Plastic Surgeon with Knife

The eminent Beverly Hills board-certified plastic surgeon Stuart Linder, M.D – the “Dr. Body” blogger—mentions a few cosmetic plastic surgery procedures worth skipping. Also weighing in with “don’t bother” procedures for face and skin is the equally well known Robert Kotler, M.D., a top Beverly Hills board-certified cosmetic plastic surgeon and former Dr. 90210 star. Dr. Kotler’s  Nome de plume in the blogosphere is “Dr. Face”.

Drs. Face and Body jointly belong to many medical organizations, including:

• · The American Academy of Facial Plastic Surgery and Reconstructive Surgery.
• · American Board of Plastic Surgery
• · The American Medical Association

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Dr. Body: (Dr. Linder): Do patients ever ask for cosmetic plastic surgery procedures that really aren’t in their own best interests?

Dr. Face: (Dr. Kotler) Do they ever! So many new operations and techniques are written up by eager, breathless marketers that some unquestioning patients are excited and willing to have the procedure.

Dr. Body: Such as?

Dr. Face: So-called “facelifts” done by threads or sutures. The threat fad hit the medical marketplace around 2006. The concept was that a barbed thread inserted in facial skin would lift and hold sagging tissues. Purportedly, with tiny incisions, less bruising and a shorter recovery period.

Dr. Body: Were patients happy with it?

Dr. Face: No. Many patients found the threads would not support the weight of the facial tissues. In many other cases, the threads popped through the skin. Other patients noticed waves in their skin. Eventually, one major company took their threads off the market.

Dr. Body: Many of my patients have read about laser liposuction and asked about it – if not for it. I explain that laser liposuction has not been shown to improve results done by tumescent liposuction which the professional plastic surgery associations consider the “golden standard.” Tumescent liposuction has a long track record of safety, produces good results and is easily tolerated by patients.

Dr. Face: I can think of another reason to avoid laser liposuction. The new machines are very expensive, easily running into six figures. That only drives up the cost of plastic surgery, sometimes as much as several thousand dollars.

Dr. Body: What other Johnny-come-latelys have you seen, doctor?

Dr. Face: For a while, there was a huge craze in so-called “lunch time”, “one hour” or “quick” facelifts. But time and experience have shown the benefits minimize after only several months. Plus, the incision marks often show. Basically, like in any human endeavor, minimal efforts will result in minimal results.

Dr. Body: I have another situation something like that in breast surgery. Somehow, the TUBA, or transumbilical breast augmentation became popular. A TUBA inserts saline breast implants into and under the breast via a tiny incision in the belly button. But the surgeon works with such long tools and so far away from the breasts, the implants are often badly placed. That results in a not-so-great appearance for the patient. Not a week goes by without seeing a patient who wants a correction surgery for her TUBA.

Dr. Face: And we work through the naval because…?

Dr. Body: Because the scar is hidden in the creases of the naval. However, working through the areola, the brown area surrounding the nipple, the surgical scar is not that noticeable and does lighten and fade in about  a year. Standing directly over the breasts gives the surgeon precise control over implant placement and controlling the symmetry of the two breasts along with the amount of cleavage, if any.

Dr.  Face: Many patients ask for a neck lift or want only neck liposuction. But that’s a mistake without removing deeper fat and tightening the platysma, the major neck muscle that results in a “turkey gobbler” neck with normal aging. Skip tightening that muscle and the vertical neck bands may look more obvious than before. The skin is not the problem; it’s the underlying excess baggage.

Dr. Body: I can think of another patient request that is not in their best interests. And that’s buttocks augmentation. In my opinion, both methods – a buttocks implant if the patient is thin or a fat transfer to the buttocks – are doomed because people spend so much time sitting. All that puts immense, killing pressure on the new fat cells injected into the patient’s rear or creates other problems for the implant.

