To answer your questions...

Reader's questions addressed, vol VII

Question #1:

>Dear Sir:
>Could you please help me with this problem? I've had nine (9) children. One set of twins weighed approximately 14 pounds. The children range in age from 24 to 35. Needless to say, my stomach is in terrible shape. I am sure my stomach gets little support from the muscles lying there which tends to aggrevate a bad back. So far, I've not had to have surgery for the back and probably can delay that problem for a long time.

>My question is this? Is there a scenario in the previous statements which would allow insurance to pay for at least part of a tummy tuck and not label it cosmetic surgery? What are the questions I should ask a surgeon when I go for a consultation?

An Answer:

On the insurance issue, I have had a few cases in which an insurance company has been involved in surgery that the company assessed as "partially cosmetic." It has been a uniformly bad experience. These insurance companies often "after the fact" decline to cover the procedure (or cover very little of it) even when they have agreed prior to the surgery. They therefore leave the patient with a larger bill than she would have had if she had paid cash. With insurance coverage being as it is, many doctors and surgical facilities give cash patients a break on the bill. Once insurance gets involved, there goes the discount. Billing companies and billing personnel needed to bill insurance companies cost $$$. I am dubious that any insurance company is going to be of assistance in the areas of liposuction or abdominoplasty. If you indeed have back pain perhaps you should see an orthopedist to have that issue addressed.

With regards to questions to ask: for starters, these may include expectations, risks, and costs.
Thanks for the question,
John Di Saia, M.D.

Question #2:

>I've been considering breast augmentation for five years. But for the past two months, I've spent two hours a day checking out EVERY Web site (too much time on my hands you say??) for info on breast augmentation. Yours, my dear, is by far the most complete, candid, and educational. Your array of photos depicting a variety of results is stellar. (How about updating them so as to not bore your frequent visitors?)
>1. Are there textured saline implants which help reduce encapsulation? I read something about the fuzzy kind being replaced with a different non-smooth capsule.
>2. Can a woman's general physical condition be an indicator of encapsulation? I had Norplant birth control sticks in my arm for only a few months, and there were adhesions when they were removed VERY early due to bad side effects. Could this be a sign I might have encapsulation? Also, I have food and fragrance allergies.
>3. Is it possible for a woman to reject the implants completely, or is that kind of what the encapsulation condition is indicating? And can encapsulation be so severe that the implants must be removed?
>4. How uncomfortable would it be NOT to have general anesthesia, rather an IV/sedative?

An Answer:

(1) There are textured implants on the market and some surgeons use these on all augmentations. Others reserve them for cases of severe encapsulation (re-operation). There is evidence that capsules may be reduced with these implants. The price however may be that the implants stay "mounted" to the chest. Scarring is incorporated into the textured surface making it less dense, but "locking" the implant in place. This may become less the case with time, but I prefer a little "bounce" in the breast when a woman walks. In addition, textured implants may be more prone to infection and tend to be harder to remove at re-operation (should it be needed). In addition, a larger incision is usually needed to put them in position. I tend to use smooth walled implants for a "virgin" augmentation for these reasons.

(2) I am not aware of any absolutes with regards to encapsulation. Patients who tend to scar poorly may be at increased risk to forming severe capsules, but this association is not well documented.

(3) Allergy or severe reaction to hard silicone (the shell) is exceedingly rare. I know of a few "case reports" in the literature, but have never seen a case. Severe capsules with discomfort occur in less than 1% of patients. In some of these patients, implant removal is performed.

(4) There are surgeons who routinely perform the surgery under a local/sedation anesthesia regimen. I think patients are more comfortable and the procedure is more expediant under a general anesthetic. With regards to how uncomfortable it would be, pain tolerance is a very individual characteristic.
Thanks for the question,
John Di Saia., M.D

Question #3:

>Hello Dr. Di Saia:
>Congratulations for the excellent web-site you have constructed. I work for an Internet server in Puerto Rico. It's the best site I' ve seen about the topics on PS, and believe me, I have navigated enough to judge so. Two questions that I did not read in your volumes and that will surely put down my doubts if you answer them are:

>1. Is it safe and/or usual to improve breast size in women by prescribing estrogen or growth hormones? I know that in UK are stores for transvestite customers that retail some breast cremes, but they are formulated for men.
>2. How safe and/or convenient is it to have an implant if one has never had children and is planning to do so in the future? Should one wait until after pregnancy and breast feeding, even if it is years away?

An Answer:

(1) I have not heard of the use of hormones for breast enlargement and would not encourage it as I am unsure of the potential side effects. Some hormones are used in the prevention of breast cancer. Others stimulate breast cancer development.

(2) Saline implants in pre-pregnancy women are safe. Breasts do however swell during pregnancy and lactation. This swelling resolves following lactation leaving some breasts with ptosis "droop." This can happen in breasts with or without implants. In rare cases, women with implants wish revision following pregnancy to compensate for this phenomenon. I have seen post-pregnancy one-sided "droop" in one patient.
Thanks for the question,
John Di Saia,M.D.

