2. United States Copyright 2009
Published by NuWay Publishers II
Without limiting the rights under copyright above, no part of this
publication may be reproduced, stored in or introduced into a
retrieval system, or transmitted, in any form, or by any means
(electronic, mechanical, photocopying, recording, or otherwise),
without the prior written permission of publisher of this book.
Cover: Art design by Micah Harmon
Disclaimer
The information presented in this book is not intended to replace
medical advice of your personal physician or any surgeon
performing Cosmetic surgery. In addition, the information
expressed by authors in this book is the opinion of the authors
based on experience in performing laser vision correction.
ii
3. Preface
ost doctor and patient consultations last no more than
thirty-minutes, whether it is cosmetic surgery or some
other medical information exchange is usually the time taken.
During this time a tremendous amount of critical information is
exchanged between you and your doctor if you are having surgery.
For a variety of reasons, your ability to remember, recall and
utilize the information days later may be considerably diminished.
M
Since patients fail to recall critical elements of information
gathered during the interview process, this sometimes leads to
confusion on the day of surgery and post surgery, so if you fail to
ask or are embarrassed to probe deeper into a particular procedure,
with this book you can review these procedures and learn what is
possible with cosmetic surgery and how it is done.
We have condensed into an easy-to-read book a number of
procedure for you gain a greater understanding. For this reason it is
wise to review this book for recall or even to consult it before
meeting with us. It will enlighten and give you a sense of security
knowing what to expect when you have a cosmetic surgery
procedure performed.
The consultation is a critical part of not only getting
acquainted with me but it offers you a change to frankly express
your concerns about your appearance and body type and possible
enhancement procedures that can be performed. In the consultation
with me you may be asked something like this, “Which part of
your body are you least happy with? I want to know. Prepare
yourself to address this concern and to ask if we can change or
enhance your appearance in a particular way. Be completely open
about your concerns and wishes for enhancement.
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4. Table of Contents
Section Page
Preface...........................................................................................iii
The Body Surgery.........................................................................1
1 Liposuction...............................................................................2
2 Breast Surgery..........................................................................22
3 Male Breast Surgery.................................................................46
4 Tummy Tuck.............................................................................55
5 Rare Complications..................................................................72
6 Conclusion................................................................................79
Glossary of Terms.........................................................................82
About Doctor Ralston....................................................................86
Contact Information......................................................................87
iv
8. hough it is a fact that the body tends to put on weight after
forty years of age, in today’s health-conscious society, many
people, young and old, wish to maintain a slender form.
Unfortunately, however, very often leanness is not uniform over all
parts of the body and many patients have problems with unwanted
fat deposits that persist in spite of dieting and exercise. Liposuction
may be a solution. With today’s technology it is possible to sculpt
away those body imperfections with liposuction, what’s more,
according to the American Society for Aesthetic Plastic Surgery,
Liposuction (Lipoplasty) is the number cosmetic procedure
performed.
T
With the use of his new power assisted liposuction
equipment and the best liposuction cannulas, it is now possible to
rid the body of those unwanted fat deposits.
Until the 1980s surgical fat removal was primarily surgical
excision of fat. The procedure involved making large, conspicuous
incisions in areas of the body that resulted in obvious, often
unfavorable, scars. Liposuction is a more recent procedure that
requires only small incisions, a few millimeters in length, to enter
the area under the skin where fat deposits bulge in the body. It was
a procedure introduced in Europe by French surgeons during the
mid-1970s and taught around the world by the mid-1980s. At first
the procedure was popularly called “lipolysis,” and in some
quarters it still is. Now its most common name is a term called
“liposuction or body contouring.”
The procedure has swept the world as one definitive
solution to removing unwanted fat deposits. Mentioned earlier, it is
now among the most frequently performed cosmetic procedure in
the nation. But with all the hype, it is not a means of weight
reduction, rather, it is a way top change the shape of the body and
the body’s fat distribution.
3
10. or wrinkling of skin, whereas the skin of younger patients will
usually tighten without sagging. However, older patients with less
elasticity are often good candidates since their improved
appearance in clothing and their sense of wellbeing offsets any
local skin irregularities.
Even those with sagging skin around the middle enjoy
slipping into smaller dresses and pants. Tummy tuck types of
procedures (removing excess skin) can of course, correct sagging
skin. These surgeries are more complicated and require long
incisions.
Recovery is also longer and may not be desired by the
patient. If the underlying structure supporting the skin is loose and
there is little fat present, there is no choice but to perform a tummy
tuck or similar procedure since there will be little effect from
simply removing a small amount of fat from under the skin.
Liposuction can be performed on many areas of the body,
including fat deposits under the chin, in the neck, the abdomen, the
chest and upper arms, the hips, thighs, knees, calves, and ankles. In
some cases liposuction may be combined with customary surgical
procedures that stretch and remove excess skin and fatty tissue,
such as a tummy tuck (abdominoplasty).
This method often permits achievement of improved results
in face-lift surgery by combining safe removal of fatty tissue with
skin tightening. Suction of the neck can also be helpful. However,
suction of the face is performed minimally and very carefully.
Liposuction surgery can be performed on any person in
reasonably good physical condition who may have localized,
unwanted fat. Large volumes of fat removal can be dangerous and
these types of procedures are performed only in a hospital and,
often, as staged procedures.
5
11. Questions frequently asked are "Will the fat return again if
I put on weight after surgery?" and "Will I look out of proportion
to the rest of my body?" It appears that in children fat cells
increase in number until they reach puberty, and thereafter the
number of fat cells in the body remains fixed or constant
throughout life. With weight gain or loss, the fat cells change size
only. This is true for all except massive weight gain of hundreds of
pounds where the body can be forced into making more fat cells.
The cells store fat which expand or contract like a balloon.
With liposuction, fat cells are removed, thereby
permanently decreasing the number of cells and excess fatty
deposits in the surgically suctioned area. Weight can still be gained
and just as easily but the distribution of the fat is more even
throughout the body rather in just a few "problem areas."
Since patients are generally “post pubertal,” the return of
fat cells does not occur, and fat deposits should therefore not return
in the treated area. This is not to say that the remaining fat cells
will not enlarge if the patient gains weight. Researchers know that
fat cells can dramatically increase in size if the body takes in too
many calories.
Unlike many procedures, it is best for the patient to be
within 20 pounds of their normal weight prior to the liposuction
procedure. This largely has to do with the technique of fat removal.
It is far better to leave a slightly thicker fat layer just beneath the
skin than to try to skeletonize it and risk the chance of puckering
and adherence of the skin to underlying structures. After the
liposuction, weight loss is a wonderful idea and many people find
the procedure a springboard to a fitter more attractive body and
lifestyle.
Surgical Procedure
6
12. The surgeon marks the patient preoperatively using a marking pen
to indicate the areas of the body where he/she wishes to reduce fat
deposits prior to administering an anesthetic. Fat deposits are best
observed with the patient in a standing position. These deposits
may shift somewhat when the patient lies down. They are marked
topographically to indicate the high and low points.
The procedure involves the use of a tumescent solution that
makes the liposuction procedure safer, more even and easier on the
patient by providing slight numbness for a few days following the
procedure. Obviously, when this solution is infiltrated under the
skin, all contours change. Although the procedure of liposuction
itself is very simple and safe, it is the surgical judgments and
planning that require a great deal of training.
The cannula can be inserted into a tiny incision near the
arm pit and reach the entire side of the breast to remove the fat and
slenderize the area.
Through a tiny incision the cannula can reach the extreme
regions of the trunk and calves of the body and remove fat located
near the surface of the body.
Here are drawings that show the areas that the cannula can
reach in the human body. A general anesthetic is commonly
administered, although small or localized areas of fat can be
treated with a local anesthetic with or without IV sedation.
Near the fat deposits, either in a skin fold or under the
bikini line, the surgeon makes a small incision, approximately a
quarter inch in length. In removing fat from the abdominal area,
the incision is often placed in the navel or in the pubic area. Fat
removal from the thighs is accomplished through small incisions in
the buttock creases, lateral hip area, and inner thigh.
The first step of the procedure, after the tiny incision may
be made, is the infiltration of tumescent solution. This is a special
7
13. sterile solution that wets the area and allows for the closure of
small blood vessels to minimize bruising and bleeding. An
offshoot is that it allows the area to be numb for a couple of hours
after the procedure thereby making the procedure much easier on
the patient.
Regions of the arms
Regions of the breast
8
16. Having fluid in an area of the body where it is needed
allows for less solution to be given intravenously and thereby
reduce the anesthetic risks. It is very important to infiltrate the area
evenly. Different surgeons will use different solutions and different
volumes depending upon their experience and judgment as well as
the total volume of fat expected to be suctioned.
