How soon after getting liposuction is it safe to fly on an airplane? What are the concerns about flying, if any?
The concerns about flying after a major surgical procedure are related to the risk of developing deep venous thrombosis, or DVT, and the related complication of pulmonary embolism, or PE. Flying in itself is a risk for these conditions. Sitting for prolonged periods, with the ability for leg movement limited, causes pooling of blood in the lower extremities. This increases the risk of clot formation in the deep veins of the legs. Anyone in a hypercoagulable state from illness, medications or recent surgery is at an increased risk for this disorder. Any major surgical procedure induces some degree of a hypercoagulable state through trauma to tissues and small blood vessels. In plastic surgery, procedures that most significantly contribute to this state include abdominoplasty and liposuction. Following either of these procedures, or any other major surgery, it would be best to avoid air travel for a minimum of 10 to 14 days. With air travel shortly after this period, prophylaxis against DVT and PE should be considered only through consultation with your surgeon. Medications used for prophylaxis would include subcutaneous heparin injections as well as aspirin and other platelet inhibiting agents.
This is a timely question. Just last week I performed a facelift on a woman in her mid 40s who had a thread lift procedure 3 years prior. During the facelift procedure, I spent part of the time removing old threads which had fallen apart and were no longer providing a lift. As with many other new and improved procedures, the thread lift was touted and promoted as a wonderful alternative to facelifts. However, it made no sense from a surgical perspective to expect that simple threads with tiny barbs threaded through the face to pull up the tissue could provide long lasting improvement and was simply unrealistic. As such, I never perform the thread lift procedure despite it being embraced by many cosmetic surgeons, a number of them who do not have surgical training, such as dermatologists, to perform traditional facelift procedures, which are the gold standard for facial rejuvenation. These procedures are fortunately hardly if at all performed as the public has become educated and physicians have finally seen the results. Any time the embracing of brand new technology is conducted prematurely, there will be disappointments. As a result I typically wait no less then 2 years for incorporating new procedures to my surgical regimentation so that I can adequately advise my patients as to the risks and benefits.
What are the most common reasons you see people seeking revision rhinoplasty?
Most plastic surgeons will agree that to truly perform correctly, rhinoplasty is the most challenging plastic surgery procedure. It essentially involves the sculpting of cartilage and bone so that enough is done to these support structures but at the same time not too much so that the support of the nose is weakened and then the overlying skin is expected to heal over the bone and cartilage to create the desired results. Any plastic surgeon can perform a basic rhinoplasty; however, the aesthetic results may not be achieved unless the surgeon is truly experienced in all the different maneuvers. Approximately one-third of the rhinoplasties I perform are revision procedures. The most common reasons for the patient desiring these procedures are the over-resection or the under-resection of cartilage and bone that results in the patient having scooped out appearances, asymmetric tips, or residual bumps whether of the bone or, more commonly, the cartilage. Other indications include nasal bridges that were not broadened or were not narrowed enough and perhaps were not even set in, asymmetry of the tip and middle of the nose, difficulty breathing due to inadequate septal work or loss of support of the nose, under projected and/or very weak tips, tips that were either rotated too high up or were left hanging down, and noses that remain crooked or that are crooked as a result of the surgery. There are a variety of advanced techniques that are used in revision rhinoplasty that allow for significant improvement in aesthetic appearances as well as the function of the nose.
What is the difference between a mini facelift versus a full facelift?
More and more patients are requesting partial facelift procedures to avoid the rather large amount of surgery and extensive recovery involved in having a facelift. The reality is that most patients do not need to have a full facelift which includes the elevation of the mid face, the lower face, the removal of fat as well as the tightening of neck skin, and sometimes extending up to the eyebrow region. Especially for younger patients, mini facelifts or mid facelifts or neck facelifts can be excellent and very effective alternatives and are becoming more and more the mainstay of my facial rejuvenation practice. Most of these procedures can be performed in the right patient under pure local anesthesia with some mild oral sedation if the patient so desires. They typically take an hour and a half to two hours and involve working in smaller parts of the face for focused distribution such as, for example, in the male patient who is only concerned about turkey gobbler or the excess skin of the neck, smaller neck work could be performed. Meanwhile, in the woman who feels that her mid face appears to be more hollow and older appearing, a direct mid facelift could be performed. To speak of these as mini or partial facelifts does not mean the results are not as long lasting and deep tissue elevation is performed similarly as in full facelifts.
What is the difference between a facial plastic surgeon and a plastic surgeon?
The number of doctors performing cosmetic surgery procedures have significantly increased over the past 18 years since I have been in practice. Originally, the only doctors who were board certified and could claim to perform plastic surgery were doctors board certified by the American Board of Plastic Surgery. To have certification by the American Board of Plastic Surgery, a surgeon needed to complete typically 5 to 6 years of training in both general surgery and plastic surgery. During the 3 to 5 years of plastic surgery training, the courses of study are divided into hand surgery, burn treatments, reconstructive surgery, cosmetic body and breast surgery, and some facial surgery depending upon the training program. Facial plastic surgeons are typically board certified by the American Board of Otolaryngology, so therefore they undergo 1 or 2 years of general surgery followed by 3 to 4 years of ear, nose and throat and head and neck surgery. This includes intensive training in both reconstructive, functional, and cosmetic surgery of the head and neck including the cheeks of the face, neck, and nose as well as eyelids. To be certified by the American Board of Facial Plastic and Reconstructive Surgery, in addition to being able to pass an examination similar to what doctors who are American Board of Plastic Surgery certified, the majority of these facial plastic surgeons must complete a 1 year Fellowship in pure facial plastic surgery. During this 1 year, the surgeon will perform reconstructive and cosmetic surgery of the nose, eyelids, neck, face, and brows and in some programs the scalp would be included in the treatment of hair in some cases. The only surgeons in all 50 United States that can claim to be Board Certified in plastic surgery are those who are either certified by the American Board of Plastic Surgery or the American Board of Facial, Plastic and Reconstructive Surgery. Other surgeons who call themselves cosmetic surgeons can in fact in most cases perform elective cosmetic procedures but they cannot state that they are board certified in these areas but they can have proficiency in these different procedures.
