ALL PROCEDURES
WHAT TO KNOW
Addressing and answering the what, who, where , how , and when question sequence can help educate and prepare patients for procedures. What is the procedure in question ? Who will benefit from the procedure of interest and who is an ideal candidate ? Where is the procedure be performed? In office, an accredited outpatient facility, or in a hospital? How will the procedure be performed and how long does it take? Will it be performed using local anesthesia alone, local anesthesia and sedation or under general anesthesia? When will you be able to resume normal activities? The following procedure sections attempt to address and answer these questions, but proper patient education requires person to person interaction. Remember questions are never stupid, but answers may be.
Body
Tummy Tuck/ Abdominoplasty
What
Abdominoplasty or tummy tuck removes excess skin and fat, but also tightens abdominal muscles. Some liposuction is usually performed as part of the procedure.
Who
Women who have excess abdominal skin and lax abdominal walls following pregnancy will benefit from a tummy tuck. Additionally women and men who have significant weight loss and excess abdominal skin are good candidates as well, but additional incisions may be required.
How
A tummy tuck usually is performed under general anesthesia, and can be combined with other procedures, i. e. Mommy Makeover. The incision is typically transversely oriented with placement and length based on the patients anatomy. it should be placed as low in the pubic region as possible. Once the skin is incised and elevated the abdominal wall will be tightened with a series of sutures. The belly button remains in position in its' original position, but skin around it changes position. Excess is the skin is the removed and the incision closed. Drains have been traditionally used, but may be obviated with progressive tension suturing and /or the use of tissue glues. Use of tissue glue necessitates an extra expense. Procedure time is typically 2 to 3 hours. Sutures are beneath the skin and are dissolvable.
Where
An accredited outpatient facility or hospital.
When
Complete recovery without physical restrictions is usually within 6 weeks. Patients are encouraged to return to light activities in 7 to 10 days.
Buttock Enhancement/ BBL
What
Buttock enhancement is the improvement of buttock shape and projection with either the insertion of implants or more commonly with fat transfer, i.e., Brazilian Butt Lift ( BBL)
Who
Implants are used in patients with inadequate deposits of fat for transfer. BBL is performed in patients with significant deposits of fat.
How
Typically the procedure(s) are performed under general anesthesia. Implants require surgical incisions and the use of drains. BBL only requires small incisions that are left open to drain in fat harvest sites. The fat is then transferred to the buttock based on the patient's anatomy. The amount of fat transferred depends on the patients anatomy. Incisions used to transfer fat usually require a single suture. Procedure time varies with the amount of liposuction performed. Procedure time is usually 2 to 3 hours. Suture removal, if any, is at 5 to 7 days following the procedure.
Where
An accredited outpatient surgical facility
When
Recovery from buttock implants takes from 3 to 6 weeks. BBL patients are usually performing unrestricted activities at 3 weeks following the procedure. Some soreness may be present in fat harvest sites up to 6 weeks
Liposuction
What
Liposuction is the removal of fat from the body with suction via small incisions. Liposuction is not a substitute for weight loss.
Who
The ideal patients has deposits of fat that persist even with loss of weight. Typical areas are thigh fat deposits in women and love handles in men.
How
Liposuction may be performed under anesthesia, local anesthesia alone or combined with sedation. In this practice power-assisted liposuction under general anesthesia is the preferred technique. Small areas of fat may be addressed with only local anesthesia. Patients will wear compressive garments for 1 to 3 weeks following the procedure based on the patient's tolerance. Procedure time is usually 1 to 3 hours.
Where
In an accredited outpatient facility or in the case of small areas of liposuction in the office.
When
Patients are encouraged to resume normal activities after 1 week, but may have discomfort up to 3 weeks.
Mommy Makeover
What
Mommy makeover is a combination the of a tummy tuck, with or without liposuction, and a breast enhancement procedure.
Who
Women who have developed abdominal wall and skin laxity as well as loss of breast volume associated with child bearing.
How
The procedures are performed under general anesthesia. The procedures are described under Tummy tuck, Liposuction, Breast Lift, and Breast Augmentation sections. Procedure time is usually 3 to 5 hours.
Where
In an accredited outpatient surgery facility
When
Limited activities are encouraged at 1 week following the procedure, but similar to tummy tuck unrestricted activities should be deferred until 6 weeks following the procedure.
Breast
Augmentation
What
Breast augmentation is the increase in breast volume with use of implants or less commonly transfer of fat. Breast implants or fat improve volume and size, but do not lift breasts.
Who
Patients that have smaller breast or those with loss of breast volume following breast feeding.