A small, hollow tube or cannula is then inserted through the
small incision. Then, with a vacuum-assisted pump that allows for
high-pressure suction, the fat is suctioned from the body through
the cannula into the tube and collects in a special receptacle. Some
surgeons use this special vacuum pump; others employ syringe
suction. Both techniques are acceptable. Different sizes and shapes
of cannula are available to treat different body areas.
The newest advance in liposuction surgery is the use of
ultrasonic energy to liquefy the fat prior to removal. This internal
ultrasonic-assisted liposuction is not to be confused with external
ultrasound where a wand is used on the skin to make heat. This has
been shown to do nothing to liquefy the fat under the skin. It can
be used as a marketing ploy and you should investigate the type of
ultrasound prior to the surgery.
Cannula
No surgeon attempts to remove all of the fat in a deposit. If this
were to happen, the result could very well cause skin depression,
contour irregularities, and an unnatural appearance. The direction
of cannula movement is in a plane parallel to the muscle and skin;
therefore, removal of the deeper portion of the fat layer is
accomplished with minimal risk. Liposuction is an artistic
procedure, often referred to as “body sculpturing” or “body
contouring” and should preferably be done by qualified, board
certified plastic surgeons that are experienced in this technique.
11
17. A good deal of the success of this procedure depends on the
surgeon’s artistic judgment and skill. Surgeons must plan carefully
in marking the areas of fat to be removed and during surgery may
readjust their plan and modify it to suit the goal. In addition to
careful planning, the surgeon achieves excellent results based on
the "feel" of the skin and the underlying fatty tissue. Surgeons use
their hands to judge the remaining amount of fat in a given area.
Many of us prefer to err on the side of leaving slightly too
much fat rather than over thinning the tissue under the skin. The
reason for this is simple. The fat cannot be put back. Fat grafts at
time are only temporary. It is difficult to correct an area that has
been over suctioned but it is relatively easy to go back and take out
slightly more fat if greater contouring is desired.
Postoperative
Upon completion of the procedure, the tiny incisions are sutured.
Rarely, but if warranted, a drain is placed in the area of the incision
to drain any extra fluid build-up. Pressure dressings, girdles, or
contouring garments may be worn for several weeks following
surgery to help the skin contract to the new shape and thereby
adhere properly.
Usually, little discomfort is felt for the first two days
following surgery. After that, there is some tenderness in the area.
Minimal discomfort is usually readily managed with Tylenol. For
extensive areas of liposuction, the recovery is more uncomfortable
and extended. Narcotic analgesics may be necessary for control of
discomfort; especially after the first few days.
Swelling, bruising, and some temporary numbness are
common in the treated areas. This may vary with the amount of fat
removed and the area treated.
12
18. The eager patient will not be able to appreciate the end
result for at least several months after surgery due to swelling that
slowly dissipates. Yet, in spite of swelling, most patients notice an
immediate change in body contour shortly after surgery.
The patient must avoid strenuous physical activity for at
least one to two weeks postoperatively. Nevertheless, patients are
encouraged to be up and about and to resume some light physical
activity within the first week.
The surgeon will usually have patients begin to massage
the areas of liposuction after a few weeks in order to stimulate
blood flow and lymphatic drainage, which in turn helps to speed
the decrease in swelling. Other adjunctive measures such as
external ultrasound may be used to help with prolonged swelling,
however this is rarely necessary.
Innovations in Liposuction Surgery
The word “tumescent” means swollen or firm. This technique,
mentioned earlier in the chapter, is accomplished by injecting a
large volume of a dilute solution of lidocaine, a local anesthetic,
and epinephrine, (a vasoconstrictive drug which shrinks small
blood vessels), into the fatty tissue. Patients find that anesthesia
injected locally is effective in reducing pain post operatively.
As mentioned, blood loss is reduced with the tumescent
method of liposuction. The epinephrine in the anesthetic solution
causes small blood vessel constriction that results in minimal blood
loss during and after surgery. Not only is recovery time reduced
(i.e., your oxygen-carrying capacity is preserved), but blood
transfusions are virtually unnecessary.
With the tumescent technique, as we mentioned, the doctor
injects a solution into the fatty tissue. Because the solution
anesthetizes the area, it also causes the area to become firm and
13
19. swollen (tumescent), which enables the surgeon to extract fat more
accurately and uniformly, and thereby produce smoother,
improved results.
With the tumescent method there is a quicker return to
normal activities. Home rest is advised for the first forty-eight
hours; then a light work schedule may be resumed. If the sculpting
is extensive and performed in several areas of the body, then
several days of recuperation may be necessary. Special elastic
garments must be worn for two to six weeks after the surgery.
These elastic garments help promote healing by reducing swelling
and bruising.
Exercise appropriate for the individual may be initiated
after consulting with the surgeon, generally in two to three weeks.
Because the tumescent technique uses very small cannulas,
minimal incisions can often be concealed in natural body creases,
such as the end of the buttock fold, the umbilicus, under the chin,
or in the pubic hair. Sutures, when used, will dissolve on their own
or be removed in the surgeon’s office following surgery.
Benefits of the Tumescent Technique
When used, general anesthesia is administered in very light doses.
Some patients may choose to have an alternative to general
anesthesia. Many of these patients receive only sedation to help
them relax and are quite comfortable during surgery. Postoperative
discomfort is significantly reduced since the local anesthesia is
effective for eight to sixteen hours after surgery.
The suction tubes used in this technique are very thin and
minimize the amount of trauma produced. The incisions usually
heal nicely with few, if any sutures. There is minimal scarring.
After surgery patients can get up and leave the office and
usually are back to their regular routine in a few days.
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29. Recovery
In general a patient returns to work ten days after surgery. The
extent of care a patient requires during the post operative phase
reflects directly on the pace of recovery.
So patients may require a pressure suit, but not all. Pain
killers are advised in the first week after surgery and should.
Unless the surgeon advises a longer time they are to be
discontinued. Resume exercises after at least a month post surgery
since there is the risk of moisture related infection and opening of
stitches.
The success of a liposuction procedure will be visible after
weeks to six months. Liposuction has to be supplemented with a
proper regime of exercise and weight control programs. The
recovery process is slow, but if care is taken and proper post
operative follow up with the doctor, it will reap the desired
dividends.
What to expect after Liposuction surgery
• You'll wear a compression garment day and night for 4
weeks.
• No exercise, house work, yard work, etc for 6 weeks.
• You'll have Bruising and swelling for a period of time.
• Numbness in the areas is usually temporary but can
occasionally be permanent.
• For safety reasons the amount of fat than can be removed is
limited.
• This sometimes requires a second & third stage surgery.
24
30. • Smoking will increase the risk of most complications such
as pneumonia, skin and tissue loss and does contribute to
delayed wound healing.
• Weight gain or loss and pregnancy can alter the result.
Rare Risks
Infection is a risk of any surgery, though this is rare. As with any
surgical procedure, complications are possible, though considering
the number of liposuction procedures performed each year, the
number of serious complications is very small. Bruising and
swelling, as noted previously, are common and are not considered
complications. In rare instances, fluid collection under the skin
may persist for several weeks postoperatively, and require simple
aspiration. Fluid tends to reabsorb with no long-term, adverse
effects. Contour irregularities can occur with this type of surgery
but are kept to a minimum by conservative fat removal. Any
irregularities in the skin itself present before surgery may not be
corrected by surgery. This is not a treatment for so called cellulite,
although improvement in cellulite areas has been noted.
Your surgeon will discuss with you the risks and benefits.
The purpose is to assist you in achieving an aesthetically pleasing
body image when conservative measures have proven ineffective.
The duration of the surgical improvement is long lasting
even permanent if the patient heeds a sensible diet and exercise.
Frequently Asked Questions
Is Ultra sonic liposuction the best form of liposuction?
25
31. Yes, we believe ultra sonic is the most thorough and smoothest
modern method of liposuction.
Will liposuction take away cellulite?
No, true cellulite can not be removed. Liposuction will reduce the
fullness in the area and make the appearance better.
How do I know if I am a good candidate for liposuction?
Liposuction is not a weight reduction procedure. The best results
are achieved for patients with localized problem areas who still
retain good skin tone.
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32. 2
Breast Surgery
ne of the most popular cosmetic surgery procedures in the
western world is augmentation mammoplasty (breast
enlargement) with breast implants. How a person views their body
image is an important part of self esteem and greater happiness.
For a woman to feel truly feminine and acceptable there are areas
O
33. of her body that she compares to culture norms of beauty. One is
having full, even breasts
Throughout the world there is a growing demand for breast
enhancement surgery. It runs a close third to rhinoplasty (nose
alteration surgery) along with liposuction in frequency worldwide.
