I see many variations of patients in my San Francisco Bay Area/Marin County plastic surgery practice that are primarily seeking correction of sagging breasts and often looking for  more youthful and fuller upper breasts.  Often because of pregnancy, breast feeding or simply a weight loss, the breasts begin to look flattened at the upper poles, the cleavage is much less firm and the general volume of the breast itself is greatly reduced.   At the cosmetic surgery consultation, I am often asked if a breast augmentation alone will “fill up” the breast enough to correct the sag.  The answer is sometimes.  Not a very definative answer and here is why.  A minor amount of sag in a small to medium sized breast is often correctable with an implant.  The implant diameter must be appropriately sized in order to achieve a natural cleavage.  If  too small diameter implants are placed, the breasts seem as if they are spaced too far apart.  When the implants are too large, the breasts seem very close and the breasts appear too large for the woman’s chest.  Sometimes,  the best solution is to lift the breast while enlarging it to a naturally full and youthful size again.  The desired outcome of breast augmentation is a larger breast with the nipple at a natural position.  It is not aesthetically pleasing to have a nipple that continues to point downward, even though the breast is fuller. A quick consultation can confirm the appropriate solution to accomplish the desired correction.

Recent years have also brought the advent of implants with moderate to high projection.  These are valuable tools because I often see small chested women that request large breasts.  When a standard moderate implant is used, the diameter of the implant may be too large for the chest.  The patient almost always is desiring projection rather than breasts that fill the entire chest wall.  A high profile implant will have the same amount of fill volume but with a smaller diameter.  Thus, more projection is achieved with a more natural look to the chest wall.

I perform a variety of different breast procedures but always recognize in the surgical planning that the outcome should correlate to the patients lifestyle, athletic choices and desired result.  

I have 2 daughters that are recent college graduates and currently exploring the difficult job market.   I  have had many discussions with both regarding the interview process and the image that is best received by an employer.  Most potential employers would expect an applicant to have a stylish haircut,  neat and well-tended nails,  pressed and freshly laudered clothing, etc.  Should we begin taxing all of these services since they could be construed as unnecessary and a reflection of vanity?  Nope.  The reality of plastic surgery and noninvasive cosmetic procedures is that most people that utilize the different options are like you and I.  They are middle class, responsible with their spending and view these procedures as maintenance.  Of course,  there will always be a few sensational bizarros like Michael Jackson and the Octomom  to tweak  negativity amongst  those that would never do any of these procedures anyway.  Then again, there are many of our politicos that I have noticed move almost nothing on their faces during interviews.

This sort of plastic surgery taxation has been tried in several states unsuccessfully already.  Currently only New Jersey still has a tax on cosmetic surgery and even the legislator that wrote the original bill has recommended canceling it.  Why you ask?  The  amount collected  by the state of New Jersey was 75% off the targeted amount.  Patients were crossing into nearby states to take advantage of nontaxable procedures.  The question of defining what was or was not a cosmetic surgery procedure became blurry.  Several examples of that are:  the woman that had a breast reconstruction requiring breast implants and required revisions,  the massive weight loss patient that required a tummy tuck to remove a large abdominal panice so that she could go on with a normal life and seek employment or the elderly patient with an upper eyelid fold that partially obscured vision.  I would guess that most of us have dealt with an insurance company that has ruled a medical procedure unnecessary.  Imagine the same group of uninformed individuals deciding on taxation.

I do believe that presidential speechwriters do alot of research and are masters of wording, but, and it is a big but, they are not physicians and neither is he.  There are many times that I believe a generic medication can be used, but often a brand named drug is the most recent addition and the most appropriate.  What is the difference?  The brand name is “on patent” for 10 years, the generic is no longer on patent.  Why does the brand name cost more?  Of course, there is profit involved, but also expensive research and development and the process of safety checking and research studies needed to gain approval by the FDA.  I and most of my colleagues understand the importance of making prescriptions financially reasonable for our patients.  Almost daily, my office deals with an insurance company that will not honor a prescription unless it is changed to a less expensive one on the drug formulary.  This is the part of health care that is broken and what does our government do?  Agree with the insurance companies!  There might be more to worry about in my opinion like the salaries of health care company CEO’s that range from a paltry 3 million to 24 million dollars a year.  Maybe if that was regulated too, we could all get the name brand medications!