How
Breast augmentation is usually performed under general anesthesia. Implants may be placed under or over the pectoralis major muscle. The long term benefits of under the muscle placement, such as decreased capsular contracture, less interference with mammography, smoother transition from breast to chest and fewer issues with rippling make it my primary choice for implant placement. Insertion is done through an armpit, areola, or under the breast incision. The armpit incision is my preferred insertion route with nearly imperceptible scars, but I have extensive experience with all routes of insertion. With the armpit incision technique I routinely use an endoscope and Keller funnel for precision and ease of implant insertion The implants may be either saline or silicone gel with most patients opting for gel due to the more natural feel and less issues with visible implant rippling. Implants may also be teardrop shaped however problems with rotation, producing an unnatural appearance, make them a secondary choice compared to round implants. The choice of implant type , placement and route of insertion remains the choice of the patient. Procedure time is usually 1 hour. Sutures may or not be dissolvable. If not suture removal is at 6 days following the procedure
Where
In an accredited outpatient surgery facility
When
Discomfort in the first days following the surgery may be significant, but by a week most patient are returning to normal activities with the exception of those involving strenuous upper extremity. Unrestricted activities are usually achieved by 3 weeks.
Breast Lift/Mastopexy
What
Breast lift is repositioning the nipple/ areolar complex in a more superior position as well as reshaping the skin envelope and breast tissue.
Who
Patients who will benefit from a breast lift are women who either have congenitally droopy breasts or those who have developed droopiness following child bearing. The ideal candidate still has adequate breast volume, but if not an implant may be placed at the same time.
How
The procedure is usually performed under general anesthesia. Breast lifts require incisions on the breast to reshape the skin envelope as well as lift the nipple. Incision patterns are described as donut, incision limited to around the areola, lollipop, incision around the areola and extending inferiorly, and anchor, incision around the areola, inferiorly with a transverse component. The incision pattern is dictated by the degree of nipple descent as well as the discrepancy between breast skin envelope and volume. Repositioning and reshaping the breast tissue can be performed in a number of ways. Because of the incisions around the areola the chance of nipple sensory disturbance is increased relative to breast augmentation. Procedure time is typically 2 to 3 hours. Sutures are beneath the skin and dissolve.
Where
The procedure is performed in and accredited outpatient surgery facility although minor revisions may be done as an office procedure.
When
Patients may return to light physical activity within a week and unrestricted activities at 3 to 4 weeks.
Face
Browlift
What
A brow lift is elevation of the eyebrows to a more pleasing rested and alert position. It can be combined with other procedures such as a facelift or eyelid surgery.
Who
The patients that benefit from a brow lift are those that have eyebrows that have descended with time. This is usually due to gravity, the downward pull of the muscles surrounding the eye, and loss of supporting tissues under the brow. Many patients present wanting their upper eyelids reduced when in fact the descended brow is the real issue. The assessment of brow position as well as frontal muscle activity is critical in decision making.
How
A brow lift may be performed with incisions along the frontal hairline, in the scalp, in the forehead, or with limited incisions and the aid of an endoscope. The more extensive procedures require general anesthesia, but lesser procedures can be performed under local anesthesia. In addition to elevating and shaping the brow the muscles that cause glabellar frownlines, also known as "the 11'S", can be weakened. Fat grafting may also be performed to add soft tissue support under the lateral brow as well as to treat deeper wrinkles. Drains may be used, but usually not in direct excisional lifts. When used drains are removed the first day following the procedure. Procedure time is 1 to 2 hours. Suture or staple removal is at 5 to 7 days following the procedure.
Where
The more extensive procedures are performed in an accredited outpatient facility, but lesser procedures may be safely performed as an office procedure.
When
Recovery from limited procedures is usually days with suture removal at one week. more extensive procedures require 1 to 3 weeks to resume unrestricted activity. Forehead and scalp numbness is common with the more extensive procedures but usually resolves in 1 to 3 months.
Upper Eyelid Surgery / Upper Blepharoplasty
What
Upper eyelid surgery or blepharoplasty involves removal of excess eyelid skin and less frequently fat.
Who
Patients with excess skin obscuring their vision or those who appear tired. Patients with true ptosis or a lid that that does not open properly when the brow is elevated will require additional procedures.
How
Upper eyelid surgery can be performed under local anesthesia, local anesthesia with sedation or under general anesthesia. It involves removal of excess skin alone, but can also remove excess deposits of fat. Procedure length is typically one hour or less. Removal of sutures is at 3 to 5 days following the procedure.
Where
Upper eyelid surgery may be performed as an office procedure, but is optimally performed in an accredited outpatient surgery facility.
When
Recovery is usually rapid although swelling and bruising are expected. Dry eyes are common following the procedure particularly in the arid climate of Nevada, but usually resolve.
Lower Eyelid Surgery / Lower Blepharoplasty
What
Lower eyelid surgery is directed more at removal or transposition of the fat that causes puffy lower eyelids with less emphasis on skin removal
Who
Patients that have puffy lower eyelids either due to aging or genetic predisposition. Patients with prominent eyeballs relative to the cheek bone may require additional procedures to guard against lower eyelid descent.
