Monthly Archives: June 2017

If there was ever a time to do a tummy tuck in Beverly Hills, it would be now.

For anyone who is planning on having a “skin reduction procedure” on their body—that would be anything like a tummy tuck, a mini tummy tuck, a body lift, leg lift or arm lift…


We are participating in a clinical trial that is evaluating a new filler called Allofill that eventually will be used in place of the fat when we do fat grafting. That’s crazy, you might think. If I’m going to have fat injection on my breasts, butt or face, I would want to use my own so I can get rid of it. That’s kind of the point of it.

However, there ARE people who don’t have enough of their own fat to have this fabulous procedure. I like to say that “I can get fat out of a rock” but sometimes it’s just not enough to make a difference in the places that we are putting it.

Here’s how the study works:

  • You decide that you’re finally going to go for it and get rid of that extra saggy, stretched out skin on your abdomen that is driving you crazy.
  • Come in and see us for a consult. (Normally $250 but we are doing complimentary consults for those who would participate in the study.)
  • Visit with the Principal Investigator on the study, Dr. John Joseph, another board-certified surgeon here in Beverly Hills and a good friend of mine.
  • One month after your surgery you will receive $2000 back from Biologica Technologies, the creators of Allofill.

Not bad, I think.

And just think, you will be on the cutting edge. Corny pun intended.




But I don’t want to go under anesthesia!”

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.

(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 calledTwilight.

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!



Before I was interviewed for Zwivel, I had not heard the term “drop and fluff” much in the breast implant world. Mainly just the pillow world.


But “drop and fluff” refers to the dropping and settling out of the breast implant over time. 

You can check out my feature in the Zwivel article HERE. And for more of my thoughts on the “drop and fluff”…read on 🙂

DROP. We all talk about the implant “dropping” over time, as gravity takes over and the surrounding tissues (muscle, breast tissue, skin) stretch out. When this happens, the implant settles into the pocket that has been created and it takes on a more natural shape. This is the…

FLUFF. The lower part of the breast becomes more projecting and the breast takes on a more natural, “teardrop” shape, even if it is a round implant. Over time the breast looks bigger and rounder than it did originally, when at first it was tighter and flatter.


It’s important for women considering breast augmentation to know about “drop and fluff” so that they understand how the implants will change over time, and what they should be watching for.

They initially start out high and tight on the chest wall. If the pocket is dissected out (created) correctly, the implants will fall into proper position. After a few days they really start to drop.

At six weeks they are usually almost there, and usually at three months they are where they are going to be, based on how the pocket is created. After that, the breasts can still stretch out and sag over time, depending on how elastic the patient’s tissue is.

When they are done “dropping” and the lower pole is done “fluffing,” you should be able to feel the edge of the implant at or just above the inframammary crease. That means it has fallen into the pocket.

Since breasts are almost never symmetric, the implant in the one with more space (a longer nipple to inframammary crease distance) will usually drop faster.

Sometimes we will give a patient a breast band to wear across the top-most part of the upper poles that can help push the implants down. Another thing that helps soften up the scar tissue is massage (imagine the implant is in a round room and you are pushing it to reach all the walls so you can feel it with your fingers), although this hasn’t really been proven.

It is important that a patient keep an eye on the progress of the implant dropping; if it doesn’t seem to be dropping correctly, you could be developing a capsular contracture. I would start considering this if by one month the implant doesn’t show any change in position.

If after six weeks the implant doesn’t seem like it has dropped correctly, and the lower part of your breast feels “empty,” you should consult with your doctor. Either the muscle was not completely released to make the pocket or you may have developed a slight capsular contracture. Treatment for and to prevent this includes ultrasound treatment (there is a system specifically designed for breast implants called the “Aspen System”) and infrared treatment that most physical therapy places offer. Also, the medication Singulair has been shown to decrease the rate of capsular contracture when given prophylactically.

I personally try to have all of my patients do prophylactic ultrasound and infrared treatments and take three months of Singulair postoperatively.


Here’s what patients can expect during the following postoperative stages:



During the first week, there is usually significant soreness, usually inferiorly and medially and the chest feels very “tight,” especially when taking deep breaths and there can even be discomfort on the upper abdominal wall. (One thing that helps with this is using a long-acting local anesthetic, “Exparel” which lasts for three days. Another thing that can help with the tightness is injecting Botox into the Pectoralis Major muscle during the procedure to keep it from contracting.)

It is normal for there to be swelling on the chest wall around the implants, so that the implants look less “defined” and less round in the beginning. They can appear full on the top part only if the breasts were small and tight to begin with. It is also normal for there to be bruising and swelling of the upper abdomen.


By week two the bruising—if there is any—should be gone, and the swelling really starts going down by two weeks.

The incisions do not start getting red until about six weeks. Over the first six weeks the tissues soften up and by six weeks the implants are sitting almost where they will be.


At three months they are usually in the position that they will remain unless other factors interfere, like childbearing—which can cause increased size of the breasts, lactation, which can cause capsular contracture, loss of skin elasticity which can cause severe stretching out of the tissue and “bottoming out” of the implant.


The incisions will lighten up after time, and by a few months usually blend in, whether they are inframammary or periareolar.

(This phenomenon of “drop and fluff” should not be any different for silicone or saline implants)


If you’ve made it this far down, well done! I know the attention span isn’t what it used to be 😉 Thanks for reading. Hope this was helpful!