To answer your questions...

Reader's questions addressed, vol XII

Question #1:

An Answer:

Liposuction is a sculpting procedure. Areas that "stick out" can be addressed far better than "dimples." Without seeing you, I can't agree totally with the previous doctor's opinion, but with the information provided it seems reasonable.
Thanks for the Question,
John Di Saia, M.D.

Question #2:

>My wife would like to know more about a breast augmentation procedure which she thinks is called trans-umbilical surgery which I believe is performed endoscopically.

An Answer:

To start off: I am not really a big fan of this procedure. The technique was presented last year in Newport Beach Ca. by a surgeon from Texas who had supposedly done over 800 patients at that point. He only had two or three sets of pre and post-operative pictures and none past 2 months. As this procedure involves placing the implant ABOVE THE PECTORALIS MUSCLE, I am suspect that long term results may not be so good. The "Rippling" Phenomenon (bottom of this linked page) can be seen in time even in sub-muscular placements in areas in which muscular coverage is absent. It would be far more likely over the entire breast in a subglandular placement (above the muscle). The issue of a scar on the breast is usually not a large one, as most of my patients with the peri-areolar incision (through the nipple) cannot even see their scars at six weeks.
Thanks for the Question,
John Di Saia, M.D.

Question #3:

>As a kid I had a stupid accident on my bike. The result of my accident was scars on my knees. I'm wondering if you could tell me what I could do to remove these scars. Is there a type of surgery, what about the laser surgery (such as the ones they use for removal of tattoos)or is there something else? I'm also curious of the complete procedure that I would be taking with the surgery? If you do not do this procedure could you refer me to someone who does?

An Answer:

It is difficult for me to adequately answer a question like this without seeing you. More likely than not the scars could be surgically removed, but this area (the knee) is prone to poor scarring. An explanation of the types of poor scarring is probably appropriate here:

Keloid scars are the rare types of scars that really represent wound healing gone amuck. The scar tissue becomes raised from the wound quite a bit sometimes forming a very large bulk for an even tiny wound (like an ear ring hole). This type of scarring is hereditary with those of African descent being the most commonly affected. This type of scarring is the most "out of control" and not surprisingly the hardest to treat.

Hypertrophic scars are fortunately much more common. They can arise from wounds with strong underlying musculature such as on the upper chest and upper back as well as across joints where the scar is placed under tension quite a bit (such as the knees). These scars don't become as raised from the wound as do the keloids. They are far more likely to be treated successfully with surgery, silicone sheeting and/or steroid injections.

Back to the scar about which you ask:

You would probably see an improvement in the appearance and, if the scar is small, this improvement would be immense. But take into account that treating a scar leaves another scar. There is a bit of chance in operation here. On the lasers, physicians are working with scar improvement using lasers but this is really experimental. There is no convincing evidence that these lasers improve scarring.
Thanks for the Question,
John Di Saia, M.D.

Question #4:

>Dear Sir,
>I just descovered your information on the web. It's very informative. I have a couple of questions though. I just had lipo this past Wed. Of course I understand that I will be swollen for a couple of weeks. I am 5' 9" and before surgery, I weighed approx. 135 lbs. and my measurements were 37-27-37. What do think my new weight and measurements will be? It was performed on my inner and outer thighs, inner knees, and waste and lower back areas. Also I had so of the fat that was removed, injected into my upper lip. How long will it take for the swelling of the lip to go down, and when will I see the end result of this procedure?

An Answer:

Understand that given the specific circumstance in which I didn't do the procedure that I can't give you an outcome prediction. I am leary about predicting outcomes even in patients for which I have performed surgery. It is difficult to infer how individual patients will heal after a given procedure. One other point, fat injection in the lip is not permanent as most of the fat is absorbed. I would predict a "final result" at about 3-6 months for both the injection and the liposuction.
Thanks for the Question,
John Di Saia, M.D.

Question #5:

>I am a 47 yo woman considering having a facelift and after surfing the web for info, found that there are different types of procedures. Can you tell me the difference, technically between a SMAS, extended SMAS and deep plane, sub-periostial facelifts, and if this is too involved for you to answer, could you perhaps refer me to the appropriate texts or articles that would explain them. How much of a difference is there (better) if I were to choose say, the deep plane over the traditional SMAS? Do the more involved procedures cost more and is there more pain?

An Answer:

The terminology for facelift is unfortunately somewhat confusing. The traditional facelift includes dissection just below the skin and fat with re-suspension of the facial skin (including wrinkles). A SMAS lift in addition includes dissection of the fatty connective tissue below the skin known as the Superficial Musculo-Aponeurotic System. Some believe that the suspension of this layer as well as the skin may lead to increased longevity of the result. Deep Plane and sub-periosteal facelift techniques delve more deeply into the musculature of the face and therefore are (at least theoretically) more risky. The facial nerves (that mediate facial muscle movement) live in the material deep to the SMAS (in most cases). Even in SMAS techniques these nerves can be bruised (or worse cut) leading to potentially permanent deformity.

The great problem in determining which of these techniques may best suit you is that the degree to which one is better (or more risky) than another is a matter of opinion. My general leaning is to perform a SMAS lift (with the classical component) to provide a reliable low risk procedure. With this being said there are many surgeons that routinely perform classical lifts alone. There is no definitive right or wrong answer.
Thanks for the Question,
John Di Saia, M.D.

Question #6:

>I am looking for information on breast augmentation with out the use of implants. Is there such a thing? What is it and who is doing it?

