Questions & Answers

Women under 50 benefit most from a facelift; the same is true for men.

My experience — and published research — indicates that patients under 50 years old have a consistently higher rate of satisfaction with their facelift results than patients over 50. A study from California Pacific Medical Center, conducted by Dr. Tom Liu and Dr. John Owsley, compared short- and long-term satisfaction ratings of patients across age groups, and also factored in expert analysis of patient photographs for a more objective analysis of surgical results. The findings are consistent with previous research as well as the experience of most surgeons.

The study concluded: “Younger patients (younger than 50 years) with mild or early signs of facial aging have the highest and most consistent satisfaction and the most natural long-term results.” The study also concluded that younger patients are ideal candidates for what is called a maintenance lift or maintenance facelift. The reason is that patients under 50, essentially because their skin is younger, will have a better result that will last longer than it will if they choose to have surgery later. Furthermore, their results will look better in the long term.

I think what happens is that you get used to this younger look and after 10 years want to refresh this appearance, as you can't stop the aging clock. Often a simpler procedure, such as a mini-lift (e.g. the LiteLift® or MACS lift), can be done later on with an abbreviated recovery. Everyone wants to age gracefully. If you feel you have an aged appearance that affects your well-being, then maybe it's time to come in for a consultation.

Yes — you should be able to close your eyes without difficulty after a blepharoplasty performed by a qualified plastic or oculoplastic surgeon. Swelling, discoloration, and some bruising are to be expected. It is not unusual to have some difficulty seeing during the first day or two after surgery because of the swelling and the eye lubricants/ointment used during and after surgery. Patients vary a great deal in their recovery rate, but usually can resume normal light activity or work 3–4 days after surgery, using dark glasses and make-up to camouflage the swelling and discoloration. The patient will usually be presentable without dark glasses in 10 days. A small amount of residual swelling persists for many weeks, but gradually disappears. Surgeons with less experience could potentially remove too much skin, which can cause dry eyes — so research your surgeon thoroughly.

Recovery time from a neck lift varies from person to person, but patients can generally expect to be presentable within three weeks from surgery. Patients should expect swelling, bruising, and discoloration of the skin during this phase of recovery (swelling normally goes down after 48 hours; most bruising will go away within two weeks). The marks from a facelift and/or neck lift are noticeable at first, but are easily hidden with a bit of “camouflage” make-up, which make-up experts can teach you to do.

The scars from a facelift/neck lift mature within six to twelve months from the surgery date. It is during this time that the rejuvenating effects of the surgery will become apparent and the real result will be seen. Other procedures may also be indicated, such as skin resurfacing, medical skin care, fine wrinkle treatment, etc.

You will always look better than if you never had surgery — while the hands of time tick on, your clock will always be set back a number of years.

The first weeks can be really difficult — physically and especially emotionally — after any cosmetic surgery, and breast augmentation is no exception. Assuming your surgery went well, this may be a normal reaction. Although several factors may be involved — including underlying stress, medications, psychological tendencies, etc. — many women experience a sequence of emotional feelings (an “emotional rollercoaster”) following aesthetic surgery. But it does pass. Having a partner, family member, or friend who is supportive can help this process. The stages of emotional ups and downs, if understood in advance, can help you stay calm and get through this process more quickly.

Phase 1 — Being out of it. Swelling and discomfort are most severe over the first few days after breast augmentation. Pain medications also can make you disoriented and emotional.

Phase 2 — Mood swings. Having just had breast augmentation, you are adjusting to a sudden change in your appearance with much anticipation. With bruising, swelling, and edema present, your breasts aren't going to look like the final outcome. Mood swings — especially sadness, worry, and depression — are common. You may even ask, “What have I done?” or think, “I never should have done it.”

Phase 3 — Being overcritical. During the second week you will probably be feeling a lot better. The edema (swelling) and muscle cramping/spasms (if implants were under the muscle) will be decreasing, and your stitches will be out. Because of anticipation, it is natural for you to look critically at your new breasts, worrying about symmetry, scars, and so on. So it's normal to wonder if you achieved your goal and got “what you paid for.” This is too soon to tell, and most concerns are resolved with time.

