Doctor Q&A

A “normal“ sternal notch to nipple distance is 18 to 22 cm. If your sternal notch to nipple distance is 15 cm, it means that your breasts sit higher up on your chest. This impacts the choice of your breast implant size because as implants get larger, they also get wider/taller and the top of larger implants will appear to be closer and closer to your clavicle if the implant is positioned correctly behind your nipple. You should have a detailed discussion about what implants would fit bes...

Hello,
Thank you for the question. It is almost impossible to tell without in-person examination. My advice is to visit with many surgeons and go with the recommendations of the one you trust the most. Using sizers in the OR would be a good option for you as your skin has stretched.
I wish you the best.
Vasileios Vasilakis, MD, FACSDouble Board Certified Plastic SurgeonHouston, TX.

The most likely reason the implants have dropped in position is the placement in the subglandular position. When implants are put on top of the muscle and fascia, the weight of the implant is supported only by the breast tissue and skin. 285cc is not a “large” implant, but it seems that it was more weight than your breast tissue is able to support on its own. With the stretching of the tissue, the implants gradually drop in position. The space between the implants could be due to the sam...

There are a few things that could potentially be done to address the rippling. Fat transfer is an option, but as you suggested, that requires that fat be harvested from somewhere else on the body. If you don't have enough fat to be used for fat transfer, another option is Alloclae, which is an injectable form of sterilized fat taken from a donor. Alloclae can be a bit pricey, depending on how much fat is needed. From a technique perspective, the fat needs to be injected into the breast...

You will likely have to consider a breast lift with an implant to lift your nipple areolar complex into a more natural higher position and reshape the breast . An implant will help provide you with a rounder shape and more cleavage.
You may also consider a breast lift by itself, which would help you achieve a natural look, but would not have the augmented cleavage appearance.
If the weight of your breast bothers you, then you may want to mention this to your surgeon. You may consider a...

Wanting a flat abdomen and defined waist without compromising your performance is completely reasonable.

In my opinion, a tummy tuck with muscle repair does not permanently reduce core strength. The repair restores muscles separated by pregnancy; it doesn’t weaken them long term. For high-demand activities like aerial silks, the limitation is temporary during healing and retraining.

A tummy tuck without muscle repair may allow earlier flexibility, but often won’t achieve the flatness or ...

While it may be possible to perform everything in one setting, the recovery would be extremely difficult. Getting up and moving around with abdomen, breasts, arms and legs would be difficult. Unfortunately, after massive weight loss, stages are commonly planned.


Rather for safety, recovery, we recommend staging these procedures.

Many combinations are possible. Generally, tummy tuck with or without breasts is one option. Also, breasts with arms as one stage, tummy tuck with or without...

While it may be possible to perform everything in one setting, the recovery would be extremely difficult. Getting up and moving around with abdomen, breasts, arms and legs would be difficult. Unfortunately, after massive weight loss, stages are commonly planned.


Rather for safety, recovery, we recommend staging these procedures.

Many combinations are possible. Generally, tummy tuck with or without breasts is one option. Also, breasts with arms as one stage, tummy tuck with or without...

As you understand now, seroma can be very challenging to take care of. The longer the seroma lasts, the more difficult it becomes to treat it. Since your plastic surgeon understands your surgery and seroma best, perhaps you can get a recommendation from them even if they are away, or perhaps from the office manager. They may be able to steer you in the best direction.

An abdominoplasty should not affect your clitoris. I would see your ob-gyn doctor and have this evaluated. Sometimes surgery can be done to reduce the size of the clitoral hood.

Hello and thank you for your questionWe have performed over 200 body affirming body contouring procedures on trans patients. Upon reviewing your photos, I can tell you that you are a good candidate for liposuction and fat transfer to the hips and buttock as well as a breast augmentation performed in the sub pectoral plane. I hope this has been helpful.

Dear Antpig44,

you should be healthy prior to any elective procedures and your blood work should be within the normal limits. If you are considering surgery, I would suggest you consult a board-certified plastic surgeon. Only after a thorough examination, you will get more information and recommendations.

Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Dear bmulvy8,

it is hard to tell for sure without an examination. If you are considering surgery, I would suggest you consult a board-certified plastic surgeon. Only after a thorough examination, you will get more information and recommendations.

Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Dear 8lien,

generally speaking, you want to reach your goal weight before you consider surgery, otherwise your results will be suboptimal if you continue to gain weight after the surgery. If you are considering surgery, I would suggest you consult a board-certified plastic surgeon. Only after a thorough examination, you will get more information and recommendations.

Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American...

Dear Adventurous809037,

it is hard to tell for sure without an examination. If you are considering surgery, I would suggest you consult a board-certified plastic surgeon. Only after a thorough examination, you will get more information and recommendations.

Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Hello and thank you for your question. Additional photographs and evaluation would be helpful to determine if having a revision would be beneficial for your nostril asymmetry. There are many maneuvers that could help correct this. I recommend that you seek consultation with a qualified board-certified rhinoplasty surgeon who can evaluate you in person.

Best wishes and good luck.

Richard G. Reish, M.D.
Harvard-trained plastic surgeon

Straightening the frontal view of a nose is often not very predictable. However, when we have the opportunity to change the overall size or shape of the nose, that helps a lot in working on asymmetries. For example, (caveat: my assessment is based on these few small photos, but here goes anyway) if you love your nose exactly as it is, and just want it symmetric from the front, I'd probably advise against trying, because the attempt is more likely to change one asymmetry for another, or make...

A rhinoplasty only uncommonly would change the length of the philtrum, and the surgeon should be able to tell you, based on your photos, whether you have the kind of nose where that might happen. But it's rare-ish. If, however, your tip is so droopy that it covers part of your philtrum, and if the surgery is successful at elevating your tip, then you may be able to *see* more of the philtrum after surgery, even if the length of the philtrum didn't change. Get it? I think it'd be really rare...

Hello and thank you for your question. Based on your photographs, the best way to fix this is with a surgical revision. Support with cartilage grafts needs to be established and noninvasive ways such as thread lift or Botox would never work for this. With good surgical technique, you could have an outstanding result. I recommend that you seek consultation with a qualified board-certified rhinoplasty surgeon who can evaluate you in person.

Best wishes and good luck.

Richard G. Reish, M.D...

As rhinoplasty surgeons, we have long used the cut off of 6 mm as a minimum amount of cartilage to leave to avoid causing issues with external valve collapse and breathing related issues or long-term issues with tip contour. However, many surgeons would now agree that trying to preserve the cartilage structures of the nose is advantageous when it can be done by using a variety of techniques such as suture methods to reshape the cartilages of the nose, or special means of treating the lower...

A March surgery date can absolutely be realistic, but it depends on a few key factors. If you have your consultation in December or January, and there are no medical issues, March is typically achievable depending on the surgeon’s availability, financing approval, and completion of pre-operative requirements.
As far as recovery and time off work, this varies by procedure and the physical demands of your job. For mommy makeovers that include a tummy tuck, I generally recommend 2 weeks off f...

If your primary concern is loose, sagging abdominal skin, the most definitive solution is a tummy tuck. A tummy tuck physically removes excess skin and tightens the abdominal wall, which is why it is the best option for the “lumpy” appearance you notice when bending over. Stretch marks alone don’t drive this decision; it’s the skin laxity, and that cannot be corrected with non-surgical treatments.
From a contour standpoint, I would typically recommend a tummy tuck with lipo 360 and BBL, co...

Based on your history, goals, and current anatomy, you have both surgical and non-surgical options, but it’s important to be upfront about what will and will not realistically achieve the changes you’re looking for.
You’ve had under-the-muscle silicone implants for 15 years, three pregnancies, and breastfeeding, which commonly leads to skin laxity and loss of upper-pole fullness, even when implant volume is still acceptable. Non-surgical treatments cannot tighten breast skin or restore upper...

I routinely combine breast surgery with a tummy tuck and liposuction, including 360 liposuction, in healthy patients. That combination is generally safe when planned carefully and allows for one recovery period.
I do not recommend combining a tummy tuck with a thigh lift in the same surgery. The incisions for a tummy tuck and a thigh lift sit very close to one another in the groin and hip crease. Performing both at once increases tension on the skin, reduces blood supply to the area, and...

Congratulations on your weight loss. Losing over 100 pounds is a major accomplishment, and what you’re experiencing with excess skin is very common after that kind of transformation.
For the midsection, based on your photos, most patients in this situation benefit more from a belt lipectomy (also called a 360 tummy tuck) rather than a standard tummy tuck alone. A traditional tummy tuck primarily addresses loose skin and muscle laxity in the front of the abdomen. After massive weight loss, e...