The ideal liposuction candidate is at a comfortable, stable body weight pounds.  Liposuction is commonly performed on the neck, arms, abdomen, flanks, thighs and knees.  Vaser liposuction is not a method of weight reduction but very often my patients will continue to lose a small amount of weight after the procedure to compliment their result.  It really is a  “feel good” surgical procedure in that it resculpts annoying areas that previously were resistant to weight loss or exercise.  I also utilize  liposuction to tailor bulky adjacent areas when performing breast lift or abdominoplasty (tummy tuck).

I find that with Vaser liposuction there is very little postoperative pain.  Most of my patients experience about 2 hours of real discomfort after the procedure and are minimally sore in the following days.  I do require that they wear a special liposuction garment for about 3 weeks that greatly assists in postoperative swelling and skin retraction.

The above patient is an excellent example of a woman that is of normal weight but has experienced accumulations of fat on her abdomen, hips and upper thighs.   The contour of her hips and thighs were greatly improved and her  abdominal definition and shapely waist were redefined.  Her general appearance in and out of clothing was very pleasing to her.

For the past 11 years, liposuction has always been the top surgical procedure.  This year breast augmention has taken over with liposuction as 2nd, eyelid surgery 3rd, rhinoplasty 4th and abdominoplasty 5th.  Botox continues to lead the nonsurgical procedures as most popular with  laser hair removal and hyaluronic Acid dermal fillers in popularity.

The top 2 procedures for women were breast augmentation and liposuction.  The top 2 procedures for men were liposuction and rhinoplasty, with eyelid surgery following the top two for both sexes.    At my Marin County cosmetic surgery practice, I would probably designate vaser liposuction and eyelid surgery as my top 2 requested  procedures.  Often, different areas are addressed at the same  time surgically,  particularly with mommy makeover  (breast and tummy)  and facial surgery.  Of  interest this year is the increased usage of dermal fillers and Botox for patients interested in correcting minor facial issues with little downtime.

Her friend was correct in questioning the procedure. After examining this delightful lady, it was clear that she had many of the typical aging changes associated with being in her 60′s with no prior corrective procedures. Her neck had lost definition and had sagging skin. Her jowls, midface and facial muscles were lax. What she really needed was a complete facelift that would resuspend and redefine her neck. Her facial muscles needed to be lifted and skin needed to be removed from in front of the ear and behind to lift the face and neck homogenously. To have kept this lady comfortable, general anesthesia would have been necessary for a 3 to 4 hour procedure, not 1 hour. A minifacelift would only have lifted the skin in front of the ear and would not have addressed her concerns adequately. Her neck would have remained the same and her muscles would not have been lifted. She would have seen very little improvement based on her initial facial issues.

When digging a little further, she had seen before and after photos but wasn’t sure they were the results of the doctor that had consulted with her, or even if he would be performing the surgery. She was pressured that she needed to sign up today for this great deal. Her free consultation turned into a $400 visit by the end of the appointment.

My opinion is this: here in the San Francisco Bay Area, we are lucky to have many plastic surgeons certified by the American Board of Plastic Surgery and that are members in good standing of the American Society of Plastic Surgeons . Additionally, many of those are members of the American Society of Aesthetic Plastic Surgery, a society that recognizes experience and proficiency in aesthetic cosmetic surgery. Both of these organizations represent the gold standard for plastic and cosmetic surgery training. In California, any doctor can represent themselves as a cosmetic surgeon if he or she is board certified in something, anything. Think about a OB/GYN, ER doctor or radiologist taking a weekend course and viola, a procedure is learned. Experience, training and education matter. Research your doctor, do not be pressured, go in for as many consults as you need and don’t fall in love with the salesperson at the office that promises great things. The surgeon is the one doing the surgery and should answer all of your questions until a complete understanding is achieved. Photos that are presented should be of patients your doctor has performed the surgery on, not of someone else’s work . Make sure the surgeon is doing your followup and will be accessible for hand holding after a procedure. A patient should know how often followup will be scheduled and that a drop in appointment is available for concerns, any concerns.