It is also one of the most satisfying of all cosmetic operations in
terms of patient happiness, ranking on a par with cosmetic surgery
of the nose and liposuction.
Women want to look as good as possible in clothing and to
have a well-proportioned, pleasing silhouette. Classic beauties of
the world have had firm, lifted breasts with balance and symmetry
to the waist and hips.
There is no question that aesthetic surgery of the breasts
can result in a more pleasing appearance and a rebirth of self-
confidence. There is a new flair for life and deeper sense of pride
in appearance for women who have grown up with small breasts
and suddenly have a full figure. They feel more fulfilled and less
cheated by nature’s meager endowment. It is no wonder that
women who observe fashion models and movie stars with full
breasts have a desire to be what the world considers more
attractive.
Part of life’s challenge is to feel a rich sense of acceptance.
Breast augmentation surgery alone will not accomplish this, any
more than a nose change or liposuction will, but it does contribute
to the overall satisfaction of feeling more feminine and lovely, and
that is why so many women seek the procedure in today’s world.
Two groups of women generally seek breast augmentation.
The first is made up of women in their late teens or early twenties
who have never enjoyed a well-proportioned bosom. The second
includes women from the late twenties, all the way to the sixties.
They may have lost breast size and shape after childbearing and/or
28
34. breast-feeding. Or they may be women who have come to terms
with their dissatisfaction of so many years without full breasts.
They can afford the surgery and want the results that this
procedure can bring. Both groups of women desire a more pleasing
shape that is usually associated with a more youthful body and a
better appearance in all types of clothing.
What Breast Surgery Will Do
Basically, breast implants will make small breasts appear larger
and fuller. To help you understand what this will do for you, the
surgeon must visually examine your breasts. At the time of
examination, you will be asked what it is you wish to achieve in
breast enlargement in terms of size and shape—correct asymmetry,
increase size, or alter discrepancies. Your surgeon may have some
questions for you and point out what is possible and what is not.
Torso size, fat distribution, amount and distribution of breast tissue
all play a role in what will give you the best result. Listen carefully
to what he/she tells you. Make mental and written notes of what is
discussed, so that you can determine in your own mind the
probable results of the surgery.
The surgeon will discuss with you the pros and cons of
where the incisions will be placed and what type of implant will be
used. He or she may show you samples of implants. If the doctor
doesn’t, you may want to ask to see them. At the examination time
the surgeon will undoubtedly explain the best approach, above or
below the muscle with the least amount of scarring for you.
29
35. Patient Choice of Implant
Allow your surgeon to indicate what he thinks is best for you.
Occasionally, after surgery patients wish that they had selected a
larger or smaller implant. There are some who insist on smaller
implants and know just what they want and why. The jogger or
athlete may want them smaller for sports reasons, yet would like to
fill out an evening dress or swimsuit. The choice may be difficult,
but there is choice involved.
Surgeons recognize that a cosmetic surgery patient is the
type of person who is not satisfied with their present appearance
and wants a visible change. It is important neither to overdo nor to
under improve the appearance. The desire to change the
appearance is a strong drive. This is normal, healthy, and
fortunately often attainable.
A B
The drawings depict the two methods of breast implants. One
method is to place the implant (A) atop the muscle and the
other method is to place the implant (B) behind the muscle.
30
36. The best common question regarding size of implants is
what will look best for your body. Ask yourself what size you
would like to be. Do you want to fill a "B," "C," or a "D" cup? In
part, the answer to this question depends on how much breast
tissue you already have. This may even be different for each
breast. It is also not uncommon for a person to have different size
breasts.
Occasionally, a patient will choose implants that are too
large for the body, or they may be so large that they over stretch
the skin and may develop stretch marks that can be unattractive.
This is why it is important to listen to the advice of your surgeon.
Also, the larger the implant, the less problem you may have
with formation of capsule contractures. With smaller implants the
feeling of firmness may be less noticeable. Also, the possibility of
distortion is less with the same amount of capsule formation when
the implants are smaller.
There are very few older ladies who desire size D breasts.
Having said this, a large number of studies have been done on
satisfaction following breast augmentation surgery. Over 95% of
women would repeat having their surgery done. The only thing
that most would change is that the vast majority said that they
would like to be larger.
On the other hand, you want the implant large enough to
achieve fuller breasts. You will have a fuller look with larger
implants and enhanced cleavage. Before and after pictures of
previous patients can be helpful in selecting size of implants. Let
the surgeon point out those patients’ photos that most closely fit
your body type. Viewing the photos of those who have undergone
the procedure allows you to see graphically what someone else has
achieved by seeing the person before breast augmentation, and
31
37. after. In addition, some doctors will allow you to try different sizes
to estimate your new size.
Be open with your surgeon. It is important that you
communicate your desires, your concerns, as well as any fears you
may have. Feel free to ask any questions you may have. Listen
carefully to the answers. Be sure you understand and that the
comments make sense to you. Some surgeons perform exactly the
same operation on every patient. There are many differences
between patients, thus your surgery should be tailored to you
specifically, what your end goals are and what is best for you in
terms of scarring and long-term sequelae.
Your surgeon should be able to show you a repertoire of
different approaches and results which were tailored to each
patient. You should leave with all questions answered and a clear
idea of what to expect. Remember though, breast augmentation
and/or a breast lift will provide improvement, though not always
yield perfection.
In cases of unequal breast size, the surgeon can usually
minimize this defect. Correction of asymmetry in volume,
combined at times with a change in position of the inframammary
fold (the underside of the breast on the smaller side) can give a
pleasing balance to the breasts. The breasts will look more alike.
Other asymmetries, such as inverted nipple, large areola, or ptosis
(drooping or sagging) on one side require additional techniques for
correction in addition to augmentation.
A slight amount of droop can be corrected with just the
augmentation and this is desirable due to the small incisions
necessary for the procedure. Do not make the mistake of having
too large an implant placed just to correct a significant droop, in
this instance a breast lift procedure should be done at the same
32
38. time as a more reasonable augmentation (this is called
augmentation mastopexy).
There are several implant manufacturers currently in the
market. They offer the safest, most natural-appearing implants
available. Implants are filled with a saline solution. In the history
of breast-enhancement surgery, it was discovered as early as the
1960s that silicone liquid injections for breast augmentation led to
unacceptable results fraught with complications. In 1963 the
silicone-gel implant was developed. The bag consisted of a silicone
membrane filled with gel that felt firm and had a round shape.
Circa 1990, the FDA disallowed silicone implants for breast
augmentation. The use of silicone implants was reinstated by the
FDA in 2004.
Today the technology of implants has improved. Saline-
filled breast implants are presently available for initial breast
augmentation. Improved and natural feeling silicone gel implants
are available for reconstruction and repeat augmentation patients.
Extensive research on silicone gel implants has found no harmful
affects from their use. Newer implants are under development and
there is a new gel silicone implant that does not flow when it is
sectioned. These may provide the most natural feel yet provide
patient peace of mind.
Sites of Incision
As a rule, the patient selects the site of incision with the aid of the
surgeon. There are at least four entry areas of the breast to insert
the implant (areola, inframammary fold, axilla, belly button). The
surgeon will discuss the site of implant entry and may even offer a
choice, but it is best to follow the recommendation for best results.
Most patients accept the surgeon’s evaluation as to the best
incision site.
33
39. For the patient with mild drooping of the breasts, in which
the skin of the breast touches the skin of the chest wall when the
patient is standing upright, the inframammary incision (under the
breast) is performed by placing the incision slightly up on the
breast, perhaps one-fourth to one-half inch above the
inframammary fold. The incision will be almost completely hidden
and may be the most preferred site of entry.
Ordinarily, the areola incision, made in the wrinkles of the
brown skin of the areola, heals with the least amount of visible
scarring, except in pendulous breasts. This is often the preferred
incision site in all individuals with especially dark skin since the
incision is almost imperceptible. This incision also allows full
access to the breast tissue and can be used should re-operation be
necessary.
The areola approach is the only one of the three most-used
incision sites that invades the breast tissue itself. The thousands of
surgeries performed have demonstrated that there is almost no
danger of breast nodules or cysts developing in the lower portion
of the breast when this approach is used. Many patients who have
had this approach have subsequently become pregnant and have
breast fed their babies, although not recommended if they plan to
breast feed. This is true of all approaches. Breast self-examination
and mammography can also be done without difficulty.
34
40. Possible Incision Sites
The underarm incision is the only one of the three most
common incisions which leaves no scar at all on the breast or
chest. This is preferred if the patient is to be seen nude a great deal.