Phase 4 — Happy at last. Finally, about week 3 or so, you will probably start liking how you look and feeling much better. You may be in the mood to buy a new bra to check out the size difference, or check out some bathing suits or tops to show off your new figure.

Under the muscle (submuscular) — When you hear the words “under the muscle,” this actually means the breast implant is placed partially under the pectoralis major muscle. Submuscular placement may be more uncomfortable the first few days following surgery due to the disruption of the muscle. The possible benefits of submuscular placement are that it may result in less palpable implants, decreased risk of capsular contracture, and easier imaging of the breast with a mammogram. Under-the-muscle placement is recommended for women who are very thin, with very little breast tissue. The partial muscle coverage will hide the implant better and help avoid visibility of any implant imperfections such as rippling. The appearance will also look more natural.

Over the muscle (subglandular) — Over the muscle means above the muscle and under the breast tissue. This placement may make your surgery and recovery shorter, and you will likely have less discomfort. This placement can provide a slight “lift.” Subglandular placement can result in more palpable implants, increased risk of capsular contracture, and more difficult imaging of the breast with a mammogram. This placement is often recommended for those patients with mild breast sag who do not want a breast lift (mastopexy), and for tubular breast deformity.

Dual-plane — This placement method is a widely used technique, most often chosen when there is mild breast sag and the patient does not want a breast lift. The breast tissue and muscle are partially separated to allow the breast tissue to sit in a better position. Dual-plane can be discussed further during the consultation should breast sag be of concern.

For women with moderate to severe breast sag, a breast lift (mastopexy) may be recommended to ensure the best and longest-lasting result. Failing to have a breast lift when necessary will only lead to a less-than-ideal result, leaving the patient unhappy and needing a revision surgery. A larger breast implant can help lift the breast, but the low-hanging breast tissue will still be present, causing a disconnect between the implant and the breast tissue located at the bottom of the breast.

It is very difficult to determine the exact size and shape implant you will require to best match your ideal breast image without an examination by a board certified plastic surgeon. Not just any board certified plastic surgeon, but one with many years of frequently performing breast augmentation surgery, including different approaches, techniques, and implant choices. This is because several measurements — not to mention your breast characteristics — are needed to determine the optimal implant size to obtain your goals. Without knowing these dimensions it would be difficult to make this determination. For example, the existing base width of your breast will determine, in many cases, the maximal volume per implant profile that you can accommodate. To illustrate: a 100 cc difference may make a significant difference with a narrow base width breast, but much less of a difference if you have a wide chest wall and wide breast “footprint.” Therefore, just because your friend may have a great result with, let's say, a 350 cc implant to make her go from an “A” cup to a “C” cup size does not mean that you will have the same result with the same size implant. Furthermore, simply placing implants in a bra to determine the size best for you is not always accurate, as the bra often distorts the size and is dependent on the pressure the bra places — plus the implant is outside your breast and not under it, among other variables. Computer software morphing programs that automatically determine the best implant size can be helpful in some but not all cases (in my experience they don't work well with existing implants, sagging, or asymmetric breasts). Using “want to be” photos, however, is useful if simply provided to the surgeon, as I will further explain in a bit.

Additional critical decisions will also be made by your plastic surgeon, such as whether your implants will be above or below your pectoralis muscle. These choices are recommended to you based on the look you desire, the amount of sagging you may have, and other deciding factors. For decades, I have tried just about every method to best understand and achieve the patient's optimal goal. The following is what I have found to be most accurate: to start with, I have found it most helpful for patients to bring in photos from my or other plastic surgeons' websites to illustrate what they would like to look like. This gives me detailed standardized views and information, both qualitative (shape, perkiness) and quantitative (size), and allows me to discuss with my patients how I can best achieve their objectives as well as realistic expectations. I always tell my patients that I cannot make them exactly the same as a photo, because everyone has different anatomical constraints. However, these “ideal” breast photos are brought to the operating room for reference during surgery so that I have the advantage of “seeing through my patient's eyes” to best achieve their wishes. Even if the photo does not match your height or weight, I and most plastic surgeons are very good at translating the proportionality of the photo to your features.