The patient I just discussed went on the further research the clinic that had seemed so promising and realized she would not have been happy with the procedure. She is now making a plan to have a facelift procedure that will actually correct her concerns when she is ready to schedule.

Let me give you an example,  the patient below needed a facelift and eyelid lift.  Her neck had lost definition, her jowl lines were softened and her midface was sagging.  To have merely injected dermal fillers and Botox into her face would have created relaxed muscles in the areas that were already relaxed and a puffiness to her face that did not match her distinctive look.  She was better served by performing a facelift and an eyelid lift, followed by strategically utilizing  injectable dermal fillers, Radiesse and Restylane, to correct the nasolabial lines.  Her facial muscles were tightened, her midface was lifted with her eyelid lift, her neckline redefined and the extra skin from her face and eyelids were removed.  No Botox was used on this patient.

The next patient was an excellent candidate for Botox and injectable dermal fillers, but again, they were used as an adjunct to cosmetic surgery.  Before surgery, this patient had lower lid puffiness and upper lid drooping that was correctable only by an eye lift.  She had midface laxity and her nasolabial lines were prominent,  as were the lines between her brows.  Botox was  utilized to weaken her brow lines and the the lines in her crow’s feet areas, and to slightly lift her brows.   Restylane was used to correct her nasolabial lines.  However, the greatest correction was seen following her upper and lower eyelid lift.  At that time, extra skin and muscle were removed, the malar fat pads (over the cheekbones) were repositioned and the midface was lifted.

There are certainly times when the physical anatomy of the face or financial choices make the usage of Botox and injectable dermal fillers, without cosmetic surgery, a wonderful choice.  My concern is that patients need to be informed of all methods, tried and true, that may be of benefit  for the cosmetic concerns that they are trying to solve.  Dermal fillers and Botox are great temporary solutions, but when used in great quantities to avoid a surgical solution, their costs can be equally as daunting.

My recommendation:  By all means utilize these valuable nonsurgical solutions, however, an informed plastic surgeon can assist you in providing a reality based plan for your short-term and long-term goals.  At my Marin County plastic surgery practice, I evaluate every patient’s individual needs so that you understand all of your options prior to treatment.

Since this is a prescription treatment, a quick appointment and discussion about  the application of Latisse will be necessary.  My office staff will be using Latisse and documenting their progress monthly.  Stop by and get your supply.  We’ll photograph you at 2 month intervals to document your progress too! 

These photos are unretouched patients prior to starting treatment with Latisse and then again at 16 weeks.  Pretty impressive!  Call our Marin County office  (415-461-6742)  in the San Francisco Bay Area soon to get started.

Welcome to my inaugural blog!  For so many years I have had the privilege of treating wonderful patients from all over the San Francisco Bay Area and beyond.  My challenge has always been keeping up with new and old faces (sorry for the pun!) and making  my patients aware of the latest in interesting cosmetic surgery procedures as well as what is happening in our practice.  I will share with you innovative research and techniques in the plastic surgery community and my opinions regarding their value.  I can most often be found with a medical journal in the evenings and have seen in my years of practice, many variations on almost every procedure.  Some are time tested and true.  Some are hype.  I will share my honest opinions and experiences. 

My Marin County plastic surgery practice provides face, breast and body recontouring procedures as well as non-invasive procedures such as Botox, injectable fillers and Latisse.  Thanks for checking out my blog, more soon!