Dr. Face: Speaking of skin, I’ve noticed that the non-invasive surface skin treatments, Thermage and Titan, purport to tighten sagging skin usually but usually result in disappointed patients who are also unhappy with the high cost of the procedures. For instance, I notice on realself.com that of 179 reviews of Thermage or Titan neck lifts, only 40 percent of patients said it was worth it.

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Look at Dr. Body’s before and after breast augmentation revision pictures

See Dr. Face’s before and after nose surgery revisions pictures.

Researching surgeons

In real life, our blogger Dr. Face is the eminent Beverly Hills board-certified facial plastic surgeon Robert Kotler, M.D.  Joining the discussion is an equally eminent Beverly Hills board-certified plastic surgeon, Stuart Linder, M.D. (who blogs as Dr. Body.) Both are constant consumers of professional cosmetic plastic surgery publications and help patients – along with other American plastic surgeons  – understand the importance of new scientific findings about the rejuvenation arts.

Doctors Face and Body frequently boil down the articles for News & Views, a capsulated review of the latest and greatest from the professional press.

Here is their second such offering.

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Dr. Face: (Dr. Kotler) Have you read any interesting articles about plastic surgery work on the body, doctor?

Dr. Body: (Dr. Linder) Odd you should ask. I spotted a survey, asking 500 board certified American plastic surgeons about their current breast augmentation practices.

Dr. Face:  Do you mean practices like location of the incision, type of implant, length of the operation and so on?

Dr. Body: Exactly. Because I place hundreds and hundreds of saline and silicone breast implants yearly, I was very curious how other surgeons approach and do their work.

Dr. Face: Did you find any surprises?

Dr. Body: A few. For instance, I noticed that only 32 percent of board-certified surgeons can perform an operation in under an hour. Actually, a well trained, board-certified plastic surgeon should take no more than 30 to 40 minutes to complete the procedure. And that’s with minimal blood loss and operating with a board-certified anesthesiologist.

Dr. Face: Did all the respondents use a board-certified anesthesiologist?

Dr. Body: Actually, one-third of the survey group reported using registered nurse anesthetists. That may keep costs down somewhat but to insure patient safety, a plastic surgeon should use a board-certified anesthesiologist – who is another M.D. He or she knows precisely what to do in any emergency.

Dr. Face: A good point, doctor. In point of fact, the development of the nurse anesthetist position was in the military where it was designed to be under the direct supervision of an anesthesiologist. The concept was one M.D.-anesthesiologist could supervise a handful of nurse anesthetists during operations.

Dr. Body: I also note that 81 percent of the survey group report using 300 to 400 cc breast implants. That’s about what I use in my practice. And, also like in my breast augmentation practice, I note that while silicone is available, the surgeons report more patients choosing saline breast implants.

Dr. Face: There are four possible incisions a plastic surgeon can use in breast augmentation. Did the survey show any preference for any particular one?

Dr. Body: About 66 percent of the surgeons report starting a breast enhancement with an incision in the inframammary location, the place where the bottom of the breast meets the chest wall. About 25 percent say they use a periareolar, or around the nipple, approach. I was surprised the figures were not reversed.

Dr. Face: Why the surprise?

Dr. Body: The inframammary was the standard approach to breast enhancement during the 1970s and 80s and is considered outdated for extremely busy surgeons who perform large volume of breast enlargements. Also, the majority of the responders were from the American South and East. If more California plastic surgeons had returned the survey, I think readers would have seen more up to date responses. In my opinion, the periareolar approach allows the surgeon to work right over the breast. So, looking down,  it is much easier to line everything up for natural looking results.

Dr. Face: I’ve read that starting a breast augmentation through the areola results only in temporary nipple numbness for a few patients.

Dr. Body: That’s true. But the medical literature of breast augmentation shows that the most common long-term complications are bleeding and then infections.

Dr. Face: Where could we find the study?

Dr. Body: In the March-April, 2009, Aesthetic Surgery Journal; it’s a magazine written and read by, plastic surgeons. The title is: Primary Breast Augmentation Today: A Survey of Current Breast Augmentation Practice Patterns.