Yes, it is absolutely possible in many cases to keep your current implants and still perform a breast reduction — but it must be done with the right technique and for the right reason.This situation is actually a classic indication for a Push-Up Lift–style reduction.How breasts get “too big” with implantsOver time, breasts can enlarge due to:Weight changesHormonal factorsPregnancySkin and tissue stretchIn these cases, the excess volume is usually your own breast tissue, not the impla...

Being told that a free nipple graft (FNG) is “required” to go from a G cup to a D cup is common — but it is not always true, even for large reductions.With modern tissue-preserving reduction techniques, it is often possible to achieve:Significant size reductionGood upper-pole fullnessNipple sensation preservationViable nipple–areola complex— without a free nipple graft.Why surgeons recommend free nipple graftsFNG is usually suggested when surgeons are concerned about:Nipple blood...

Surgeons have the ability to remove armpit fat during the same case, but that portion of the surgery likely would not be covered by insurance. The insurance company will say that they are covering a breast reduction surgery that is being performed with the intent of improving symptoms of macromastia (e.g. shoulder pain, shoulder grooving, neck pain, upper back pain, headaches, rashes underneath or between the breasts). Fat that is in the armpit area is not contributing to those symptoms, so...

Yes, a breast reduction could help create better symmetry and also improve any symptoms you may have from your large breasts, like back pain. Talk to your surgeon about your goals and he/she should be able to help you achieve a very nice outcome. Best of luck!

Unfortunately, breastfeeding is not possible after a free nipple graft. During a free nipple graft, the nipple-areola complex is completely detached from the breast and then reapplied in its new position, similar to a skin graft. This process transects the milk ducts, which subsequently scar and do not reconnect. As a result, patients are unable to breastfeed following this procedure.
If preserving the ability to breastfeed is important to you, it may be worth seeking additional...

Thank you for your question and photos. Based on these photos, your best results in reshaping your breasts will be with a dual plane submuscular breast augmentation using a smooth round silicone gel implants with a vertical or short scar breast lift. Without a lift you will end up with a "rock in the sock" deformity. You have sagging or ptotic breast tissue inferiorly which an augmentation alone will not correct. I use the Vectra 3D in my office to simulate the surgery and give you a visual...

Yes — you can have a natural-looking result with implants alone, and in your situation the best way to do that is with a Preservé (tissue-preserving) augmentation approach.A Preservé augmentation focuses on:Preserving your natural breast tissue, ligaments, and footprintAvoiding unnecessary skin or nipple surgeryCorrecting asymmetry through precise pocket control, not lifting scarsWhy Preservé works well for small, asymmetrical breastsIf your breasts are small, not sagging, and ni...

Based on the findings, this is not simply small breasts — it is most consistent with an advanced (moderate–severe) tuberous breast deformity.Why this is tuberous (and more advanced)Your description includes several classic and significant signs:Large, soft, puffy areolae relative to breast sizeAreola positioned very low on the breast moundLittle to no under-breast (“underboob”) tissueMarked lack of upper-pole fullness and cleavageWide-set breasts with asymmetryBreast tissue displ...

Based on your height, weight, age, post-pregnancy changes, and current 34B with mild droop, it’s important to be very honest about expectations.Augmentation alone (dual plane with a 265–300 cc implant) can add volume, but it will not reliably correct droop or create upper-pole fullness in a natural way at 52. An implant can fill the breast, but it does not reposition breast tissue or the nipple. This is why many patients feel “bigger but still droopy” after implant-only surgery.For your go...

The older 83% vs 17% breastfeeding numbers are outdated and oversimplified. Current evidence and clinical experience show that both under-the-muscle (UTM) and over-the-muscle (OTM) implants can allow successful breastfeeding. What matters more than the implant plane is surgical technique—specifically preserving milk ducts, nerves, and blood supply, and choosing incisions that avoid ductal injury.OTM implants can theoretically increase pressure on the ducts in some patients, especially...

You have hooding of your upper eyelids laterally which will not be adequately corrected with upper blepharoplasty alone. In these cases I combine upper blepharoplasty with a lateral browlift which I routinely perform under local anesthesia with light oral sedation as an office procedure with long lasting natural results that do not change eyelid shape or raise the brow unnaturally. Doing a browlift alone will not correct the eyelid excess without elevating the brow to an unnaturally high...

Fractional laser is an amazing and highly effective treatment in our office. We use the laser treatment to help with acne scars, large pores, fine wrinkles, tissue collagen loss, scars, sebaceous hyperplasia, active acne, and for brightening dark pigmentation. Although there are very strong fractional lasers such as CO2 laser, we use lighter treatments for corrective skincare and maintenance of results. Our Thulium fractional laser, clear and brilliant laser, and Ultra Thulium laser are...

