Technical questions
How is a breast lift different than breast augmentation?
Answer: A breast lift or mastopexy is a completely different operation than a breast augmentation. A lift raises the position of the nipple and areola and takes a tuck out of the lower part of the breast without changing the size or volume of the breast. An augmentation is pure volume addition to the breast without lifting it. Some breasts have sagged too far to be augmented and require a lift procedure before considering an augmentation.
What is capsular contracture?
Answer: All breast implants heal by formation of a scar tissue layer around the implant. This is called a capsule. If the capsule is normal there is no contracture and no problem. However if the capsule thickens and contracts the implant gets compressed and the breast looks and feels too firm or even distorted. There is some controversy over what causes capsule contracture. The leading theory is that it is caused by low grade bacteria in the space around the implant.
What is a high, moderate, or low profile implant?
Answer: In order to properly size a breast implant so that it fits and looks natural, the width of the implant must match the width of the breast. The forward of volume or profile of the implant could vary. A low profile implant must match the width of the breast but has the least forward projection and the high profile implant has the largest forward projection. The medium profile implant is in between. The choice of these profiles determines how much bigger the breasts look after augmentation.
Does it matter where the surgery is performed? My doctor has his own surgical suite is that suitable?
Answer: The best way to answer this question is that the patient should have the choice of where the surgery is performed. Office surgical suites offer a number of advantages including privacy, specific personal and setup for cosmetic procedures, and cost. However the surgeon should have privileges to perform the same procedure in a hospital operating room and the patient should have this choice available to them. The trend today is also to have office surgical suites accredited by a national crediting organization for the level of procedures that are performed there.
What is the difference between over the muscle and under the muscle?
Answer: Long years of experience with breast augmentation have shown that there are three major reasons why breast implants do better underneath the pectoralis muscle. There are no significant advantages to putting the implant above the pectoralis muscle. Therefore the best choice today based on experience is to have the implant behind the pectoralis muscle. It is important to note that this does not mean that the implant is completely behind the muscle. The pectoralis muscle only covers the upper portion of the area behind the breast.
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Should I have breast augmentation before or after having children?
Answer: It doesn’t make any difference. The breast implant, properly done, does not change the effect of pregnancy on breasts. There is a group of women whose breasts have never developed and they would like to have an augmentation before pregnancy. There is another group of women that have lost breast volume due to pregnancy and would like to have an augmentation procedure to replace the volume. Unfortunately there is no way to predict or control the effects of pregnancy on a breast.
How do I know what size to become? Do I decide or does my surgeon?
Answer: This is a difficult question and different plastic surgeons will give different answers. My opinion is that in order for the result to look natural the width of the implant must match the width of your breast. The implant also has to be filled properly. The choice is there for low, medium and high profile implants which mean that the patient has a choice to increase her size by a cup, a cup and a half or two cup sizes in bra size compared to what she started with and compared to her chest circumference which does not change.
Am I too old to have breast augmentation?
Answer: In my opinion a patient for breast augmentation needs to be at least 18 years old so that it is reasonably certain that breast growth is completed and the patient can sign their own consent for the procedure. There is no upper limit for this procedure. The requirements are that the patient is in good health and understands the nature of the procedure, what they expect to gain from it, and the attendant risks.
Should I bring pictures with me to the consultation so the surgeon knows the look I want?
Answer: In my opinion this is not helpful for the same reason that it is not useful to show pictures of what you would like your nose to look like in a rhinoplasty. Properly done and natural looking a breast augmentation should look like your breast larger, not someone else’s. Looking at clinical examples of other patients is of some value. Also if the patient has had a term pregnancy she will know what her breasts look like larger which is of some help.
Is a plastic surgeon different from a cosmetic surgeon?
Answer: There is no recognized surgical specialty of cosmetic surgery in the sense that there is a surgical specialty of plastic surgery or other surgical sub-specialties such as cardiac surgery or neurosurgery. Plastic surgery includes both reconstructive and cosmetic procedures on the surface of the body. Doctors that are not plastic surgeons can perform cosmetic surgical procedures. They sometimes call themselves cosmetic surgeons.