The down side of this incision is that it is visible when the patient
raises their arm or is in sleeveless dresses. There is also a problem
in that if repeat surgery is necessary or if there is a problem with
35
41. bleeding during the surgery, a second incision may be necessary.
The use of an endoscope allows for full view of the breast pocket
through this incision. It is still necessary to place a second incision
for future surgeries should they become necessary.
There are other lesser-used incisions such as that at the
level of the belly button. This incision is almost imperceptible but
it is far removed from the area of surgery and special
instrumentation is needed. The breast pocket (the space where the
implant is to be placed) cannot be made directly by this route and it
is very difficult to make the breasts as even as by other methods of
implant placement. This raises the risk of implant rupture or
patient injury. Should re-operation be necessary, additional
incisions are needed.
Many implant manufacturers do not cover the cost of
implant replacement in the event of rupture if placed by this
method. The incisions used in augmentation surgery with saline-
filled implants is only about one inch to one and a half inches long,
it stands to reason that this incision placed closer to the site of the
procedure is the best for most patients.
Breast Implants
Government regulators control implant manufacturers today. It is
their job to offer the safest implant. It is very difficult to make a
completely safe implant that looks natural. The saline-filled
implants are not optimal aesthetically but are safe in the event of
rupture. Many strides have been made in the past few years in this
area.
The manufacturers know that what the patient wants is the
best possible appearance with the least amount of problems. Some
implants are filled with a saline solution that, if they should leak
(rare), will not cause infection or other medical problems. Others
36
42. are filled with a silicone gel. There is also a combination saline and
gel implant that is used. Gel filled implants and combinations are
less used today because of increased government regulations.
In the 1970s, saline-filled implants came on the scene. The
problem with these early saline implants was the leakage and
deflation rate, which had crept up to nearly 25 percent of those
receiving the implants. Saline implants used today rarely leak (1-
2% per year), due to improved technology. Both saline and silicone
gel implants come with a smooth surface or with a textured
surface. A capsule forms within 3 weeks. This is the inside scar
that forms around the implant.
Capsular contracture (a tightening around the implant
causing it to feel abnormally firm) is thought to be less frequent
with the textured surface implants. There are two possible
locations for implants in the breast: beneath the pectoral muscles or
between the muscle and the breast tissue. Your surgeon will help
you decide which is best.
You should ask about the placement of the implant. Where
the implant is placed is important and you should rely on the
surgeon’s preference in each individual case. Remember, he is
there to help and assist you. Basically, the placement of the
implant beneath the muscle is not physiological. The breasts will
be further apart and will move with certain arm exercises.
The problem is that with the currently available saline-
filled implant, the outline of the implant can be visible if not
placed under sufficient tissue. This is partially corrected by going
under the muscle. When a more natural looking implant filled with
viscous filler becomes available, all implants will likely be placed
on top of the muscle.
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43. Breast Volume
The size of the breast can be controlled. The doctor can use
implants of different volume to help correct asymmetries in size
and shape. There is a wide range of implant sizes and shapes to fit
the needs of individual patients, and an experienced surgeon knows
which size to place in which breast.
Firmness
Firmness occurs due to capsular contracture. There is a tightening
of tissue around the implant, causing it to feel abnormally firm.
Often it may affect overall appearance. Be assured that this is not a
medical problem in the usual sense. It is a matter of softness versus
firmness. There are exercises that your doctor can show you to
help soften the breasts following implant surgery. At times, despite
these exercises, additional surgery is needed to correct the
firmness.
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46. Breast Lift (Mastoplexy)
This procedure raises and reshapes sagging breasts. It is called a
mastopexy. The surgeon removes excessive skin and repositions
the remaining breast tissue and nipple. Their will be swelling and
bruising along with discomfort, even numbness, but the results are
most often rewarding. Some scarring is to be expected, but in most
patients it is quite acceptable.
The scar varies with the amount of droop that was present
and the amount of skin that needs to be removed. In order to
achieve a natural appearing breast, an incision in the shape of a
lollipop is necessary. This leaves a small scar around the areola,
down the meridian of the breast and slightly along the
inframammary fold. The procedure and scar length can be
abbreviated for smaller lifts to the point that a small lift can be
done with only an incision around the areola. To try to perform a
major lift through just this incision is a terrible procedure in my
opinion with very wide scarring around the areola and a flattened
breast shape as a result. The lifting procedure can be combined
with breast augmentation (augmentation mastopexy) in those
individuals who desire to be larger and have a large amount of
droop.
Recovery takes one to two weeks depending upon the
degree of lift performed. The results last many years.
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49. Breast Reduction
Large, sagging breasts can cause many problems including back
pain, pain of the shoulders from bra straps almost embedded within
the skin, infection and sweating constantly under the breasts and a
host of other discomforts. There are also psychological and
practical problems when a woman has large breasts. The breast
reduction procedure removes excess breast fat, glandular tissue,
and skin.
As in mastopexy, there is repositioning of the nipple and
areola and remaining tissue with a scar pattern either a lollipop or
an anchor (The horizontal incision runs side to side along the
inframammary crease).
Occasionally, in very large reductions, it may be necessary
to detach the nipple and areolas and place them as free grafts on
the new breast mound. This obviously completely denervates the
nipple and severs all of the glands so that erogenous sensation and
breast-feeding are not possible. This is only done in a very small
number of cases and may be discussed fully with you by your
surgeon prior to it being contemplated.
Drains are often necessary for a few days. This is
occasionally a medical problem that is covered by medical
insurance. Surgery can take up to four hours and may be done
under a general anesthetic. At times it can be performed in the
surgeon’s surgicenter, or otherwise, hospital surgery is required.
Cosmetic Breast Reduction
Cosmetic Reduction, is designed for women who are troubled by
their large, sagging breasts which may restrict their activities or
cause physical neck and back pain. The fat is removed, as well as
glandular tissue, and skin from the breasts, making them smaller,
lighter, and firmer. This procedure can also reduce the size of the
44
50. areola, the darker skin surrounding the nipple. This gives you
smaller, better-shaped breasts in proportion with the rest of her
body. If you're considering cosmetic reduction meeting with Dr.
Ralston and his staff will give you a basic understanding of the
procedure- when it can help, how it's performed, and what results
you can expect. They will answer all of your questions, since a lot
depends on your individual circumstances.
This is a complex surgical procedure with very real risks of
bleeding and infection. Yet, it should only be performed by a
highly trained plastic surgeon that routinely performs many such
procedures. When so done, the procedure is one of the most
rewarding for both patient and physician. The patients tend to be
even more appreciative than those following augmentation
procedures.
Following surgery there will be bruising, some numbness,
and swelling. Also, there is sum scarring that remains, though a
highly qualified surgeon will try to hide it in folds or hair. There is
usually some shift in the size of breasts after a few years, but not a
great deal unless there is excessive weight gain. There is no long-
term hardening of the breasts since only your own tissue is present.
The initial recovery time is usually two to three weeks. Finally, a
lesser procedure that removes the fat of the breast, decreasing the
size, can be done with almost no scarring with liposuction.
Surgery for breast reduction is performed by removing a
section of the breast above and to the sides of the large breast. Next
the surgeon will shift the nipple higher to achieve a more lifted
look to the breast. The final scar pattern will be determined by the
amount of excess skin.
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51. Mastectomy
The absence of the breast following mastectomy for breast cancer
can be emotionally devastating and an awkward adjustment in
appearance. Fortunately, there are several surgical techniques that
can restore the shape and contour of the removed breast.
These techniques include placing an implant under the
chest muscle or tissue expansion followed by placement of a
permanent implant, and flaps. Flaps involve taking tissue from
another part of the body to use in building a new breast. The
latissimus flap uses tissue from the back, while the TRAM flap
uses tissue from the abdomen. Very pleasing results can often be
achieved with these techniques, allowing a more complete self-
image. The final result can be made complete with making of a
nipple and tattooing of the areola.
As was stated in the beginning, breast surgery is the most
satisfying of all cosmetic surgery procedures.
Recovery
Immediate post-operative care lasts up to 24 hours, during which
time professional medical care is applied. The following day sterile
dressings on the breasts are changed and a pressure bra is applied,
which makes movement easier for the patient.
Subcutaneous (beneath the skin) stitches will be removed
10 days after surgery. The pressure bra should be worn all the time
– two months after surgery.
Usually patients can return to normal activity within a
week, with strenuous activity possible within four weeks.
Temporary bruising and swelling are part of the recovery process
and vary from patient to patient, all signs will usually be gone
within six months. Scarring will result from any incision but will
46
52. fade over time. Recovery is faster in healthy, fit individuals who
refrain from smoking.
It will be apparent during the first changing of dressings 24
hours later you will see the results However, it will take several
weeks for the final appearance to form.
