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Monthly Archives: October 2012

Not scary looking, and not scary for your bank account. 🙂

It’s a fact. This Botox®/Filler game is expensive. The older you get, the more it costs to get back to square one. I often ask myself, if I wasn’t in an industry where it was so accessible (and cheaper, obviously) would I even be able to do it? If I didn’t have an ongoing trade with my hairdresser who likes his face to be frozen and filled out at all times, would I be doing my roots myself? By the way, if you’re in a bind and you can’t get to your hair guy/girl L’Oreal Root Rescue® is fantastic! Under ten dollars at CVS, easy to apply, doesn’t smell, you can pick the wrong color and it still looks fine…

But back to the main issue. Here are my insider’s tips on how to make the most of your Botox Budget”:

1) Find an injector you like (preferably referred by someone you know) and if you’re getting the results you want with that person (whether it’s a nurse, nurse practitioner, dermatologist or plastic surgeon) stick with them.This is not the time to go jumping around with Groupon deals. All Botox is not created equal. LITERALLY. It comes as a powder and is diluted with saline to turn it into liquid. This means that the injector can dilute it out as much as they want, to get the most mileage from it. Which means if you’re paying half-price somewhere, it’s likely that the Botox is half as strong. There are definitely places where they use so much of it that they get a discount they’ll pass on to the patient, but a good question to ask the injector is, “How much do you use to dilute it?”

Besides, when you stay loyal with one injector, they will usually start giving you discounts after a certain period of time. I have a starting rate per unit, and then what I call the “F and F”( friends and family) rate for my long-term patients.

2) If you’re a Botox virgin, first starting out, GO SLOW. You may not need as much as you’re paying for. For instance, someone with deep frown lines may need twenty-five units or more to erase them, but if yours aren’t that bad, you may be able to get rid of them with fifteen. You can always go back and get more. But you may never know if you’ve been getting twenty-five from the get-go.

So keep track of how much you’re getting in each area. Record it in the notepad in your phone. (I know most of you already have your phone in your hands and you’re texting away while you’re getting it done anyway because that’s what my patients do :))

3) And to specifically avoid this famous scary look:

Make sure your injector puts a couple of units above the arch of your brow.

Happy Halloween!

XO

LQ

Most likely, YES. I’ve been doing this fat-transfer-to-the-breasts thing for over three years now and it really is the closest thing to a miracle that exists in plastic surgery. I’ve said it to all of my patients and I’ll say it again: If I hadn’t already had all my fat sucked out ten years ago I would totally have it done in a second. I know I’ve already blogged multiple times about it, but now I would like to address this specific question that everyone who wants to get rid of their breast implants asks me.

Let me start out by saying that I am absolutely all for breast implants. I still put a lot of them in and they’re great. They are. Most of the time. When everything’s good, they usually look better than real breasts of comparable size, because they give you that upper breast fullness that we start losing in our mid-twenties. You can get them done in a way that nobody will know, or in a way that everyone will know and show them off. You can go without wearing a bra. Men like them (see previous post, Do Men Like Breast Implants?) And they don’t sag like natural breast tissue does.  Women who come to see me for breast reductions can never understand why anyone would want to make their breasts bigger. It’s simple–DD breast implants defy gravity much better than real DD breasts that hang and pull, causing back and neck pain and bra-strap grooving and rashes.

But, as many of you out there know–and you’re probably the only ones still reading this blog–with breast implants, you’re never out of the woods. They move, they ripple, they (RARELY) rupture (rupture rate of the new Sientra implants recently reported at less than two percent, so that’s good.) They can be great for five years and then, for no reason you develop a capsular contracture (rates reported at anywhere from eight to thirteen percent for all gel implants). Or even worse, you could be one of the unlucky ones who gets a contracture from the beginning, and winds up getting one side removed and replaced three times in less than two years. Dr. Roger Khouri, one of the “fathers” of fat grafting to the breast calls those patients “Implant Cripples.” Sounds harsh, but he makes a point. For some women, they just never work.

So far, my patients and I have been extremely happy with the results with this procedure–removing breast implants from someone who’s “done” with them and re-augmenting with their own fat.

My goal with this particular blog is to help those of you who are genuinely investigating this procedure to understand how it’s being done. When patients ask me about it, they seem to have an image of me just taking out the implants and putting a big glob of fat in the space that’s left behind.