I went to a plastic surgeon that wasn’t board certified, is this a problem?
Answer: Board certified plastic surgeons are certified by the American Board of Plastic Surgery. This is a board of the American Board of medical specialties which is the same type of board certification as cardiac surgeons, neurosurgeons and general surgeons. Other doctors and surgeons doing cosmetic surgical procedures will often claim some type of board certification that sounds like plastic surgery. This does not mean that they cannot perform the cosmetic surgical procedure or that they are incapable of performing the procedure properly. Board certified plastic surgeons are the most highly trained surgeons performing cosmetic surgical procedures and therefore your odds of receiving proper treatment are better in general than with someone who does not have the same degree of training or experience.
Who is an ideal candidate for liposuction?
Answer: The best candidates for liposuction are healthy people with reasonably normal weight who realize that they cannot diet or exercise off the area that they are concerned with, and have an area of fat deposit that is out of proportion to other areas. These are usually inherited or personal fat distribution areas.
I want to get a head start on my weight loss goal, and I was thinking of having some liposuction done. Is this appropriate?
Answer: No. Liposuction is not a weight loss procedure. It is a way to change body contour and areas of disproportionate fat deposits but in most cases is not done for weight loss and is not helpful in losing weight. Unlike tuck procedures that need to be done after the weight is lost, liposuction can be done before weight loss is complete as long as the patient understands what is actually going to be changed by the liposuction.
Is it better to have liposuction done on my stomach now or should I wait until after I have children?
Answer: First there has to be excess fat between the skin and the muscle wall in the abdomen in order to consider liposuction of this area. Generally the skin and muscle wall are in better condition before pregnancy but liposuction can be done before as well as after pregnancy and really has no affect on the issue of the skin and abdominal wall layers.
Can liposuction help me with my cellulite?
Answer: The real cause of cellulite is the way the connective tissue under the skin attaches to the underside of the skin. This is not altered by weight loss or liposuction. Clinical experience has shown that areas of cellulite may look better after liposuction but it is best to consider the surface characteristics of the skin to be unchanged by properly done liposuction.
Will my stretch marks be more noticeable after this procedure?
Answer: Temporarily stretch marks might seem more apparent after liposuction due to the swelling and stiffness that requires about three months to resolve. In the long run or permanently stretch marks are part of the skin and are not expected to be improved or made worse by liposuction.
My husband is getting a “fat tire”, are men suitable for this procedure?
Answer: Statistically about 10-15% of liposuction cases are male. There are no fundamental differences in the evaluation technique and approach for liposuction in males. There are some differences in typical thickness of skin and fat distribution in males, but men can certainly benefit from liposuction body contouring.
What happens if I gain weight after I have liposuction? Does the fat go somewhere else?
Answer 1: It is just as easy to gain or lose weight after liposuction as it is before liposuction. The procedure really has nothing to do with weight and metabolism issues in the normal cosmetic situation. We now have over twenty years experience in the United States to say that fat cells can swell and shrink but they cannot multiply or duplicate and they do not appear someplace else. Therefore liposuction permanently reduces the number of fat cells in a given area.
Answer 2: If you go on to gain weight, all of your residual fat cells over the whole body will swell.
Will my skin be “saggy” from liposuction?
Answer: We now have over twenty years clinical experience in the United States to say that properly done liposuction has no adverse effects on the skin. It will also not improve the skin. It is best to think of the skin as a separate layer that will not be improved or made worse by liposuction. Skin that is already “saggy” will still be “saggy” after liposuction but if it was not “saggy” before the liposuction it will not become “saggy” if the liposuction was done appropriately.
Will my stretch marks be more noticeable after this procedure?
Answer: Temporarily stretch marks might seem more apparent after liposuction due to the swelling and stiffness that requires about three months to resolve. In the long run or permanently stretch marks are part of the skin and are not expected to be improved or made worse by liposuction.