What to expect following Breast Surgery
• Expect pain and swelling for a period of time.
• Numbness or possibly increase sensitivity of the breast and
nipples is common following surgery.
• Restrictions on strenuous activities are for 3 weeks. No
heavy lifting, exercise, house work, yard work, etc for 3
weeks.
• No soaking in tubs, hot tubs, pools etc until incision sites
are completely healed.
• Stay away from underwire bras for 9 months.
• Smoking will increase the risk of most complications such
as pneumonia, skin and tissue loss and does contribute to
delayed wound healing.
• Over time, post surgical swelling will resolve and incision
sites will fade.
• Pregnancy and weight changes will affect the result.
Risks
Infection is always a risk with any surgery. Breast surgery is no
different. Should infection develop, the surgeon has a host of
acceptable methods to deal with it. The fact that there is a foreign
body in place increases the risk of infection when compared to
surgery where only the patient’s tissues remain. In the extremely
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53. rare cases where the breast patient develops an infection, it is
usually best to remove the implant and leave it out until all
infection is gone. When the tissues are soft and pliable again (a
minimum of three months in most cases), then the implants can be
replaced in the breast.
Bleeding is another factor to guard against and breast
hematomas are a not too infrequent complication of the surgery. In
severe cases this may require return to the operating room for
removal of the blood clot. Drains may be used when necessary to
help prevent this complication but careful surgery by a highly
trained plastic surgeon is the best way to reduce the risk of this
complication.
Scarring occurs due to the nature of placing an implant
under the surface of the skin, where an opening has to be made.
Most incisions are made in an area where they are hidden from
view. Many things can be done to make scars look better, should it
be necessary. These range from the use of silicone gel or sheeting
on the scar surface to injection of the scar with steroids to excision
of the scar and changing its direction with plastic surgical
techniques. These procedures are rarely necessary.
Asymmetry
As with scars, all breasts are different to some extent. It can be
mentioned that nature made no two snowflakes, grains of sand, or
anything else a human can see, exactly alike. Whether or not there
is significant asymmetry is a matter of opinion. The patient is the
best judge of this and it is important for you to discuss with the
doctor any perceived uneven features of your breasts prior to the
surgery. These can often be addressed by the surgery and largely
corrected.
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54. Many asymmetries exist before surgery. The surgeon will
try to correct what is visible and make the two breasts as
symmetrical as possible during surgery. The surgeon may also be
able to improve abnormal shaping of the chest with implants.
With time, in the event of a capsule forming around the
implant and contracture of the scar tissue occurring, the breasts
may become firm and asymmetrical. This often needs to be
corrected with a repeat surgery.
Summary
Breast augmentation, or augmentation mammoplasty, is a surgical
procedure to enhance the size and shape of a woman's breast for a
number of reasons:
• To enhance the body contour of a woman who feels her
breast size is too small.
• To correct a reduction in breast volume after pregnancy.
• To lift breast dropped with age and pregnancies.
If you're considering breast augmentation, an introductory
meeting with Dr. Ralston and his friendly professional staff will
give you a basic understanding of the procedure--when it can help,
how it's performed, and what results you can expect. They will
answer all of your questions, since a lot depends on your individual
circumstances.
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55. Frequently Asked Questions
Do implants have to be changed over time?
Yes, implants aren't meant to be a lifetime product. Changes may
need to be made over a period of time, but there is no schedule for
replacement.
Is it best to wait until I am done having children?
There is no advantage to waiting, it is not necessary.
Will breasts sag over time?
Augmentation turns the clock back in time and gives breasts a
more youthful look, but breasts will settle in time.
Do breast implants effect nursing?
Not generally. If you breast fed in the past, you should be able to
breast feed after surgery. However, not all women can breast feed.
Is behind the muscle the best placement for today's implants?
Generally speaking, yes. Saline implants need as much padding as
possible. This position is also best for mammogram interpretations.
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56. 3
Male Breast
Surgery
(Gynecomastia Surgery)
ynecomastia means enlargement of male breast. It can affect
one or both breasts. The condition may be familial or have
no cause or occasionally due to medical related problems like liver
disease and drugs related
G
The breast enlarges either by increasing the glandular tissue
or just by fatty deposits
57. Surgery in breast reduction depends upon the nature of the
enlargement:
• Glandular enlargement will need excision.
• Fatty tissue in excess will need liposuction.
• A combination of liposuction and excision is usually done
to get optimum cosmetic result.
Some improvements of techniques in the treatment of
breast hypertrophy have also allowed a better result in the surgery
for gynecomastia. Although it would seem that a simple solution
should be adequate for a simple, visible subcutaneous mass, the
challenge of obtaining a smooth and flat result has been helped by
the technique of liposuction with circumareolar excision.
For body-builders who are relatively thin, presenting a very
small amount of fat over the area of the chest, treatment has been
found to be satisfactory by simply excising the actual hypertrophic
gland without having to remove any fat However, in older patients
as well as the average adolescent or middle-aged man,
gynecomastia is often a mixture of breast tissue and fat, and the
combination of gland excision with liposuction is most useful.
Indications
The diagnosis of gynecomastia is simple and straightforward. It
consists of a visible and palpable enlargement of the chest area
around the nipple, similar in configuration to the female breast.
Gynecomastia is found in adolescent and middle-aged men,
thus indicating some hormonal factors. It is sometimes tender,
always embarrassing to the patients, and rarely malignant.
Laboratory tests rarely will show any hormonal problem.
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58. The condition is common and often improves
spontaneously in young men, to return when they reach middle
age.
The Procedure
In cases of pure glandular hypertrophy, the treatment consists of a
subcutaneous mastectomy performed preferably through an infra-
areolar incision. This treatment is done in cases in which there is
no excess skin development, thus allowing redraping in the
postoperative period.
A semicircular incision is made at the junction of the skin
and areola, leaving a layer of 0.5cm of dermis, and the ducts are
transected, freeing completely the areola by sharp dissection. The
remaining portion of the surgery is performed by blunt
undermining of the skin, using curved scissors and attempting to
leave a layer of fat if it is present under the skin. The undermining
encompasses the whole gland which occupies the chest wall for a
large surface.
With the gland lifted, its medial border is dissected from
the pectoralis fascia underneath, freeing the whole gland by sharp
and blunt dissection. The lateral aspect of the gland is freed from
the pectoralis fascia and the fascia of the serratus below. Closure of
the large cavity is performed by tacking sutures applied
circumferentially to maintain the skin against the chest wall and
prevent a large hematoma formation.
Drains are left, especially in body-builders. In whom large
muscles with an excess circulation is present.
Gynecomastia Treatment When Fat Is Associated with
Glandular Hypertrophy
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59. In some cases in adolescent and middle-aged men, a combination
of fat interspersed with glandular hypertrophy is found around the
gland, and it extends into the gland itself and above it. In these
cases, it is advisable to perform liposuction either before the
glandular excision or after it, to obtain a smooth contour to the
chest wall.
In such cases of gynecomastia, either pure or with fat
hypertrophy, the treatment is often a combination of the two
techniques of liposuction and excision. In cases in which there is
an excess skin that will probably not adapt to the new chest wall, it
is often necessary to excise a horizontal portion of skin at the level
and below the level of the areola. The patients will have less
aesthetically pleasing results, because they are marred by a large
scar.
Preparing for the Operation
A Mammogram may be necessary prior to surgery as well as doing
an Ultrasound. These investigations may have to be done to rule
out any breast disease or possible tumors.
Products that contain Aspirin, Vitamin E, or Evening
Primrose oil should be avoided for four weeks before surgery. The
use of Vitamin K (10mg daily) for three days before surgery is
recommended. Strong alcoholic drinks should be avoided before
surgery.
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60. Caution
Patients should not smoke for two weeks before surgery and for a
few days after surgery. Smoking interferes with the circulation of
blood to the skin and can cause death of the skin flaps.
If the patient develops any signs of infection, pustules or
boils on the face or body before surgery, the doctor should be
notified immediately.
Day of Surgery
On the day of the surgery, the patient should wear comfortable,
loose Clothing that do not have to be pulled over the head, Patients
must not wear any make-up (including mascara and nail polish)
when they go into surgery. If the patient tints, dyes or bleaches his
or her hair, this should be done no later than one week before
surgery. Surgery is done under local or general anesthesia.
Post Operative Care
• Take a week off work.
• Takes 4 to 5 weeks to resume normal activity
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63. Recovery
Post operative care requires careful attention
• Take a week off work.
• Takes 4 to 5 weeks to resume normal activity
Men who are stoic, who do not want to accept help from
others during recovery have a greater difficulty during recovery.