That’s not how it works.

I think that as surgeons, we make the mistake of assuming that our patients have a clear mental picture  of the anatomy of their surgery without explaining it to them, and then we’re confused when they don’t understand the limitations and mechanics of a certain procedure.

Just warning you, this is about to get somewhat dry and technical, but is extremely useful information for those of you who really need to know:

Whenever I am discussing a breast procedure with a new patient, I usually draw pictures like the ones below, which are diagrams of where  “under the muscle” (left)  and “over the muscle” (right) breast implants sit.

The white line around the implant is the “capsule.” This is your own normal scar tissue that has formed around the implant. If this scar tissue becomes thick, it squeezes on the implant, making it feel hard, and that’s a capsular contracture

When I am switching someone’s implants out for their own fat, after the lipo, I remove the implant through an inframammary (in the crease under your breast) incision. The fat is then placed not in the space where the implant was, but in tiny micro-tunnels in the layers of tissue between the capsule and the skin. This is one of the cases where we say that the “capsule is your friend” because it is keeping the fat from getting into the space where the implant used to be. And it’s okay to leave the capsule there. If we’re not putting a new implant in, and there’s not ruptured silicone all over the place, it doesn’t have to come out. It’s your own tissue and it will eventually reabsorb. A drain is placed in that space (those of you who’ve had multiple breast aug revisions are probably familiar with those) and the space closes down on its own.

How much fat can you get in there?

Depends on how much you have, and how thick the layer of tissue is that I’m putting it in. As you can imagine, it’s better for everyone if your implants are sub-muscular, because then there’s the added layer of muscle to put the fat into. Most of the time I can get enough fat in so that when I’m done, the breasts look almost as big as they did with the implants. In fact, most of my patients who have undergone this procedure laugh about how their friends say, “Are you sure she took them out?” (Obviously they haven’t explained the lipo part of it. :))

But won’t my breasts be saggy afterward?

They might. And you may elect to do a mastopexy (lift.) I personally prefer to wait to do the lift as a second surgery because the breasts get swollen when the fat is placed, and you can get a better lift if you wait till the swelling goes down.

So, for those of you who are considering this procedure, I hope that this blog helped you understand exactly what it’s all about.

Before I leave you–here’s an update on the “Paris Girl” that everyone always asks me about, two years out from her fat transfer to the breast, still wearing a C cup.

She has no scars, and her breasts look and feel so natural in fact, that when she had a little tryst with a member of a royal family over there in Europe…well, I guess you could call it, “The Prince and the Pea.” 🙂

XO

LQ

Well, now of course. 😉

No, seriously–this advice is not coming from someone who makes a living contouring women’s bodies. This is girlfriend-to-girlfriend chat, from someone who’s had it done herself–about how and when to do it on the down-low. Because if you’ve been thinking about it, pinching those areas you just can’t get rid of at the gym, and years have gone by because there’s always a scheduling conflict, the time window between Halloween and Thanksgiving is as optimal as it’s going to get. It’s like everyone always says, “there’s never a good time to have kids,” except I can pretty much guarantee that having liposuction is much easier.

The deal-breaker for most of us when we want to “get something done” is the down-time. With body contouring, these are the main questions:

For how long am I going to be out of commission?

Fortunately, the thing about lipo is that since there is no muscle work involved in the procedure, (like when you have a breast augmentation, and the muscle has to be lifted to place the implant) and there are no big incisions to protect postoperatively (like with a tummy tuck or breast reduction), you are limited only by your own discomfort. There’s really nothing that you’re going to do that will “ruin” your results. All that’s going to happen if you “overdo” it is that you will get tired, achey, and more swollen. I recommend to my patients to take a week off from “responsibilities”(i.e. work, participation in school activities, social gatherings, strenuous exercising) but it’s not a week in bed. You can do whatever your body allows you to do. That’s not to say that you should do what I did–go Christmas shopping the next day and suddenly realize six hours into it, half a mile from your car in the mall parking lot, that you’re not feeling so great. Because the truth is, after lipo you don’t really feel “sharp” pain. Speaking from my own experience–and most of my patients agree–it just feels like you worked out really, really, really hard. Like you did a million sit-ups or ran a marathon. Just, no matter how good you think you feel, don’t stray too far from your home or mode of transportation.

