willow bark, tumeric, and bilberry.

There was a case report on echinacea- commonly used for colds- which caused bleeding in a woman who used it chronically.  How? Her chronic use likely lead to liver issues, which caused the bleeding problem.

SO.

Remember herbals are medications.  Tell your doctor what you are on, and likely stop them for two weeks ahead of surgery (at least if you are my patient).  But that extra piece of garlic bread is okay.