Studies have shown that men often deny their pain and feel
foolish about asking for help after surgery. Men who reject help
may have an especially difficult recovery if post-operative
depression sets in during the weeks following surgery.
Frequently Asked Questions
After gynecomastia, how soon can I go back to work?
This of course depends on many things. In most cases, patients
return to work within 1-3 days. If your work involves physical
activity, it may be somewhat longer. However, in our practice even
house painters and carpenters have usually been back at work
within 2-3 days. This is not to say that you won't be sore if you are
using your arms and chest muscles though.
After how soon can I do my workouts?
This varies quite a bit with the individual. It depends on what you
are comfortable doing. You will find that doing some activities
which do not involve impact or heavy pectoral muscle use can be
done right away, but activities which do involve those you may
want to put off for a while. Most patients probably prefer to avoid
bench pressing for a couple of weeks or more, running can take a
while longer to be comfortable.
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64. After surgery, how often are follow-up visits?
I would like to see you at least a couple of times after your
surgery. After your surgery, you will be able to contact me directly
at any time if you have any questions or concerns. The first office
visit is usually 6 weeks after the procedure, and then another
several months after that. For patients who live in the Chicago
area, a visit at 6 weeks, and 3, 6, and 12 months is usually
recommended. You are welcome to come in as often as you wish.
There is no charge for any follow-up visit.
How soon can I shower?
You can take a shower within 24 hours, but you should not bathe
in a tub for at least a week.
Are stitches used?
No. In my experience, the tiny incisions actually heal better
without stitches.
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67. Abdominoplasty
Among the popular procedures of cosmetic surgery, the "tummy
tuck" or abdominoplasty operation is high on the list. The tummy
tuck removes excess skin and fat from the abdominal wall. At the
same time, the muscles of the abdomen are tightened and
reinforced. Though it does remove fat, it is not considered a
method to reduce obesity. Primary goals are contouring,
tightening, and flattening of the flaccid abdominal wall. One of the
side effects of the surgery, particularly for women who have had
children or massive weight loss, is the removal of a large number
of the stretch marks that are common on the lower abdomen.
Over the past decade the number of tummy tucks has
increased by 80%. This indicates the trend toward reducing the
bulging middle by surgery rather than the perhaps impossible
reduction in girth by extreme exercise, regardless of what the ads
tout on television with their new exercise machines.
• Reduces excess skin resulting from previous
pregnancies as well as weight loss.
• Abdominal muscle is tightened.
• Ideal patients should be done having children.
• You should be physically healthy and at a stable
weight.
• Your expectations should be realistic
• You must be a NON SMOKER
Mini Tummy Tuck
Many patients require only what is referred to as a Mini Tummy
Tuck (mini-abdominoplasty). Where there is minimal extra skin
and abdominal wall weakness a patient may only need a mini
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68. tummy tuck procedure. A mini tummy tuck requires a small
incision above the pubic area.
Notice the slight bulge to the abdominal region of the trunk
that required only a mini tummy tuck.
A varied group of people seeks abdominoplasty. Some are
relatively thin women who have had multiple pregnancies. They
may have had just one pregnancy, but the skin and muscle was
severely stretched. Exercise and diet alone will not achieve a flat
tummy without stretch marks. Also, there may be a lower
abdominal protuberance that is covered with stretch marked and
wrinkled skin.
Others include men and women who have lost a massive
amount of weight. Diet, stomach stapling, gastric bypass, or
exercise may have achieved large weight loss. Nevertheless, a
prolonged skin stretch and/or aging may have decreased the skin’s
ability to contract. The patient is now faced with a hanging apron
or panniculus of skin. No matter how much the weight loss or
exercise performed, the apron of skin will not shrink.
There are also people who seek improvement of their
abdominal wall who have undergone multiple surgical procedures
that have resulted in pouches or overhanging skin. In some cases,
liposuction may be able to flatten the bulges; however, an
abdominoplasty can remove excess skin and tighten the muscles of
the abdominal wall at the same time. There are a variety of
methods to treat defects: some require suction of fat, others require
a smaller or greater amount of skin removal, while others will want
to have the abdominal muscles tightened for maximum flatness
and slim waistline. The latter is not done if a woman is still going
to bear children.
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69. Procedure
Tummy tuck surgeries can be performed under general anesthesia,
epidural or IV sedation. The procedure can take place either in the
surgeon’s surgical center or hospital. The procedure takes two to
four hours. Full recovery to vigorous activity may take three to six
weeks or longer, depending on the patient’s recuperative ability.
Varied incisions are often utilized in tummy tucks. The
classic "bikini" incision starts just above the pubic hair, follows the
groin lines and over the hipbones. The low cut swimsuit is
designed to fall within this small area below the navel. The
surgeon is careful to make the incision below this line. A
modification of this design is to sweep the sides higher on the outer
abdomen in order for the incisions not to be visible in the higher
sided French-cut bikini style. It is best to bring the style of bathing
suit that you like to wear in to your surgery so that the surgeon can
make his/her markings based on the style of clothing that you
wear.
The second type of incision is often used in males or
patients with a hanging apron of skin. The skin-line incision
follows the natural curve that is found just beneath the fold of
abdominal skin. This can lead to a more visible incision once the
pannus is removed. After making the incisions, skin and fat are
lifted off the abdominal muscles to a level above the ribs. The
navel is detached from the skin and left attached to the abdominal
wall. Stretched and lax muscles are then repaired.
When the skin has been lifted, tightening the fascia
overlying the muscles tightens the abdominal wall. This results in
flattening and firming of the entire structure of the abdomen. This
can be done in various orientations in order to help to cinch the
abdomen and make the waist smaller and longer.
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70. Liposuction often plays a part in this procedure. It is
employed to thin out the waist and hips at the time of surgery and
allows for better contouring and shorter incisions. Other areas in
need of fat removal can often also be addressed at this time.
Before
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76. High Lateral Lift
There is another very different modification of the tummy tuck
procedure where a high lateral lift is made, essentially in the area
high above the thighs. This type of procedure is necessary for those
who have had a falling of much of the skin of the buttocks and
thigh. It is often coupled with a thigh lift (on the inner aspect of the
thigh). This procedure is major, may require 8 to 10 hours of
general anesthesia and involves a great deal of blood loss and
healing time.
Usually patients give their own blood prior to the procedure
so that it can be transfused as needed during the procedure. Most
of these procedures are performed in the hospital and require
hospitalization for a few days afterwards. The risks are great but in
those individuals requiring and desiring this type of surgery the
results are gratifying.
Other procedures involving the surgical removal of skin
and fatty tissue from different areas of the body are less frequently
performed. Thigh lifts, buttock lifts and brachioplasty (upper arm
skin tightening) are all performed occasionally for the select
patient. The down side of all of these procedures is the scar that
must be made for the skin removal.
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79. Before
After
Mini Tummy Tuck
There are important differences between a mini and a full tummy
tuck. The majority of patients will benefit from the full procedure.
The full procedure tightens the skin of the upper and lower
abdomen. The mini tummy tuck tightens only the skin below the
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80. belly button. The full procedure tightens all of the muscles of the
upper and lower abdomen. The mini tightens only the muscles of
the lower abdomen. The full procedure removes enough skin that it
requires repositioning of the belly button with a circular scar
resulting.
The mini removes a smaller amount of skin and does not
require repositioning of the belly button. The improvements made
with a full tummy tuck are more dramatic than those made with the
mini.
Recovery
Usually patients do not resume work until ca 10-14 days after the
operation. An elastic garment is recommended for a period of 2
months after the surgery.
Ice bags are helpful used intermittently for the first 24 hours after
surgery. This decreases bruising, swelling and pain.
After 24 hours, heat in the form of a heating pad or a hot
water bottle is very soothing.
Remove gauze dressings two days after surgery. Leave
clear plastic dressings, skin glue, and/or Steri-Strips on until you
come back into the office.
You may shower and gently wash your wound with soap
and water starting two days after surgery. It is okay to wash
directly on Steri-Strips, skin glue, and clear plastic dressings.
You will recover faster, and get released sooner if you start
moving around. Additionally, this cause your bowels move. It will
take you off a liquid diet sooner.
Avoid lifting, heavy housecleaning, or vacuuming or
exercise. Your muscles need time to heal. Do not lift things heavier
than recommended by your doctor (typically this is about 5 lbs),
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81. including, but not limited to children, cats, dogs, grocery bags, and
laundry baskets or any heavy manual labor.
Begin light exercise as soon as you are able. Your recovery
will go in stages. First walking. Don't wear yourself out, but walk
as much as you are able. When the surgeon releases you to do
more, start into an exercise program slowly.