But how long till I can work out again?!?

I know, I know, telling many of you that you probably won’t be able to work out strenuously for a few weeks strikes fear in your hearts. But guess what? For about a month to six weeks after surgery, your body is in stress mode, and your metabolism is jacked up about one and a half times normal while it’s healing. Your body doesn’t know you did this crazy thing on purpose–on a cellular level you may as well have just been in a car accident or had a sixty percent body surface area third-degree burn. So if you just eat as you usually do, even if you’re not doing five days a week of cardio and pilates, you won’t gain weight. You may actually lose moreYou’ll be the only person who comes back to the office the Monday after Thanksgiving not complaining about how all you did was eat all weekend and you just gained six pounds.

So when am I going to look normal?

Back to this again. 🙂 Even with body contouring procedures that you can hide under your clothes, there are different definitions of “normal.”  (see previous post: How long after having my eyes done will I look “normal” again, and what does that have to do with the CW’s new show, “Emily Owens, MD”?)

Postoperatively, you will need to wear a compression garment (or what many of my patients fondly refer to as “the suit”) to reduce the swelling. For upper body lipo including arms, my patients usually only wear  it for a week or two, as the swelling in that area goes down pretty quickly. For the lower body (muffin top, abdomen, inner/outer thighs, knees) you really should be wearing something for six weeks. Yes, the first one we put you in is pretty industrial-grade but after a couple of weeks you can switch to something thinner and lighter like a Spanx®. Regardless, even the surgical compression garments (we get really cute ones from Design Veronique®, see below) can be easily hidden under clothes:

Just maybe not your skinny jeans the first week out.

So it will be easy to hide your little secret from your extended family over Thanksgiving weekend and your colleagues when you go back to work.

But by the time the Holidays roll around, you’ll be ready to go in your little black cocktail dress ;).

Mila Kunis in an Herve Leger black bandage dress. And if you don’t know about these, you need to.

What about my significant other?

Well, if you’re married, you’re probably going to have to tell your husband. At least, I would hope so.

But if you’re in a relationship and you don’t live together, there are ways around fessing up. I’ve pretty much heard it all, from “I told him the suit is a back brace” to “He’s colorblind and can’t see the incisions.” The “suits” we get for our patients (and we are in the process of designing our own “Lipo Queen” line!) are cute enough that he might even think it’s some kind of planned sexy lingerie (“Look, Honey, open crotch!” ;)) After a couple of weeks, the bruising should be gone and you can intermittently take the garment off. If your partner isn’t colorblind, and he’s not particularly savvy, you might be able to convince him that the tiny incisions were mole removals.

This is how one of my patients handled it:

He said, “What are those?”

I said, “Oh, I had those moles taken off.”

He said, “What moles?”

I said, “Don’t you remember? I had those moles and I told you I had to get them taken off! You never listen to anything I say!”

And you better believe he backed off.

Or you can always use the foolproof back-up, “I had to have a surgery for…you know…it was one of those female things…” and you know he’ll immediately change the subject.

Hope this answered some of your questions! If you have more, ask away!

XO

LQ

This is the second thing I hear from half of the women I meet. The first is a wish list of where they want the fat removed: from here, from there…and what do you think about the backs of my arms…and then, inevitably, about fifty percent of the time the next thing they say is: “but I don’t want to go under!”

For those of you who have knee-jerk-reaction fear of general anesthesia, I get it. You have obligations…young children, a job to go back to…and it freaks you out to think you’re risking your life for your vanity, and you figure if you can do it without “going under,” you’ll be safer.

I know I am not going to wipe out the general fear of “going under” with one blog. It’s like that thing that happened with the bagged spinach back in 2006. The E. Coli outbreak has long since been over but I still haven’t been able to bring myself to buy spinach in a bag.

But somebody needs to clear up the facts.

 So here goes:

The definition of general anesthesia is:

The absence of sensation and consciousness as induced by various anesthetic medications, given by inhalation or IV injection.

 (http://medical-dictionary.thefreedictionary.com/general+anesthesia)

(You can skip down to the red print if the following paragraph looks too boring and technical—you’ll still get the gist of it from the rest of the blog.)