Can I go back to work the next day or do I need to take time off?
Answer: Properly done liposuction is protected by an elastic binder following the procedure and does not require restrictions on activity or position. However the area is going to swell and bruise to some extent and will be sore. Therefore it is unlikely that the patient will feel like going back to work the next day, but it is physically possible. In general, I recommend thinking that you will be sore and not feeling like using the area that has been suctioned for five to seven days following the procedure.
I want to wear a bikini this summer, how long will it take to see my final result?
Answer: I currently use five days of continuous elastic compression for any area treated by liposuction. By one week all restrictions are lifted and the patient is encouraged to return to normal activities along with massage and skin conditioning. Visible swelling and bruising on the legs and trunk will generally resolved to the point of not being noticeable by two weeks, but full resolution and the final result is evaluated at three months.
Is it true that you take out all the fat cells in the areas I’m having treated and they never come back?
Answer: It is not normal to have absolutely no fat cells in a given area between the skin and muscle layer, therefore it is not true that all the fat cells are removed from a given area. However if they are removed it does not matter weather they are suctioned out or surgically cut out, they are gone and cannot return to that area. The goal of liposuction is to do this without cutting nerves, blood vessels, or connective tissue and therefore creating scar tissue and potential deformities.
Do I need general anesthesia to have liposuction done?
Answer: Not anymore. Liposuction used to require general anesthesia and was associated with significant blood loss before there were techniques available to do the procedure under local anesthesia and without significant blood loss. Today you can choose to have liposuction done under general anesthesia or under local anesthesia with or without intravenous sedation.
What type of liposuction do you specialize in?
Answer: There actually is only one type of liposuction in general and that is blunt suction lipectomy. We now have over 20 years experience with this technique in the United States. There have been some modifications in instruments and the use of ultrasonic assisted liposuction, but the actual fat extraction is done essentially the same way. There has also been a modification in anesthesia techniques to carry out the procedure. The term “tumescent liposuction” has been applied to this, but is misleading in that it is an anesthesia term rather than an actual difference in liposuction technique.
What is the difference between liposuction and a tummy tuck?
Answer: These are completely different procedures both in their approach and also in the layers or areas that they work on. Liposuction is done without cutting anything for the most part and only works on the layer between the skin and the muscle layer. Tuck procedures including tummy tucks work on the skin layer and the muscle layer underneath and involve incisions, skin removal, internal suturing, and other more major surgical techniques. The cost, the magnitude of the surgery, the recovery, and the risk, are also quite different for these two types of procedures.
How can my doctor tell if all the fat has been removed when doing a specific area?
Answer: All the fat is never removed from a given area. This would be abnormal and undesirable. All the fat that can or should be removed from an area is what liposuction is attempting to achieve. Knowing that this has been accomplished is where the experience comes in, in not only evaluating the patient for suitable areas but in carrying out the procedure properly. Extensive training in and experience in both surgical and liposuction techniques is optimal for proper fat removal.
Is it better to have liposuction done on my stomach now or should I wait until after I have children?
Answer: First there has to be excess fat between the skin and the muscle wall in the abdomen in order to consider liposuction of this area. Generally the skin and muscle wall are in better condition before pregnancy but liposuction can be done before as well as after pregnancy and really has no affect on the issue of the skin and abdominal wall layers.
My Dermatologist performs liposuction. Is this acceptable?
Answer: If the patient feels comfortable having their liposuction carried out by a Dermatologist, then that is certainly acceptable. However Dermatologists are not fully trained surgeons, they are not plastic surgeons, and they are not certified by the American Board of Plastic surgery. Extensive training in all areas of surgery and specifically cosmetic surgery is optimal for carrying out procedures like liposuction, but any doctor is legally allowed to perform such procedures and therefore the choice of doctors is up to the individual patient.
What happens if I gain weight after I have liposuction? Does the fat go somewhere else?