I personally order more than one set of implant sizes and use sterile implant “sizers” (temporary implants) placed in the created implant pocket during surgery to know in advance exactly which implant would work best for you, in both a sitting and lying-down position. This also allows me the opportunity to modify the pocket to meet some of the more subtle shape features desired. This enables me to use my full artistic potential to achieve your desired goals.

The key to success lies in letting your surgeon know specifically what you would like to look like following the surgery. For example, how perky do you want to be? What shape do you want to have?

Here is a rule of thumb that works for most patients. If your nipple is above your lower breast crease, then often a periareolar lift will be sufficient. If your nipple is at or below your crease, then a vertical lift (lollipop lift), inverted T, or anchor pattern may be required. The lollipop incision for Grade 3 or 4 ptosis (areola near or below your breast crease) works best in my hands, and the use of a lollipop technique can lift your breast to the perkiness you desire. However, other plastic surgeons are more comfortable with an inverted T or anchor pattern technique.

The donut lift does tend to both flatten the breast and have its scars widen: you are removing skin around the areola, which causes tension in that single area, causing it to “spring” apart over time. With the lollipop incision, the tension is spread out over the greater distance of the lower vertical scar (where the areola once was), causing less tension on the areola and the entire closure. The vertical lift tends to cone the breast, making it more shapely (conical) and less flat. For a visual, take a paper circle, cut out a small wedge at the bottom, and bring the edges together to see this effect.

In general, I would pick the best surgeon — and explain fully what you want to achieve — rather than the technique. Always choose a board-certified plastic surgeon.

Recovery all depends on how it is defined. For example, if you simply sit at a desk and answer the phone or just do computer work, then many return to work in as short as 10 days. If heavy lifting is involved, then it can be as long as 6 weeks. The time for recovery for a breast lift is about the same as for a tummy tuck.

In the case of extensive surgery, abdominoplasty recovery can be uncomfortable and may take longer. Scars take a long time to mature to look their best — but if done well and hidden in a bikini, you could be back on the beach in 3 or more months.

Breast reduction is a complicated procedure that is best done by those with the most training and experience. It is very difficult to determine the resultant cup size and shape based solely on the number of grams that are removed from your breast to best match your ideal breast image without an examination by a board certified plastic surgeon. Not just any board certified plastic surgeon, but one with many years of frequently performing breast reduction and lift surgeries, including different approaches, techniques, and even fat transfer and implant choices if you are lacking superior breast fullness.

This is because several measurements — not to mention breast characteristics such as density — are needed to determine how much and where to remove breast tissue to meet your goals. Without knowing your existing breast shape, dimensions, and the density of your breast tissue, it would be difficult to make this determination. For example, the same volume of breast tissue will weigh different amounts (measured in ounces or grams) in different people depending on its density. The existing base width of your breast, and what you will ultimately want to look like, will determine, in many cases, the maximal volume and weight that will need to be removed for the best result.

To illustrate: removing 300 grams of breast tissue may make a significant difference in cup sizes (e.g. 2–3 cup sizes) with a narrow base width breast, but much less of a difference (perhaps 0.5–1 cup size) if you have a wide chest wall and wide breast “footprint.” Your friend may have a great result from removing 500 grams of breast tissue to make her go from a “DDD” cup to a “C” cup size, but this does not mean that you will have the same result with the same weight of breast tissue removed.

To make matters even more complicated, different bra manufacturers have different cup size labels for the same breast size. Using “want to be” photos, however, is useful if simply provided to your surgeon in advance for preoperative discussion.