The components of general anesthesia are analgesia (NO PAIN) amnesia (NO MEMORY), muscle relaxation, control of vital signs, and unconsciousness. The depth of anesthesia is planned to allow the surgical procedure to be performed without the patient’s experiencing pain, moving, or having any recall of the procedure. Endotracheal intubation or insertion of another artificial airway device and respiratory support are often necessary. General anesthesia may be administered only by an anesthesiologist with or without an anesthesia assistant or a Certified Registered Nurse Anesthetist.

 So, it is a fact that many of you have actually had general anesthesia and you don’t know it. You think you had something called “Twilight.”

 “Twilight” is not a technical term in the anesthesia dictionary. It is—besides being the biggest Vampire movie franchise of all time—a catchy marketing phrase that many cosmetic surgeons use to allay your fears about having “general anesthesia.”

 Newsflash: once you’re asleep on the table, you’re asleep. It doesn’t matter how you get to that state. Just because you didn’t have a breathing tube in and all you got was IV propofol/”the Michael Jackson drug” (which, by the way, there’s nothing wrong with, as long as someone’s watching you while you’re getting it) doesn’t mean you didn’t have “general anesthesia.”

In fact, the truth is that it is usually safer to have “the tube” monitored by an anesthesiologist, controlling your airway, than just the sedation alone, or what is being sold to you as “Twilight.” Because if you are basically asleep without an airway, and your reflexes are blunted, you are at increased risk for complications of aspiration of your own saliva (ie, aspiration pneumonia) and not getting enough oxygen.

Then the inevitable question:

But what about like in one of those movies—what if I wake up in the middle?

It’s not going to happen. Not in an accredited facility with a Board-Certified Anesthesiologist (the only way I practice surgery.) When you are under “general,” The anesthesiologist has all kinds of fancy state-of-the-art equipment to monitor exactly how “asleep” you are, and it is second nature to him to keep you at the perfect level of sleep.

So how long will I be under?

Those of you plastic surgery virgins are shocked when you find out that it’s probably going to be at least a few hours, because getting your gallbladder out only took twenty minutes. While it sounds scary that your cosmetic procedure, depending on the complexity, could require you to be “under” for as long as six hours, the thing is that, this is not like having six hours of heart surgery. The anesthesia you’re getting is not as “deep.”

And remember, you want your results as perfect and as even as possible, and you don’t want your plastic surgeon rushing, or having his partner or resident doing one breast while he’s doing the other. So it takes time.

Well, what about all those things I hear, about people dying from surgery and anesthesia?

And the subject of Kanye West’s mother invariably comes up.

It has been shown that Donda West’s unfortunate outcome was not due to the anesthesia or the surgery itself, but the fact that she had a pre-existing cardiac condition that was not addressed. And if you look into all of the other folklore about how “dangerous” general anesthesia is, you will see that almost all of those other stories have similar explanations. That is, not all of the I’s were dotted and T’s crossed before the surgery.

 So, what are the I’s and T’s?

In my practice, safety always comes first, and I am extremely OCD about this:

1)   Pre-op labs for everyone

2)   Electrocardiogram (EKG) for you’re over thirty-five, or have any history of ANY kind of cardiac issue.

3)   Chest X-Ray if you’re over fifty

4)   Medical Clearance by your internist if you’re over fifty

5)   Cardiac stress test if there is any question about cardiac disease

6)   You should be off any birth control pills or (if it doesn’t turn you into a monster) peri- and post-menopausal hormonal replacement since estrogen and progesterone can increase risks of blood clots (ie, pulmonary embolus and deep venous thrombosis.)

7)   Full past medical and surgical history, including family history of bleeding disorders, blood clotting disorders, or problems with general anesthesia.

8) STOP all recreational drugs (i.e., coke, ecstasy) at least two weeks before your procedure. I don’t judge, but you need to time your breast reduction/lipo/breast aug well around events like Coachella. You must know that these drugs can have serious interactions with anesthetic agents and need to be out of your system well before the surgery, and some of the “horror stories” you hear about reactions to general anesthesia are due to patients withholding information about what they do in their spare time.

I only work with board-certified anesthesiologists in fully-accredited facilities, where all of the resources and equipment are available to take care of any out-of-the ordinary issue that might arise, including the diagnosis and treatment of malignant hyperthermia (a rare condition with an incidence of 1/50,000 to 1/100,000), which is really the one and only thing that truly is a reaction from the anesthesia itself.