Answer 1: It is just as easy to gain or lose weight after liposuction as it is before liposuction. The procedure really has nothing to do with weight and metabolism issues in the normal cosmetic situation. We now have over twenty years experience in the United States to say that fat cells can swell and shrink but they cannot multiply or duplicate and they do not appear someplace else. Therefore liposuction permanently reduces the number of fat cells in a given area.
Answer 2: If you go on to gain weight, all of your residual fat cells over the whole body will swell.
Will my stretch marks be more noticeable after this procedure?
Answer: Temporarily stretch marks might seem more apparent after liposuction due to the swelling and stiffness that requires about three months to resolve. In the long run or permanently stretch marks are part of the skin and are not expected to be improved or made worse by liposuction.
I'm thinking of having some liposuction done on my hips & thighs. What is the best way to choose a surgeon for this?
Answer: I recommend a full consultation with a board certified plastic surgeon who is experienced in liposuction and provides a full explanation of all aspects of the procedure in relation to your personal situation and choices before proceeding. A friend who has had a good experience with a plastic surgeon (or a good result from liposuction) would be someone to ask, but ultimately you have to feel comfortable with your choice so get consultations until you feel you've found the right surgeon.
Is there an association that tracks complaints against plastic surgeons?
Answer: No. The Tom Martino Troubleshooters network is the best group to look out for the interest of consumers and avoid endorsing companies or practices that have serious complaints against them.
Dr. Replogle performed my breast augmentation 10 years ago. I am still very happy with the augmentation, but since then I have lost size(not breast size). At that time I was lifting a lot of weights and therefore to make the augmentation a success the breast had to be larger to compensate for the size of my back. My cup size is a Full C. Is it possible to go to a smaller size...
Answer: The simple answer is that today there are saline breast implants available that will allow for more or less projection (and thus size) and still fit across the diameter of the breast. This means that if everything else is doing fine, you could increase or decrease your cup size by about a half cup in bra size by a simple change of implants through the same very small incision you already have (if it was in the crease under the breast).
Beyond that, a consultation to evaluate your current situation and any other size, lift, or change options would complete your understanding of what's available and what would be involved.
and what is the recovery time?
Answer: If it's simple replacement of implants, the recovery should be very modest restrictions for a week and minimal to no massage and rehab. The cost is also much less than a first time augmentation for patients whose original augmentation was done by Dr. Replogle
Would you have excess skin or is that taken out?
Answer: Removing excess skin is a different operation. If the implant is sized properly across the diameter of the breast and the forward projection is changed to low profile there should be no excess skin created.
Is the method of incision under the armpit for an augmentation outdated?
Answer: That's a very good way of putting it. In a sense, it is outdated. There is a better alternative when all the pros and cons and years of experience are reviewed, at least with saline breast implants.
What is the advantage/disadvantage of under the armpit...
Answer: The only advantage is that the scar from the incision is hidden in the armpit. There are a number of disadvantages including reduced control of getting the pocket for the implant created properly, positioning the implant correctly, making adjustments in the shape of the breast (particularly in certain types of breast shapes, disrupting the lymphatics tracts from the breast to the armpit, and not being able to get back to the implant easily and make adjustments or replace the implant later on if this is needed.
vs. an incision around the nipple?
Answer: The only advantage of this approach is that it attempts, often unsuccessfully, to hide the incision scar around the edge of the areola (the disk around the nipple). It has major disadvantages including violating the breast tissue, contaminating the pocket around the implant by exposure to skin bacteria in the breast ducts, cutting nerves around the nipple/areola, and again making it difficult or not recommended to go back through this route if it's ever needed to get back to the implant a second time. The scar can also be the most noticeable of any of the approaches for augmentation.
What is the recovery like for each type?
Answer: There is more recovery in the breast if the incision goes through the center of it and more recovery in the arm if the incision is in the armpit. It should be mentioned that these are minor and short term issues when it comes to things like the quality of the result, higher risks, and inability to access the implant in the future.