What are the pros and cons of breast implant placement under the muscle compared with on top of the muscle?
Breast implant positioning with augmentation surgery can be described as a subglandular position, which is on top of the muscle and beneath the glandular tissue of the breast, or a subpectoral position, which is under both the glandular tissue and the pectoralis major muscle. An alternative is what is described as submuscular positioning where the implant is positioned beneath the pectoralis major muscle as well as beneath a second muscle called the serratus anterior muscle.
The main benefit of placing a breast implant beneath the pectoralis major muscle is to provide greater soft tissue coverage of the implant. This primarily is performed to minimize the risk of the complication of capsular contracture and this effect is well documented in the medical literature. Another benefit of this positioning of implants is to decrease the risk of visible rippling or wrinkling of the implant. The implant not only may be less visible but may also be less palpable, particularly in the upper pole in the area of the pectoralis major muscle. Additionally, this implant placement can lead to greater fullness in the upper pole of the breast, which results in, at times, an augmented appearance to the breast with convexity of the upper pole. Subpectoral or submuscular position of implants generally results in slightly higher positioning of the implants on the chest wall.
Subglandular positioning of the breast implants on top of the pectoralis major muscle and beneath the glandular tissue, although being less protective against capsular contracture and resulting in a higher likelihood of visible rippling and wrinkling, has other potential benefits. The possible benefits include lower positioning of the implant on the chest wall, which may result in a slight lifting effect, or upward rotation of the nipple, which may be desirable in a case where there is some ptosis or sagging of the breast. Subglandular positioning of implants results in less dramatic upper pole fullness and a more natural appearing result, with a less obviously augmented look. Additionally, placing implants in a subglandular position should be less painful than subpectoral or submuscular positioning.
In general, patients with smaller breasts with little or no ptosis or sagging are more likely to have implants placed in a subpectoral position. Patients with larger breasts and possibly with some ptosis or sagging are more likely to have implants positioned in a subglandular position for augmentation.
Can you explain what capsular contracture is and how it’s treated?
Any time any type of implant is placed in the body, a fibrous layer of connective tissue will develop and surround the implant. This is called a capsule. Particularly with breast implants, this layer of connective tissue may at any time shrink and tighten around the implant. This process of tightening is called capsular contracture. With mild forms of capsular contracture, the breast becomes somewhat more firm to the touch. With more severe forms, the implant may become distorted or displaced, which can alter the shape of the breast and result in asymmetry.
Once capsular contracture is recognized after breast implant surgery, it should be addressed immediately. There is a window of opportunity during which the process may be reversible. Early interventions include aggressive massage of the breast to stretch and soften the capsule as well as strapping the breast with the use of garments and tapes to displace the implant back to the desired position. Treatment with high energy external ultrasound devices may also help to soften the capsule and breast.
If these non-surgical interactions fail then surgical revision may be required. Surgery to treat capsular contracture may involve any of the following: excising part or all of the capsule; repositioning implants beneath the muscle or exchanging to textured surface implants to prevent recurrent contracture; and introducing steroids or other anti-inflammatory agents to the pocket to prevent recurrence.
Recent use of acellular dermal grafts to replace the excised capsule and to line the implant pocket has also proven to help correct capsular contracture and to decrease the risk of recurrence.
How important is it to wear compression garments after liposuction? What do they do and how long should they be worn for?
It is extremely important to wear compression garments after liposuction. This is an integral part of the procedure and is critical to achieving the best possible result. First stage garments are worn for the first two weeks. These are high compression garments with reinforced panels and snaps and zippers on the seams. These garments should be worn around the clock except for dressing changes and bathing. These garments control bleeding and bruising immediately after liposuction. Later, they help prevent the development of fluid collections during the following several days. After that, they support and stimulate skin contraction to achieve the new and improved body contour.
Between two and six weeks after liposuction, second stage garments are worn during daytime hours and may be removed at night. These are more comfortable, more practical garments with less compression, that are easier to take off and put on and easier to wear under clothes. Second stage garments should be continued beyond six weeks until swelling has completely resolved and maximal skin contracture has occurred.
What areas of the body are the most painful for undergoing liposuction?
There are some minor variations in the amount of pain experienced from liposuction of different body parts. In general, liposuction of the extremities, arms and legs, is a little more painful than liposuction of the abdomen, flanks and back. This is at least in part due to more movement and weight bearing on the extremities and more manipulation of the treatment areas on these parts when removing and replacing garments. Liposuction, for example, of the lateral thighs, which is one of the more commonly treated areas, can be more painful than other areas due to the fact that pressure is frequently applied to these areas after surgery when sitting or lying down and when removing or replacing girdle-type garments. The location of treatment areas is probably a less important factor in determining the degree of pain after liposuction than the type of liposuction performed. Many modern liposuction techniques include the use of energy sources such as ultrasound or laser that first partially dissolves fat before it is evacuated by traditional liposuction techniques. These advanced procedures may allow more aggressive treatment and may result in more of a burning-type pain sensation after treatment.
In spite of these relatively minor variations, liposuction of any body part and with advanced techniques is usually very well tolerated by most patients. The use of narcotic pain medication is most often required only for a few days after surgery.