I’m not saying that there are zero risks. But there are not zero risks to walking out onto the street, either, and if nothing else, you should understand that, if you are healthy and not excessively overweight (and by that I mean morbidly obese, not just trying to lose that extra five to ten pounds), and all the I’s have been dotted and T’s crossed before the surgery, the risks of something happening to you because of the anesthesia are less than the risk of you getting in your car and driving home, and not just on the 405.

Perhaps the best testament to the safety of anesthesia is that those of us who work in “the business” (the business of plastic surgery, not entertainment, although I’ll be the first to admit, there’s kind of a grey area) are ready to jump on the table at a moment’s notice if there’s a procedure that we want to get done.

So, if nothing else, I hope that this blog has given you a little more perspective on the scary, ambiguous topic of “general anesthesia.” And if you have more questions, please come talk to us!

And if you saw theEmily Owens, MD pilot last night on the CW(I thought it was great—has a lot of potential :-))—don’t be scared by what they say. It sounds funny, but it’s not true that all  anesthesiologists are “former high school stoners.”

XO

LQ

Okay, you guys know I’ll somehow tie this together at the end, so just stay with me.

First of all, the question that I get before every procedure–“when will I look normal again?”—needs to be defined. Are you talking “normal” enough to drive to a Whole Foods in a different neighborhood to pick up more Arnica and a few pre-cooked meals, wearing a scarf, hat and sunglasses so that everyone  thinks you’re trying to look like an incognito movie star but the woman standing next to you on the check-out line can see the bruises under your eyes and thinks, “Oh, yeah, she had something done,” but you don’t care because you’ll never see her again?

Or are you talking about an impromptu reunion with the hottest guy from your Med School class who you haven’t seen for over a decade but just happens to be in town for a meeting and wants to catch up over drinks two weeks after you just had a brow lift and your lower lids done?

Speaking from personal experience, I can answer both questions.

Shortly after opening my practice in Beverly Hills, I had an endoscopic brow lift (with tiny incisions in the hairline ) and fat transposition of my lower eyelids (see earlier post “What can I do about the bags under my eyes?”)

To those of you who don’t live here in La La Land, I know this sounds like a lot of surgery for someone who’s still relatively “young” but really, this wasn’t me being crazy because I’d just moved to Beverly Hills. It was a procedure I’d been thinking about for years (and had been told by several colleagues–not so tactfully–that I could really use.)  Sometimes you look at your parents and the writing’s just on the wall. It’s not aging, it’s genetics and you shouldn’t have to apologize for wanting to fix it. In my case it was those fat bulges under my eyes, and the constant creases across my forehead from trying to keep my eyebrows off my upper lids. The upside was that I saved a lot of money on make-up because there was nowhere to put eyeshadow. Too much Botox in this situation–to get rid of transverse forehead creases on someone who has a short forehead and a low brow–risks making you looking like a Neanderthal:

So I had the procedure done. I had the best doctor in town—Dr. Andrew Frankel, at the Lasky Clinic in Beverly Hills—and I would recommend him to anyone in a second. And everything went swimmingly, except…I am a bruiser. I don’t know if it was the lower lids or the brow lift, but I was scary swollen and bruised for about a month. Like blue-black, can’t-cover-with-professional-makeup bruised. Even with all of the Arnica and Bromelein and Hyperbaric Oxygen Treatments in town.

I believe that for most people, it would be reasonable to expect this kind of swelling and bruising for a week. But everyone responds differently and after my experience, I have to say that if you have an event that you really care about, give yourself at least a month to six weeks after this kind of surgery.

Okay, let’s define “care about”:

I was able to drive and go back to work three days later. Swollen and bruised and looking scary, but my patients were all so intrigued, and full of questions, and I didn’t mind telling them about it because you have to practice what you preach, right?

Don’t care.

One week post-op, while picking up dry cleaning I heard some teenage girls on skateboards say (not even whisper) as I passed them, “That lady had plastic surgery.” I was more upset that they had referred to me as a “lady” than the fact that they had called me out on my surgery.

But, never going to see them again and I don’t know their mothers. So, still don’t care.