Repair of diastasis recti is typically done as part of a tummy tuck or mommy makeover procedure (regardless of technique) and consists of bringing the rectus abdominis muscles together by suturing (sewing) the inside edges of the muscle fascia together. I have found that it makes no difference if the suture material is absorbable or permanent, and typically I perform a two-layer repair to ensure that the correction is secure. Single-layer closures may have a higher tendency of dehiscence (separation) that would require reoperation for repair. Although diastasis recti repair can be done endoscopically for minor separations, this is no longer as popular a procedure, as there is a tendency for midline redundant skin unless there is wide undermining. Recovery is similar to most plastic surgical muscle-repair procedures: no heavy lifting or vigorous exercise for 4–6 weeks, depending on your plastic surgeon's wishes. With core exercises as part of your daily routine following this procedure, you are well on your way to developing “abs of steel.”

Liposuction is a procedure which removes fat from the body. It is one of the most popular procedures in the field of plastic surgery because of its simplicity and effectiveness. There are many different techniques and methods for liposuction, which can be performed on many areas of the body.

You are a candidate if you have excessive subcutaneous fat which is resistant to diet and exercise, and if you wish to change the contours of your body. Commonly involved areas are the anterior part of the neck (under the chin), upper arms and armpits, male chest/breasts, trunk, abdomen, waist, hips, thighs, inner knees, calves, and ankles.

Most patients are near normal weight and desire permanent contour changes. Patients with average weight, localized fat collections, and healthy elastic skin are the best candidates for liposuction. Obesity, cellulite, or loose, sagging, and inelastic skin are several conditions which may tend towards less desirable results. In fact, these problems may be worsened by liposuction.

Frequently, patients seek liposuction to reduce their weight and general obesity. Unfortunately, liposuction is not indicated to treat these problems. Standard methods of weight reduction are required for these patients. Liposuction is intended to re-sculpt isolated collections of body fat that would not generally respond to diet and exercise — it is a method of body contouring to reduce inches, not pounds. The good news is that the suctioned fat cells are permanently removed.

Cost factors vary significantly, for a number of good reasons: prices vary greatly because the surgery itself encompasses a wide range of techniques that can be performed to different extents. My recommendation is to first find the most qualified surgeons — board certified by the American Board of Plastic Surgery — whom you trust, then compare prices between them. General factors that influence the price of plastic surgery include:

1. Location — will it be performed in a hospital with an overnight stay, an independent outpatient facility, or a doctor's office? Geographical location also has a significant influence.

2. Type of anesthesia — local, IV sedation, or general anesthesia? Will a board certified anesthesiologist, a nurse anesthetist, or an RN be used?

3. Experience and training of your surgeon — the best and longest trained is most often a plastic surgeon board certified by the American Board of Plastic Surgery.

4. Length and complexity of surgery — how difficult will your surgery be, how long will it take, and will other complementary procedures also be performed during the same surgery?

The minimum recovery time after a tummy tuck is highly dependent on your job requirements, the extent of your surgery, and how fast you recover.

If your job is sedentary, you may plan on returning to work in 10–14 days, with the understanding that you can still have discomfort with motion. Please discuss this with — and have approval from — your surgeon; this is very important. Excess swelling may indicate too much activity. Do not plan on resuming aerobic or strenuous exercise for about 6 weeks after surgery. Let your body tell you what it can do.

Following surgery, you will be walking in a bent-over position to keep tension off the newly tightened skin incision site. Softening of the surgical scars, return of sensation, and loosening of the tight sensation may take several months to a year or more. Abdominoplasty involves a recovery period 10 to 14 days longer than most plastic surgical procedures. Initial discomfort and decreased mobility are typical, and 3–5 days or more of assistance at home is usually indicated.

You will be encouraged to move and walk regularly starting the day of surgery. Wearing your compression (TED) stockings at all times except while washing, to prevent venous clots (deep vein thrombosis), is mandatory. Light activity is comfortable in 10–20 days. No sports or heavy lifting for 6 weeks or more — please discuss specific questions with your doctor.