No sex until the doctor releases you. Don't be nervous
discussing with your surgeon about when you will be well enough
to have sex. This is a personal decision that also needs to be
discussed with your partner, and will depend on your comfort
level.
A pillow between the knees, and another held against the
stomach helps with discomfort during sleeping.
Have someone to help you with preparing meals, household
chores.
What to expect after abdominal surgery
• Following the surgery, you will be transferred to an
outpatient facility for a 23 hour interim care.
• You will be placed in a compression garment that you wear
day and night for 4 weeks.
• Two Jackson Pratt drains will be placed following your
surgery.
• These drains stay in place and are removed depending on
drainage totals that you will keep track of on an 8 hour
basis.
• Your posture will be affected for a period of time until you
are able to stand straight.
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82. • The navel plug will need to be removed by you at 5 days
post surgery. Sutures around your navel need to be
removed at 14 days post surgery.
• No soaking of incision site until completely healed.
Risks
Patients who undergo this surgery must recognize that the surgical
incision always results in a scar that crosses the pubis and may
extend from hipbone to hipbone. Smaller incisions (mini-
abdominoplasty) can often be performed in patients with less
abdominal laxity; the resultant scar can be limited to the pubic
area. This is only possible if there is minimal skin excess. In those
individuals who have laxity of the muscle but no skin excess, the
muscle can be tightened through rather small incisions without the
long scars necessary when skin removal is an important part of the
procedure. Horizontal incisions often heal better than up and down
(vertical) incisions. It is true that any surgery is subject to
asymmetry, wide scars, bleeding, infection, and poor healing. All
of these rarely occur. The surgery is dramatic, with resulting scars,
but the reward for so many who have it done are great.
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83. Frequently Asked Questions
Is it possible to remove stretch marks with an abdominoplasty?
Depending on the distribution of the marks across the abdominal
skin, many, if not all of these marks, can be removed during an
abdominoplasty.
Can scars in the abdominal region, such as those from
Cesarean sections or appendicitis, be corrected during
surgery?
Old scars can often be removed as part of a standard
abdominoplasty, without additional complication.
Am I candidate for a tummy tuck?
Protruding, rounded abdomens are a common problem, particular
among thin, athletic women. In these cases, a "mini"-tummy tuck is
indicated.
After losing a lot of weight my tummy hangs out. Can you fix
this?
This condition can be corrected with an abdominal lipectomy, a
procedure which removes not only surplus tummy skin, but also
“love handles” and excess back flesh.
How painful is abdominoplasty?
Abdominoplasties are performed while the patient is under general
anesthesia, so there's no discomfort during the surgery.
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84. 5
Rare
Complications
t is not the intention here to alarm you or to cause undue concern, but
it is important, however, to mention rare complications that can and
do occur. This is a general list; there may be others not mentioned.
I
By its very nature, cosmetic surgery is elective. It is not an
emergency. In fact, it does not have to be done at all. Therefore, when
you have elective surgery, you should be fully informed of the possible
complications so that you can make an intelligent, informed decision.
Since we are starting with something that is almost always functionally
normal, we desire it to end that way as well. We never want to trade
beauty for function – if that function is optimal.
Elective surgery should be safer and have fewer risks and
complications than other non-elective surgery. The finesse and “small
points” of the procedures, which often make all of the difference, will not
85. be applied to the procedure and the outcome will not be optimal, if
performed by a surgeon who has not had proper training. It is important
for the public to realize that many highly trained surgeons perform
cosmetic procedures in a slightly different way than perhaps the norm.
This is particularly true of the emerging field of laser surgery since there
are few “rules” as to who can perform the procedures.
In determining if the anxiety and discomfort associated with a
deformity is sufficient enough to warrant the risk of some of these
complications, you need adequate information to make that decision.
Being aware of possible complications means that you will not be unduly
alarmed and will realize that the decision was made being aware of such
risks.
The human body is a marvelous structure. Every part of it is
connected with every other part by an intricate system of nerves, arteries,
veins, lymphatics, hormonal communications, and chemical messengers.
When recognizing this incomparable miracle, it is amazing that we lead
such uneventful lives. In a hostile environment of microbial organisms
and dangerous machinery whenever the body is treated or manipulated in
any way, alteration of other body functions occurs at the same time.
Under the best of circumstances, in a world-class facility,
complications can and will occur. We say that if a surgeon denies having
any complications it is because he is not doing any surgery.
As you review these complications, please bear in mind that
these are rare but should be part of your background information.
Complications can and do occur in as much as five to ten percent
of cases. Often the complication is trivial, as when a small wound
separates at the incision, when bruising is extensive, or when the length
of time required before going back to work stretches from one week to
two. But they can also be profound, such as death and dismemberment.
There are complications that are considered general in nature,
such as infection or bleeding. There are also possible complications
associated specifically with the type of surgery being performed: for
example too much of the white portion of the eyes showing above the
lower eyelid after a blepharoplasty (ectropion).
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86. There are complications as a result of an inappropriate procedure
being performed: for example an eye which does not close properly
(lagophthalmos) after too much skin is removed from the upper eyelid
when the problem was too low an eyebrow giving the hooded look to the
eyelid in the first place.
General complications for invasive surgical procedures, whether
a root canal or a heart transplant, include wound infection, shock related
to surgery, excessive bleeding, or undue pain. Other complications, more
specific to cosmetic surgery, include skin discoloration, keloid and
hypertrophic scars, asymmetry, nerve injury, skin loss, and psychological
effects.
Infection
Infection is one of the worst complications in any procedure, including
cosmetic surgery. Wound infection usually shows up 5 to 6 days after
surgery. It involves bacteria growing in the wound and invading the
body. Although very rare in elective surgery, especially in a specialized
clinic situation, the most profound infection can lead to septic shock and
death. Clinics dedicated to aesthetic and elective surgery are probably the
safest environment, because operations are performed on otherwise
healthy individuals who are infection-free. Many of these are
standardized as in the hospital setting, however, many more infections
occur in hospitals than in our facility.
In the cleanest, most sterile facility, wound infections still
occasionally occur. The bacteria usually come from areas of the patient’s
own body. This could be from a hangnail, an infected tooth, or some
other source of bacteria that may cause the blood borne organisms to end
up in the area of surgery where it is able to grow and proliferate because
of the decreased body defense mechanism in this treated area. The use of
preventative antibiotics before, during, and after surgery does not prevent
wound infections entirely.
Many surgeons choose not to use antibiotics prophylactically in
all cases. For example, in clean, short procedures such as upper eyelid
blepharoplasties. In cases where a patient is either immune compromised
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87. or whose health would be affected in a dire manner if they were to
acquire an infection, then antibiotics are often used.
Shock
Shock related to surgery is also a general complication that is not
common. It occurs either from an invasive infection or from massive
blood loss. Normally, shock is associated with serious trauma, and not
elective surgery. Some people mistake the psychological effects of
trauma as “shock” but this has a different meaning in medical circles.
There are a few patients who have vaso-vagal reactions (faint at the sight
of blood or needles). This is not shock and can be readily treated. It is
best to avoid this reaction by knowing about it before hand.
Bleeding
This complication, too, can be trivial or tragic. It is not unusual for a
liposuction patient to have quite a bit of drainage. The small incisions we
create allow some fluids to come through. It is possible with larger cases,
such as breast augmentation, for a blood vessel sealed at the time of
surgery to rupture after surgery. This is most often due to tissue
movement that results from changes due to swelling or from excessive
arm movements immediately after surgery.
Major bleeding can occur, but is not life threatening with prompt
attention. Sometimes the condition requires returning to the operating
room. Such post-operative bleeding is not rare, especially with facelifts,
breast augmentation and tummy tucks, but it is not common (maybe one
or two out of 1000 cases). Post-operative bleeding will usually occur the
day of surgery or the following day. If it is self-limiting and in a small
amount, the complication will result in bruises that take several weeks to
resolve. Most clinics and facilities supporting outpatient surgery will
have a nurse call the patient at home the evening after surgery to check
on the patient’s condition. In our clinic, I do this myself. Bleeding is one
of the things we ask about.
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88. Skin Discoloration
After a tummy tuck, liposuction, or even after something small like the
sclerotherapy of leg veins, the skin can be either temporarily or
permanently discolored or stained. This happens when there is a small
amount of blood which tracks under the skin. Temporary staining
usually results from blood collecting as it does in a bruise. This is usually
self-limiting and the bruise passes through all of the different coloration
known to us all until it disappears. In some instances, the darkening can
be permanent.
The most common cause of pigmentation of the skin after
procedures being performed is a condition which is very common in non-
Caucasian patients, called postinflammatory hyperpigmentation. This is
a condition where, for any reason inflammation is initiated, the body
responds by making more normal pigment (melanin). Some people have
a very marked reaction of this sort and a tiny bee sting, which occurred
when they were children, still remains as a dark spot on the skin decades
later. Most people have this to some extent.