Fractional laser is an amazing and highly effective treatment in our office. We use the laser treatment to help with acne scars, large pores, fine wrinkles, tissue collagen loss, scars, sebaceous hyperplasia, active acne, and for brightening dark pigmentation. Although there are very strong fractional lasers such as CO2 laser, we use lighter treatments for corrective skincare and maintenance of results. Our Thulium fractional laser, clear and brilliant laser, and Ultra Thulium laser are...

Fractional laser is an amazing and highly effective treatment in our office. We use the laser treatment to help with acne scars, large pores, fine wrinkles, tissue collagen loss, scars, sebaceous hyperplasia, active acne, and for brightening dark pigmentation. Although there are very strong fractional lasers such as CO2 laser, we use lighter treatments for corrective skincare and maintenance of results. Our Thulium fractional laser, clear and brilliant laser, and Ultra Thulium laser are...

Fractional laser is an amazing and highly effective treatment in our office. We use the laser treatment to help with acne scars, large pores, fine wrinkles, tissue collagen loss, scars, sebaceous hyperplasia, active acne, and for brightening dark pigmentation. Although there are very strong fractional lasers such as CO2 laser, we use lighter treatments for corrective skincare and maintenance of results. Our Thulium fractional laser, clear and brilliant laser, and Ultra Thulium laser are...

I would never recommend doing a facelift and necklift in stages. The operations overlap so when you do a facelift the neck is lifted with it. You may want to consider a browlift. This would lower your forehead.

Best Wishes,

Gary Horndeski, M.D.

Thank you for your query. You may benefit from non surgical procedures. I would recommend radio-frequency based skin tightening along with autologous fat grafting. Please find an experienced board certified Plastic surgeon who can examine you and help you with all your concerns. All the best!

Hi there! I recommend a face lift to help reposition your SMAS. Different surgeons tend to have different definitions of what a "mini" face lift is, but ultimately you should be certain that your surgeon is accessing and lifting your SMAS, which is what I would consider a face lift- nothing "mini" about it!

Hi there. I do not think you would benefit greatly from a face lift, and your fat pad descent is not as pronounced as your volume loss, so even a minimally invasive option like the so called "pony tail" or endoscopic lift would not be of great benefit. However, a small volume of autologous fat grafting, Renuva, or HA filler could look very nice.

Looking at you to post photos I am not sure what you mean by vertical lines?? An appearance I might recommend the Endo laser, full face and lower eyelid treatment under local anesthesia or IV sedation local anesthesia. But I also might recommend a mini face neck lift with muscle multiplication with the Endo laser?? Best of virtual console with expect fee fees to range from $5000-$15,000 depending on what surgical options you decide to use again best of virtual consult with.

Recovery after inner knee liposuction varies by individual, but most patients can resume light walking within a few days.Bruising and swelling are common and usually improve over 1–2 weeks.
For jobs that involve moderate walking, many patients choose to take a few days to about one week off, depending on comfort level.Final contour refinement can take several weeks to months, and both recovery speed and results vary from person to person.

Chin and arm liposuction are commonly performed together in suitable candidates.For most patients, basic arm movement needed for daily activities and adjusting facial compression garments is manageable.However, recovery tolerance varies by individual, so whether to combine procedures should be decided after an in-person consultation based on overall health and the extent of treatment.

Based on the photos, the main concern appears to be excess fat rather than significant skin laxity. In cases like this, arm liposuction alone may be sufficient, and an arm lift may not be necessary. However, the final decision depends on your skin elasticity and the degree of looseness, which can only be accurately assessed during an in-person consultation.

Based on the photos, there appears to be a combination of excess fat and skin laxity, particularly in the abdomen and upper arms.In cases like this, liposuction alone may provide limited improvement and may not fully address the overall shape.
If the primary concern is fat volume with relatively good skin recoil, liposuction can be considered. However, when there is significant skin looseness, procedures such as a tummy tuck and/or arm lift may be more effective for achieving a smoother,...

Thigh liposuction can reduce thigh circumference when the fullness is mainly due to localized fat, and results similar to the example photo may be achievable in selected cases.
However, the amount of reduction depends on fat thickness, muscle structure, and skin elasticity, and there are limits to how much girth can be safely removed. Liposuction reshapes the thighs but does not replace the role of diet and exercise, which are still important for maintaining results.
For the best outcome, it...