Marie E. Montag, MD

Losing weight is a major goal for people, especially around this time of year. Who hasn’t made a new year’s resolution to get back to the gym or to shed a few pounds? If you are successful, that is fabulous! But, unfortunately sometimes the weight comes off of areas you didn’t want to get smaller…specifically, the breasts! The breast is made up of a combination of fatty tissue and glandular tissue and with weight loss the fatty component shrinks making the skin loose. Depending on the elasticity of your skin and the amount of shrinkage of tissue that happens, a simple implant may reverse the damage. But, if the skin is loose and the nipple is in too low of a position, then a lift may be necessary. It does not work to just put a larger implant in when the skin is lax…the heavier implant will make the breast sag even worse! Every situation is a little different, but as a rule of thumb, if the nipple is at or above the fold or the breast an implant may be all you need. If the nipple is below the fold or the distance from the nipple to the fold of the breast is greater than 5cm, then it is much more likely you need a lift. The best advice is to be evaluated by a board certified plastic surgeon who is experienced in breast augmentation and lifts, who can guide you to the right treatment to meet your aesthetic goals.  

When contemplating multiple surgeries at the same time, the length of the anesthetics is felt to be a rate limiting factor for safety. Generally it is understood that if an anesthetic is longer than 5 hours that the complication rates escalate. Wound infections are more common, blood clots are more likely to form, and respiratory, fluid and electrolyte issues become a problem. At that point the benefits of the surgery are outweighed by the potential risks. In order to make the surgery safer, we need to find ways to cut back the length of time spent in surgery. This can be done by limiting the number of things done with your procedure, speeding up the time each portion takes, or doing different parts of the surgery simultaneously (at the same time). Most plastic surgeons would agree that addressing two major areas (such as the tummy tuck for the abdomen and augmentation, lift, or both for breasts) and one minor issue (like liposuction to hips, thighs and/or back) at the same time can be done safely and in a reasonable time frame. It will be up to your surgeon to tell you what he/she can reasonably do in 5 hours. This may partly depend on how complex your particular case is, but also has to do with how efficiently the operating room runs and the speed of the surgeon. At our facility, we have trained our scrub technicians to sew (up to our standards) and that cuts away a lot of time from the overall length of the case. Out practice also has multiple board-certified plastic surgeons, and in these types of cases we work together on the same patient so we can do that tummy and breasts at the same time. Typically a mommy makeover with tummy tuck, breast augmentation and lift and liposuction takes us about 3 to 3.5 hours. That is well within the safe window for anesthetic length. This ability to work simultaneously is not available in all practices or cities. Be sure to ask your plastic surgeon what he/she is able to do to control the added risk associated with extended anesthetic for combination procedures. The goal is always to keep you, the patient, as safe as possible, but also let you enjoy the benefits these surgeries can provide.

You hear amazing stories everyday about how normal people achieve fantastic success with weight loss through hard work and determination. The side of the story that you don’t hear about often is what happens long-term to those people. Obviously a good percentage of them maintain their healthy lifestyle and their body shape transformation and live happily ever after, but this is the real world…it’s easy to slide back into old, unhealthy habits, especially when life’s stresses get ahead of  you. Bad relationships, injuries or health issues are only a few of the things that can really upset your routine. For those who do eventually regain the weight, their bodies go through the same unfortunate changes they did the first time, and the amount of relapse depends on the amount of weight regained. Skin that was previously overstretched does not ever get back its elasticity and will only stretch thinner and have worse tone. Also, muscles that were sewn back together from a tummy tuck can separate again. If the weight is then lost again the sagging will come back (especially from the weight gain involved with a pregnancy and all of the stretching pressure that puts on the tummy). The good news is that we can go back and remove skin and tighten muscles again to get you back to a better figure. The best situation would be to avoid wide weight swings and yo-yo dieting, but at least there are procedures we can do to tailor your shape when you get back to a weight you are happy with.

Everyone today wants to combine as many surgeries together as they can to achieve their aesthetic goals, save money and have only one recovery. We as surgeons are happy to combine procedures as long as it can be done safely and if doing one part of the surgery does not worsen the results of another part. One combination that causes problems when trying to do almost anything with it would be the Brazilian butt lift. The main reason is that for the Brazilian butt lift you have to avoid pressure on the areas we transfer fat into. Patients are instructed to sleep on their abdomen and not on their back or sides. The pressure of your own weight on the fat can cause it not to take (to grow in) or to die. If the transferred fat cells die, you do not get your enhancement. Procedures like breast augmentations and tummy tucks require you to sleep on your back to avoid pressure on the implants and the tummy stitches. If you would sleep on your tummy after these procedures you could push the implants out of position or pop stitches and result in healing problems or bad scars. It would be a waste of time and money to do these together and risk ruining your final result. When considering a Brazilian butt lift and mommy makeover, I would recommend starting with the Brazilian butt lift (so we can use all of the fat on your tummy) to enhance your back side, and then when we go ahead later with the tummy tuck or the mommy makeover where we can remove the extra skin. Timing is everything when designing the schedule for your surgeries. I would recommend starting with a visit to a board-certified plastic surgeon so you can start planning the safest and most efficient way to reach your body contouring goals!