When it is anticipated that this will occur due to a procedure
prone to inducing it or because of the individual patient, a bleaching
cream can be used prophylactically in order to try to curb the production
of the melanin. In most instances, the darker color of the skin returns to
normal after a few months.
The second reason for darkening of the skin is due to the
deposition of hemosiderin within the skin. All blood cells have iron.
Within the hemoglobin ring, there is a single iron molecule. That
molecule can actually rust, which, if it is near the surface of the skin,
may cause, essentially a rust stain that may last for months. It usually
fades and goes away, but occasionally those rust stains can be
permanent. Tattoos are mostly ferric oxide, which is simply iron rust, and
is quite permanent if a large amount occurs near the surface. Usually
small amounts are removed by the body’s defense mechanisms and
disappear in a few months.
Early in the deposition, if permanent staining is anticipated, a
cream using the saliva of leaches can be used to break down the blood
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89. such that the body reabsorbs the pigment. If this is ineffective or if the
staining occurred many years previously, lasers specific for pigment
removal can be used to remove the iron oxide, much as in tattoo removal.
Keloid and Hypertrophic Scars
Keloids are large, knobby, masses of disorganized scar tissue that form
in response to a small injury. For a person prone to keloids, piercing the
ear may produce a scar that looks like broccoli or cauliflower and may
measure inches across. Keloid-formers tend to be people of pigmented
races, which may be Oriental, African, or Mediterranean, but can occur
in any individual.
Fortunately, keloids do not usually form in the area of the eyes,
the face, or the nose. They can be removed surgically and the area treated
with high doses of injected steroids. There are a multitude of other
treatments that can be used to help with keloid scar formation including
laser treatments, silastic sheeting, pressure garments, etc.
“Hypertrophic” or “thick” scars usually result from tension.
They are not keloids. The difference is that a keloid goes well beyond the
site of the original injury.
By injecting steroids, hypertrophic scars can be treated. This
may have to be repeated every month or so for several months.
Consequently, even the thickest scars will thin. Again, there are many
ancillary treatments that can be used to help with hypertrophic scars.
There is a group of individuals who are expert at the wound healing
process and guiding it through its various phases. Most of us belong to an
organization called the Wound Healing Society. We have performed
extensive training in the field of wound healing and scarring and are best
able to guide scars to heal as best as is possible.
Hypertrophic scars and keloids can become serious problems for
plastic surgeons and their patients. One added note is that there is no way
to “erase scars.” We do not have as yet, sufficient knowledge to be able
to cause healing without scarring. There is intensive research being
performed in this area but the control over the process is, as yet, not able
to be performed with any specificity.
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90. Asymmetry
Asymmetry happens when the face or parts of the face or body are not
evenly matched, such as one eyelid lower that the other or nostrils one
smaller than the other, one cheek fuller than the other. A skilled surgeon
is very much aware that this can become a serious defect in the overall
appearance of a patient who has had cosmetic surgery. That surgeon will
make every effort to maintain uniformity and avoid at all cost
asymmetry.
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91. 6
Conclusion
tudies suggest that physical appearance is one of the most
important components in the initial appeal or attraction we
have for one another people. After the initial impression, however,
S
92. other factors tend to replace appearance in determining the type of
relationship that ultimately develops. Yet, a good first impression
counts.
Even so, with most of us our “self-image” is a major factor
in determining our economic and psychosocial success in today’s
society, and in addition our perception of our physical appearance
is a major component of our self-image.
Full breasts, for women, good pecs for men may be
important, but often the most visible and outstanding elements of
attractive appearance is the face. Perhaps this is why there is such
an increase in attractive, balanced facial features through cosmetic
surgery.
In an effort to provide information, it is here in this detailed
presentation for you to study and decide what offers the best
overall appearance, whether it is age, youthful attractiveness, or
defects that need correcting. It is understandable why in the past
decade cosmetic surgery tops the list of elective surgeries
throughout the world.
Testimonals
Thank you for taking such good care of me last month with
surgery. I really appreciated your patience and input during the
consultation. Thanks again for being so good to me. I've seemed to
heal without any complications and am very happy with the
results.
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93. Thank you so much, my breasts are so much better than I ever
imagined, you did an outstanding job, and my nose is perfect!!! I
can't thank you enough; I will recommend you to anyone!
"Thank You"
Small words. . . Big Meaning! Thank you for your medical skills in
helping me through surgery, thank you for your people skills in
making me feel I was important. Thank you to all your kind nurses
in helping me through the emotional part of laser. You are a
wonderful doctor with a great staff.
I just wanted to write to express my thanks and appreciation for
the wonderful treatment and care you all shows to me following
my surgery. Before I came into the office for surgery, I was very
nervous and daunted by the fear of the unknown ~ but you were all
so kind and so reassuring when I arrived and it took away a lot of
my apprehension. Thank you all once again for all your care and
support.
Thank you so much for the thoughtful way in which I was cared
for. The gentle atmosphere of the office and staff made a difficult
situation easier. Thanks again for your beautiful work.
You are very skilled in your abilities . . . thanks so much for the
beautiful breasts.
Thank you so much for doing an excellent job. I really appreciate
your talent and the kindness from both you and your staff.
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94. Glossary of Terms
Abdominoplasty
A procedure that minimizes the abdominal area. In
abdominoplasty, the surgeon makes a long incision from one side
of the hipbone to the other. Excess fat and skin are surgically
removed from the middle and lower abdomen and the muscles of
the abdomen wall are tightened.
Anesthesia
Lack of a normal sensation brought on by an anesthetic drug
Anomaly
A health problem or feature not normally present in a healthy
individual; a deviation from the normal.
Apert syndrome
A craniofacial abnormality characterized by an abnormal head
shape, small upper jaw, and fusion of the fingers and toes.
Areola
Dark area of skin that surrounds the nipple of the breast.
Asymmetry
Lacking symmetry; parts of the body are unequal in shape or size.
Augmentation mammoplasty
A procedure to reshape the breast in order to make it larger. The
procedure can also be performed to reconstruct the breast
following breast surgery.
Autologous tissue breast reconstruction
The use of the patient’s own tissues to reconstruct a new breast
mound. The common technique is the TRAM (transverse rectus
abdominous muscle) flap. A TRAM flap involves removing an
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95. area of fat, skin, and muscle from the abdomen and stitching it in
place to the mastectomy wound.
Breast augmentation
A procedure to reshape the breast in order to make it larger. The
procedure can also be performed to reconstruct the breast
following breast surgery.
Capsular contracture
The most common complication of breast reconstruction surgery;
occurs if the scar or capsule around the implant begins to tighten.
Congenital
A physical or mental condition present at birth.
Congenital anomaly
A health problem present at birth (not necessarily genetic).
Contractures
An abnormal condition of a joint caused by a loss of muscle fibers
or a loss of the normal flexibility of the skin.
Cosmetic plastic surgery
One type of plastic surgery performed to repair or reshape
otherwise normal structures of the body, primarily to improve the
patient's appearance and self-esteem.
Expander/implant breast reconstruction
The use of an expander to create a breast mound, followed by the
placement with a permanently filled breast implant.
Facial implant
Cosmetic plastic surgery employed to change the shape of the chin,
check, or jaw. This procedure is typically done to enhance certain
facial features, or to bring a certain aspect of the face into
proportion with the rest of the facial structures.
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96. Flap surgery
This is one type of surgery that involves transporting healthy, live
tissue from one location of the body to another - often to areas that
have lost skin, fat, muscle movement, and/or skeletal support.
There are several different types of flap surgery methods that may
be utilized, depending upon the location of the flap and the
structures that need to be repaired.
Gynecomastia
A condition in which the male's breast tissue enlarges.
Gynecomastia literally means "woman breast." This increase in
tissue usually occurs at times when the male is having hormonal
changes, such as during infancy, adolescence, and old age.
Hematoma
This has to do with blood that collects under the skin or in an
organ.
Liposuction
Surgery to reduce excess fatty deposits in the face, body, arms and
legs.
Mastectomy
Surgery to remove portions of or all of the breast.
Partial Abdominoplasty
A "mini tummy tuck." This procedure is ideal for individuals who
have fat deposits limited to the area below the navel.
Plastic surgery
The surgical specialty that deals with the reconstruction of facial
and body tissue that requires a reshaping or remolding due to
disease, a defect, or disorder - in order to approximate a normal
appearance or to repair working ability.
Reconstructive plastic surgery
One type of plastic surgery that is performed on abnormal
structures of the body that may be caused by trauma, infection,
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