I no longer use either of these approaches based on my experience and an evaluation of the advantages and disadvantages of all the approaches used to make incisions to place breast implants. The current best approach for breast augmentation using saline breast implants, in my opinion, is a two centimeter scar in the center of the crease under the breast.
Is it too much surgery at once to have a brow lift, eyelid tuck, breast augmentation and thigh liposuction?
Answer: In my opinion, yes. Different well trained board certified plastic surgeons will give different opinions on this though. In addition to different types of surgical procedures and different types of anesthesia that could be used for these procedures if done separately, they involve nearly all areas of the body and would make recovery more difficult. In general, multiple procedures take longer under anesthesia and thus add to risk. The risks of each procedure are also additive so there is more likelihood of a complication or one of the procedures not having a successful outcome. In general, I limit cosmetic surgical procedures to under four hours, consider doing procedures of the same type (such as liposuction of various areas) together, and not combining procedures that are known to go together poorly (such as browlift and upper eyelid tuck) or have recovery issues that add to risk of complications (such as combining a full abdominoplasty with other procedures). Each procedure should be covered fully with the patient and then the issues of combining them should be discussed fully before proceeding. This takes time but it's often in the best interest of the patient and their safety.
Are there any changes in the Breast's sensitivity after augmentation?
Answer: In breast augmentation the breast itself does not need to be altered and sensation or sensitivity of the breast is expected to return to normal after the operation. There is a small risk of permanent
alteration of sensation in some area of the breast after augmentation.
The exact percentage risk is difficult to measure but it doesn't seem
to be dependent on the incision used.
I've had my saline breast implants for about 20 years. They are underneath the pectoralis muscle. I've had a problem with tightening and the implants are pushed up and are uncomfortable at times. What are the options?
Answer: You should view your options as choices you can make just as you made a choice when you had the implants put in. You need to know what your choices are and that requires a full consultation with a plastic surgeon certified by the American Board of Plastic Surgery and experienced with breast augmentation and particularly revisional or secondary breast augmentation. There are thousands of women out there whose augmentation was done more than fifteen years ago (the era of modern saline implants) and they may want to make changes in their augmentation result at this point. It is quite reasonable to consider this.
It is not true that implants need to be changed or replaced just because they reach a certain age. In general, the options for you will be to leave as is, to remove the implants entirely, to change to different size or type of implant, or to modify the space around the implants or the tissues around it such as the pectoralis muscle. The exact details of what is feasible and what you choose to do should be worked out in consultation with the plastic surgeon before any revisional surgery.
My wife is 52 and Diabetic
Answer: Age is not a factor in and of itself but diabetes is a risk factor for surgical procedures including cosmetic procedures. It doesn't make them impossible or high risk if there are no other significant health issues and the diabetes is treated and a stable condition. Consider smaller procedures such as blepharoplasty (eyelid tucks) first before bigger operations like a browlift or facelift.
Is there any alternative besides surgery such as Thermage?
Answer: Thermage is s new and relatively short or low-experience technique to use radio wave energy to denature collagen under the skin surface and get it to tighten up or retract as it heals. It could be used as an alternative to a procedure like a browlift or facelift but it is not clear yet who will respond, how much, and for how long as well as the assessment of any complications and their frequency. It is not used to my knowledge for eyelids so this would still be a reasonable way to get an improvement as a diabetic with a well established procedure that is not as extensive as a full facelift and more assured of a predictable result than Thermage.
How will I know the plastic surgeon I choose will do the procedure right?
Answer: This is the ultimate question for which there is no real answer. It is the same for heart surgery, brain surgery, or any surgery for which the patient is not aware of how the surgery is actually carried out. It's even the same for something as mechanical as fixing your car. The best you can do is choose a plastic surgeon certified by the American Board of Plastic Surgery, one who is experienced in the procedure you're interested in, and one who is willing to provide a complete consultation before the surgery so that you feel confident in the surgeon and in what is to be done and what is expected for the outcome.