When contemplating multiple surgeries at the same time, the length of the anesthetics is felt to be a rate limiting factor for safety. Generally it is understood that if an anesthetic is longer than 5 hours that the complication rates escalate. Wound infections are more common, blood clots are more likely to form, and respiratory, fluid and electrolyte issues become a problem. At that point the benefits of the surgery are outweighed by the potential risks. In order to make the surgery safer, we need to find ways to cut back the length of time spent in surgery. This can be done by limiting the number of things done with your procedure, speeding up the time each portion takes, or doing different parts of the surgery simultaneously (at the same time). Most plastic surgeons would agree that addressing two major areas (such as the tummy tuck for the abdomen and augmentation, lift, or both for breasts) and one minor issue (like liposuction to hips, thighs and/or back) at the same time can be done safely and in a reasonable time frame. It will be up to your surgeon to tell you what he/she can reasonably do in 5 hours. This may partly depend on how complex your particular case is, but also has to do with how efficiently the operating room runs and the speed of the surgeon. At our facility, we have trained our scrub technicians to sew (up to our standards) and that cuts away a lot of time from the overall length of the case. Out practice also has multiple board-certified plastic surgeons, and in these types of cases we work together on the same patient so we can do that tummy and breasts at the same time. Typically a mommy makeover with tummy tuck, breast augmentation and lift and liposuction takes us about 3 to 3.5 hours. That is well within the safe window for anesthetic length. This ability to work simultaneously is not available in all practices or cities. Be sure to ask your plastic surgeon what he/she is able to do to control the added risk associated with extended anesthetic for combination procedures. The goal is always to keep you, the patient, as safe as possible, but also let you enjoy the benefits these surgeries can provide.

Injection of the lips with filling materials to enhance fullness and refine shape is a very popular minimally invasive cosmetic procedure.  It is typically performed in the office with either no anesthetic, or just topical or local anesthetic to decrease the pain with injection.  After injections it is typical to experience swelling that is noticeable for between 3-5 days, and a little puffiness that may take as long as 2 weeks to completely resolve.  After that the appearance stays stable until the product begins to be metabolized by the body.  Depending on the type of filler utilized this is usually 4 months to as long as a year after injection.  If the changes achieved by the injections are what you are looking for, then reinjection periodically when it is wearing off can maintain this appearance long-term.

                Usually after injection the treated areas are a bit numb for a few days (depending on swelling and the type of product injected).  Some products contain lidocaine in them that keeps things numb to reduce pain for the first couple of days.  That anesthetic should be completely worn off by 2-3 after injection.  If numbness or an irregular feeling persists more than 2 weeks it would be a good idea to go back into your provider’s office to be re-evaluated.  Long term loss of sensation or tingling would be a very unlikely consequence of filler injections.

                Lip enhancement has been a desired cosmetic intervention for many years, but it has become much safer and less expensive since the introduction of injectable fillers.  When planning injections please take into consideration the credentials of your provider.  A Board Certified Plastic Surgeon will be the most Qualified to provide you with a thorough evaluation and appropriate treatment recommendation to get you the results that you desire!

Having multiple surgeries done at one time is a very convenient and cost effective way to get all of your body contouring goals achieved after major weight loss, but realize there are important issues to consider when planning your strategy. The length of time of the surgery crucial.  If the combination of surgeries you plan would take longer than 5 hours, the health risks and anesthetic risk exponentially increase. If the procedures are done one at a time, it limits the number of areas that can be addressed. That is what happens if one surgeon does all of the work alone. Then you have to worry about fatigue of the surgeon and diminished quality of the work toward the end of the case. At our facility we are able to utilize two or more board-certified plastic surgeons in a case of that magnitude to double the productivity and cut in half the time of surgery. The surgeon whose patient is having the surgery is in charge and directs the flow of action.  That way there are more skilled hands working together to accomplish your goals safely without the issue of fatigue interfering with quality. In this fashion it would be possible to undergo a combination such as breast lift, brachioplasty, and a full tummy tuck with a little liposuction in less than 5 hours! Still, there has to be a limit of how many areas are addressed at one time.  We usually limit ourselves to 2 or 3 major procedures possibly with some liposuction per session. Depending on the number of areas in need, and the magnitude of the procedures, it may be more prudent to break them up into a couple of sessions to accomplish everything safely.  If you are interested in going ahead with your body re-contouring the first step is to find a board-certified plastic surgeon and have a conversation about your long-term goals.  Together you can make a plan that will get you there safely. 