How
Lower eyelid surgery may be performed under local or general anesthesia. Incisions are either inside the lower eyelid, trans-conjunctival, or through an external incision under the eyelashes. Fat is removed or transposed based on anatomy. Transposition of fat is used to fill in the tear trough. Skin excision is usually conservative to help guard against lower eyelid being pulled down. Procedure length is usually one hour or less. Trans-conjunctival incisions do not require sutures whereas the external sutures are removed at 3 to 5 days following the surgery.
Where
The procedure may be performed as an office procedure, is best performed in an accredited outpatient facility.
When
Bruising and swelling is expected, but usually resolves in 3 to 7 days. Return to work and activities is usually within a week, but may vary with the patient.
Facelift
What
Regardless of the multitude of terms used for marketing purposes a facelift remains surgical lifting and suspension of the descended tissues of the face. This can be accomplished with skin only manipulation or with techniques that address the deeper tissues, i.e. SMAS lift. All techniques have advantages and disadvantages and usually reflect a surgeons preference and experience.
Who
Any person dissatisfied with their appearance because of facial tissue descent secondary to aging may benefit from a facelift. patients who use tobacco, particularly cigarettes are at increased risk for complications. An ideal age does not exist for a facelift. Longevity of the procedure is determined by multiple factors including the quality of a patients skin, technique used and lifestyle choices following the procedure.
How
Limited procedures may be performed under local anesthesia alone, but more extensive procedures require general anesthesia or local anesthesia with sedation. A facelift is performed by making incisions in front and behind the ear with extension along the posterior hairline as needed. The skin will elevated away from the underlying tissue based on technique and need. Elevation of the deeper tissue may then be performed by sutures directly in this tissue or by traction of the raised skin. the excess skin is then trimmed and closure is performed based on surgeon preference. Procedure length is 1 to 3 hours. Sutures are usually removed at 5 to 7 days following the procedure. Depending on the extent of the procedure drains may be used which are usually removed the following day.
Where
Limited procedures are safely performed in office under local anesthesia, but more extensive procedures should be performed in an accredited outpatient surgery facility.
When
Recovery is dependent on the extent of the procedure. Patients with limited procedures may return to activities in 1 to 3 days whereas with more extensive procedures it may be 1 to 3 weeks.
Rhinoplasty
What
Rhinoplasty is manipulation of the cartilage and or bone of the nose to improve appearance and function. It may be performed with incisions inside the nose or external ones. Correction of septal issues may be performed concurrently.
Who
Patients unhappy with the appearance and or function of the nose.
How
The procedure may be performed under local anesthesia , but usually is performed under general anesthesia. Nasal cartilage may be removed, reshaped or added based on the problem. Bone may be removed, altered and or added based on the patients anatomy and issues. Procedure length is 1 to 3 hours. External sutures are removed at one week and internal sutures are dissolvable.
Where
Limited tip rhinoplasty or alar wedge excisions may be performed in office , but complete rhinoplasties are best performed in an accredited outpatient facility.
When
Bruising and swelling is expected particularly when bone is manipulated. external splints are removed at 5 to 7 days. Most patients return to unrestricted activity by 3 weeks.
Perio-Oral / Lip Enhancement
What
Lip enhancement is to improve volume and definition as well as other aesthetic parameters of the lip. This can be achieved by injections of filler or fat , insertion of implants or surgeries to increase vermilion show (vermilion advancement), decrease upper lip length (central lip lift), as well as to correct down turned corners of the mouth (corner of mouth lift).
Who
Patients who have loss of lip definition, volume, or shape due to the aging process may benefit from some or all of these procedures. Additionally younger patients who are unhappy with lip volume and vermilion show.
How
All procedures can be performed under local anesthesia including insertion of lip implants. Injections of both filler and fat are easily performed although fat requires harvesting. Implants are inserted through small incisions in the corners of the upper and lower lips. Central lip lift involves excision of skin under the nose and corner of the mouth lift involves excision of triangles of skin and transposition of the corner to a higher position. Procedure length is 15 minutes to one hour. Sutures when used are either removed at 5 to 7 days or are dissolvable.
Where
Usually in office unless part of a larger facial rejuvenation.
When
Bruising and swelling are usual , but will resolve within 3 to 7 days. Return to usual activities is typically one week
Facial Fat Grafting
What
Facial fat grafting involves transfer of fat, usually from the abdomen or thigh to the face. It is an effective and economical way for facial rejuvenation. Best results are achieved with multiple sessions spaced 3 months apart.
Who
Patients who lack facial volume either due to aging or their genetic predisposition.
How
Performed as an office procedure under local anesthesia. An anesthetic mixture is injected into the area where fat will be harvested. The fat is then removed with syringe liposuction and then centrifuged. Facial anesthesia is then achieved by direct injections and nerve blocks. Once facial anesthesia is achieved the fat is transferred with fine blunt tip cannulas to multiple areas based on patient need. Procedure length is typically 1 to 2 hours. Sutures are not required.
Where
In the office
When
Recovery is rapid with minimal bruising and swelling.