An Answer:

(1) The popularity of breast augmentation using implants has been to a certain extent due to the ease of the operation, minimal scarring, and rapid recovery. The use of tissue from the patient's own body makes it far less easy and increases scarring.

(2) Some surgeons use fat removed during liposuction for augmentation. Seems like a good idea until you consider the fate of fat put into the breast. For the most part it melts away. Some of it collects calcium deposits and becomes "lumpy." Women need to carefully follow changes in their breasts for breast cancer. The placement of fat leading to nodules and calcium deposits is clearly counterproductive as it could mimic cancer on examination or mammography.

(3) Other surgeons have suggested using procedures traditionally used to reconstruct the breast following removal for cancer. These procedures using muscle and fat from the abdomen and back leave far larger scars and have higher risks (hernia formation, wound infection, loss of muscular tone/bulk in the donor sites). Higher risks, disability and larger scars are considered acceptable when reconstruction is the aim as this is a harder job in general.

The Bottom Line:

Some of these techniques do not lead to problems with surveillance for breast cancer, so they are potentially not harmful. The other techniques (cancer reconstruction techniques) have on the downside increased scarring and disability therefore most surgeons won't consider them for cosmetic breast surgery. Although breast implants have their associated problems, at present they are the best option for breast augmentation offering a simple operation with little scarring and disability.
Thanks for the Question,
John Di Saia, M.D.

Question #7:

>I had a c-section in 1990 which resulted in a vertical midline scar which begins just below my umbilicus and continues down into the start of my pubic hair. Would abdominoplasty then be a bad idea and would it possibly worsen my already pretty poor abdominal appearance? Is it possible that it could in some way be improved upon instead?

An Answer:

More likely than not a good portion of this scar could be removed during an abdominoplasty (depending upon how much skin and fat you have down there).
Thanks for the Question,
John Di Saia, M.D.

Question #8:

>I HAD THREE SURGERIES IN 1996 ON MY UPPER LIP. THE FIRST ONE THE DR. USED A DERMAL GRAFT TAKEN FROM AN EXISTING SCAR ON MY BUTTOCKS. IT WAS HEALING OFF-BALANCE...THAT IS THE RIGHT SIDE LARGER THAN THE LEFT. I ALSO WANTED THE SIDES LARGER SO THE THE DR. PLACED MORE DERMAL GRAFT ON THE SIDES AND MADE UP THE DIFFERENCE. THIS TIME THE RIGHT SIDE LEAKED WATER WHILE HEALING AND THE LEFT SIDE STAYED. FINALLY, HE INSERTED SOME ALODERM ON THE RIGHT SIDE. NOW, THE ALODERM LOOKS LIKE A BIG BLISTER. IT DID NOT BLEND WELL. I AM EXASPERATED. I WANT IT ALL TAKEN OUT AND WANT TO START OVER. WHAT CAN I DO TO GET THIS CORRECTED?

An Answer:

As you are becoming aware, lip enhancement surgery is not always easy. It is also controversial as to how (or whether) it should be done. In your situtaion, I would say you should be thankful that a prosthetic material was not used. These can produce even more problems if they become infected. Once you have had a number of operations on your lip (or anywhere else for that matter), it becomes harder to operate at this site (scarring). The degree to which skin (or aloderm) will absorb is always questionable. I would give the last procedure time to allow it to heal entirely and then carefully evaluate the area prior to trying another procedure.
Thanks for the Question,
John Di Saia, M.D.

Question #9:

I have had Breast Augumention performed. Saline Solution implants were used. I did not scar nor did I have any problems with loss of feeling or feeling hard to the touch (ed: contracture).
>
>The doctor implanted size 36C. I am not satisfied with the size of my breast. I also feel that my breast should be larger even for that size. I think my surgeon did a good job, but I am not happy with the size.
>
>Please let me know about additional risks involved with changing the size of my implants. I would like to have a full 36D size and for my breasts to be fuller. Let me know what I might expect from having this surgery. My surgeon went just below the nipple and I asked for them to be placed behind the muscle. Will there be as much pain associated with a second surgery - and will I lose more of my breast tissue. Also, are there additional risk involved in a second surgery?
An Answer:

Wishing to be "a little larger" is the most frequent complaint following augmentation surgery. I usually recommend that patients wait a few months to be sure they'd like an increase in size. With this being said, most patients will settle for the original size following a waiting period. The risk of going larger has quite a bit to do with how much tissue you had to begin with and how exactly your surgeon performed the operation. I would suggest asking him or her about this. It fortunately probably will not hurt as much as it did the first time if there are at least a few months between the procedures. You will more likely than not need new implants as saline implants are usually generously filled at the procedure.
Thanks for the Question,
John Di Saia, M.D.

Question #10:

>After reading all your answers to questions section I was still unable to find out the answer to my question. If I was to undergo a breast augmentation will the size of the areola change (as it does in pregnancy)? I am concerned about this, is so is there any way to prevent this from happening?

An Answer:

This really depends upon how large you wish to go and the relative "laxity" of the areolar skin. The areolae can get larger over time but it is rare assuming the breast is not made very large.
Thanks for the Question,
John Di Saia, M.D.

Please note that this information (as well as that on all my pages) is offered freely to individuals considering cosmetic surgery. No rights are granted and it is not to be reprinted or copied without the author's prior written consent. Beware that although efforts have been made to assure accuracy, many of the issues discussed here are a matter of professional opinion. Consultation with a qualified Plastic Surgeon should be obtained to answer more detailed and potentially personal questions.