When recovering from breast augmentation, one of the most asked questions is ‘when can I wear an underwire or push-up bra?’ Patients are always anxious to try on clothing that accentuates their new form! Unfortunately, if you do so too soon it can slow down or even derail the healing process. One concern is if you wear an upward pushing bra, that the implant may heal in that high position and create an abnormally accentuated upper cleavage…this may look good in some outfits, but is not very natural looking and may look out of place in other situations. Also, underwire bras put pressure on the skin along the fold of the breast, often where the incision is. Usually this area is numb for a few months after surgery, and if the wire rubs it too much you may not feel it before it can cause damage. I have had patients actually develop an ulcer or hole in the skin from wearing too tight of an underwire bra. This can cause worse scarring or even exposure if the implant (necessitating implant removal). I recommend to my patients not to wear an underwire bra for at least 3 months after surgery. Usually by then the sensation has begun to normalize and you can feel if the wire rubs on the incision or if it is too tight. I also suggest checking after a couple of hours with a new bra to make sure it is not causing redness or irritation, and be ready with a spare bra to change into if you find this problem. The last thing you want to do is spoil the results you have worked so hard to achieve!

When first considering breast augmentation surgery, few patients stop to think about the long-term effects of the surgery and the future maintenance that may be required to keep the ‘look’ they are trying to achieve. Many patients have their surgery in their young adult years before the damages of gravity and pregnancy take their toll. Usually, at that point an implant alone can give a beautiful result. As they continue to age and go through further life experiences (like weight gain and loss, or engorgement with pregnancy and breast feeding) the skin tone and proportion of the breast can change. Typically the skin stretches and the tissue atrophies and droops leaving a saggy, deflated breast. The implant volume will still be the same, but the tissue itself suffers, and the only way to get back to a perky appearance is to have a breast lift. A lift takes away the extra skin and reshapes the tissue to get rid of the drooping. If this happens 10 years or later after the initial augmentation, most plastic surgeons would recommend exchanging the implant since the average implant lifespan is between 10-15 years. If you require a lift earlier than that it makes perfect sense to leave the implant alone and just reshape the tissue envelope. One exception would be if you desire to change size or type of implant, then the two can easily be combined saving you an extra trip to the operating room.

Most patients who have their augmentation early can realistically expect to have 3 or 4 surgeries over the years, but there is no requirement that you have to exchange them at a certain time. Occasionally, implants will last much longer than the average. If that is the case there is no need to preventatively change them out. Also, realize that having an implant in that has ruptured is not going to make you sick. With saline you will see a size difference. With silicone you typically see a gradual buildup of scar tissue that can change the shape or feel of the breast, but it will not physically make you ill. If you have had implants in the past and they are getting older it is a good idea to visit with your plastic surgeon for a checkup so you can come up with a long-term plan.

A neck lift surgery is basically the same as a facelift when the majority of the changes involve tightening of the skin and tissue of the lower 1/3 of the face (jowls/jawline) and the neck. There are different degrees of lifting that may be necessary.

A mini lift involves a little liposuction under the chin and tightening of skin in front of and around the ear. The mini lift has a short and rather easy recovery. With a mini you will see a little bruising and swelling that typically fades and subsides in a week to 10 days (although full healing still occurs for 4-6 weeks). Most people are off pain medicine in a couple of days and feel socially acceptable at about a week, but need to stay away from vigorous exercise for at least 3 weeks.

A full facelift involves liposuction under the chin, sometimes adjustment of the muscles in the neck under the chin, removal of skin in front of the ear and around the ear, and also tightening of the deeper fibrous layer of the facial tissues called the SMAS facia (Superficial Musculo Aponeurotic System). This is a stronger layer of tissue attached to the muscles of the cheek and neck. Tightening this gives significantly more lift to the cheek, jawline and neck area and is essential in rejuvenating a more aged face.

This more involved facelift is a larger and more invasive procedure and therefore requires a longer healing time. Patients usually require pain medicine for 3-5 days to alleviate discomfort. The swelling and bruising are more intense and typically require 10-14 days to start to resolve. Most people feel well enough to go back to work at about 2 weeks, but would be fine to work from home (if that’s possible) after the first week. Vigorous exercise needs to be avoided for about a month, but you can walk and do lighter activities after the first week. Usually, it takes 6-8 weeks to feel fully healed.

Finally, sometimes a facelift can be combined with other facial rejuvenative procedures such as blepharoplasty (eyelid lift) and/or brow lift. These procedures do not add a lot of time to the healing process of a facelift, but can make the initial recovery a little more uncomfortable. The added pain, however is definitely worth the benefit of only having to go through one procedure to accomplish all of your aesthetic goals. Imagine only one surgery, one anesthetic and one recovery to achieve a refreshed, more youthful you!