Ten days post-op a colleague takes me to a big party for a Craniofacial Surgery Society. For this one I got professional makeup done because I wasn’t really looking forward to sporting my still-very- obvious cosmetic surgery bruises in a room full of male plastic surgeons. I thought the professional makeup was doing the trick, until a couple of hours into it, I caught a glimpse of myself in a mirror and realized that the packed-on concealer under my eyes was there no longer and the bruises were as dark and obvious as ever, and I wasn’t fooling anyone.

Oh, well. They’re not my crowd anyway. Still don’t care.

But then….two and a half weeks after my surgery…pretty much back to my normal routine…My browlift is looking amazing, and the bruising and swelling under my eyes is slowly getting better but still extremely obvious but, what the hell…at this point I’ve given up trying to hide it…and anyway, we’re in Beverly Hills, I’m wearing it all like a badge of honor…and then one day my office manager rips one of those phone message things from the book and hands me my copy and says, “Oh, this Doctor C.M. is coming into town for a meeting this weekend. He said to call him, maybe you guys can get together.”

At this point I am a successful Board-Certified Plastic Surgeon in Beverly Hills. I’ve got it going on. People respect and like me. My patients love me. I’m an accomplished adult.

And yet my first thought is: OMG!!! C.M.? C.M. was by far the cutest guy in my Med school class. I had not seen or spoken to C.M. for fourteen years. I didn’t think he even knew who I was. How did he find me? And did he mean to find me? I had never had another “Suzanne” in a class with me my entire life, until Med school where there were three of us. And as luck would have it, the other two were: 1) a beauty pageant queen from Maryland and 2) a cute-as-a-button girl who went by “Suzie.” Surely C.M. was confused. Surely he thought he was calling one of them.

Then there was the issue of my face. Even after I moved into the Hyperbaric Oxygen chamber for the next two days and tried the professional makeup again, there was no way my face was ready for a reunion with C.M.

He was staying two blocks away, at the Century Plaza Hyatt. I called him and we had a nice chat. We confirmed that he knew exactly which Suzanne he was talking to—that I was not the ex “Miss Maryland” or the darling five-foot-one girl that everyone was always giving piggy back rides to. He’d heard from a friend that I was in L.A. and he didn’t know anyone here and was hoping we could get together. During this conversation I tried to convey how improved I was since Med School. I was a Beverly Hills Plastic Surgeon. I had cool friends and I myself was incredibly cool, so much cooler and improved than when he knew me in fact, that I was not going to be able to meet him this weekend because in a few hours I was leaving to go snowboarding in Mammoth.

To have to lie like that was pure agony. But there was no way I was going to meet C.M. after fourteen years looking like Frankenstein.

My patients and I share stories like this all the time and when I tell this one–even to the women who are settled and married and out of the dating world (as am I!)—they feel my pain as if it were their own. Because no matter what we do as women professionally, when it comes to dating, for some reason the playing field is completely leveled out and when we get really excited about someone, we start acting like we’re in high school again.

On that note, as much as I generally dislike medical TV shows, I can’t help noticing that there are a couple of new ones this fall that resonate with me–“The Mindy Project” on Fox and “Emily Owens, MD” on the CW–about young Bridget-Jonesy female physicians failing miserably in their personal lives despite their successful careers. While the main character in my book, Lipo Queen isn’t bumbling around the hospital, mooning after her colleagues in between saving lives, what makes her interesting is her confidence in the workplace, and lack thereof around men. So I’m curious to tune in, particularly to “Emily Owens, MD,” which has the tag-line “High school in the hospital.” However, I don’t think doctors, with their stunted social development, are the only ones who tend to behave like high schoolers in the workplace. I’m guessing that behind closed doors, the big law firms and business offices are not very different.

If you don’t have a reason to watch it, I’ll give you one:

My husband can make fun of me all he wants, but he’s the one watching Vampire Diaries and asking, “Honey, why aren’t these girls taking their clothes off?” and I have to tell him, “They’re underage, and you’re on the wrong network.”

The show premieres October 16th on the CW, but the pilot is available online. Here’s a link to watch it: http://www.cwtv.com/shows/emily-owens-md 

Check it out! It looks like fun, and a dichotomy (big word for me, I know) that most women can relate to!  But please remember, no matter what those TV doctors say—not all of us plastic surgeons are mean girls. 😉

XO

LQ