Question #4:

>I am considering having upper and lower eyelid surgery. Today I spoke to an Ophthalmologist who has a clinic for this kind of surgery. He uses laser to do both procedures and on the lower lids he does not remove any skin but removes fat from inside the eyelid and then treats the loose skin with laser dermabrasion.

>Two questions - Do I want a plastic surgeon rather than an Ophthalmologist?
>What do you think of the laser procedure with no removal of skin in the lower lid? Would I be better off with traditional surgery?

An Answer:

The question of whether an Ophthalmologist or a Plastic Surgeon operates on your eyelids is an open question. Many Ophthalmologists are competant to do the procedure. You may wish to check whether or not he has done a Plastic (or some kind of Cosmetic) fellowship as not all Ophthalmologists are trained in their residencies how to perform cosmetic eye surgery. If your surgeon is adequately trained, it doesn't matter if he is a Plastic Surgeon or an Ophthalmologist.

On the procedure you described, it is being done more and more frequently. Lower lid blepharoplasty usually includes little or no skin excision. In some cases in which no skin excision is needed, a transconjunctival lower lid fat excision coupled with a laser resurfacing is reasonable.
Thanks for the Question,
John Di Saia, M.D.

Question #5:

> I have read your page with quite some interest. Very interesting. My problem..... I'm a 39 year old male with gynecomastia...not a bad case, but enough to make me self conscious about it. It is not bad as only the right side seems to be affected, but enough that I don't want to take off my shirt in front of other people. Have decided to have I guess liposuction done, as I do not want to lose any sensitivity or have any large scars, BUT, I can't seem to find a plastic surgeon in the Dallas area that will do this! Any suggestions, or have you or your collegues done any work on men? Also am considering having those unsightly "love handles" removed. What hazards am I confronting,and is there any type of "negative" effect to having liposuction done that would surface in later years? An Answer:

I am curious as to why you can't find a surgeon to do this. We commonly perform liposuction as an adjunct to gynecomastia excision. Quite often however the breast tissue directly under the nipple is firm and cannot be adequately removed with liposuction alone, so an incision beneath the areola is required. With rtegards to sensation, you can expect a temoporary loss of sensation both in the area treated with liposuction and the incision. In most cases, this sensation returns to normal. There could conceivably be a loss, but I have not seen a case in which the loss (usually quite small if any) was a bother to the patient. Incisions when they heal form scars, but again these are usually not objectionable.
Thanks for the Question,
John Di Saia, M.D.

Question #6:

>Dr. Di Saia,
I have found your web site to be a wonderful resource for individuals seeking initial information regarding cosmetic & reconstructive surgery. I recently had the 'new' liposuction technique performed and incurred medical complications. I would like to offer to you what occurred and ask that you consider my experience when advising visitors to your web site of potential complications. I am still not quite sure of all the reasons my surgery did not go as well but some obvious points should help others:

>I am 36 years old, 5'3" and weigh 107 pounds. I have two children (5 & 9) and am very active. I chose to have the procedure performed because I felt my back-end and thighs were out of proportion to the rest of my body. Losing additional weight did not make sense---I would look more 'anorexic' from the waist up and show little improvement in the lower area. I selected a well respected & recommended surgeon in Atlanta.

My surgery was last Thursday (one week ago). I was scheduled for surgery at 1:30pm. My last meal was at 6pm the previous day (and of course, nothing to drink after midnight). My physician was delayed due to 2 previous surgeries that day. I did not begin to be prepped until 4:30pm on Thursday.

>During this process, I began to faint. The anesthesiologist gave me a shot to boost my heart (not quite sure what this was) for surgery. He pronounced me ready to go for my Dr. I awoke after surgery. I was told that 2 containers (I was shown 2 clear plastic cylinders) were filled during the process. I was very weak and continued to feel faint. My blood pressure was 70 over 30.

>After a few hours and repeated attempts to boost the pressure, the Dr. had an ambulance called. I was admitted to the ICU at the local hospital at approx. 1am. The blood pressure had not risen. They positioned me in kind of a 'stand on your head' position. After testing, I was told a blood transfusion was required due to severe blood loss. This was 'concentrated' blood (i.e. no plasma, etc.) to evidently help me over a very low count of hemoglobins (3 or 4 I think). Overall diagnosis?
>Severe dehydration & blood loss

>I remained in ICU till the next afternoon and then was transferred to the post surgery ward (blood pressure had risen to 104/50---my normal is very close to this--111/60). I am now back at home and doing much better. I asked my doctor why this occurred and he stated that it 'appears you continued to bleed after surgery'.

>I realize my case may be a bit rare but I think it must be used to counterbalance perceptions built by the 'Prime Time Live' type stories that show ladies talking on the phone during the procedure---totally distorting the reality of what could go wrong and what recovery is truly like.

A Few Questions for the Young Lady:

(1) Is your surgeon a boarded Plastic and Reconstructive Surgeon (meaning boards from the American Board Of Plastic Surgery)?

(2) Did you have any bleeding tendency prior to the surgery (easy bruising, easy or prolonged nose bleeds)? Were tests ordered?

(3) How much material was removed at the operation? There are limits over which blood transfusion is potentially indicated. Did your doctor plan on removing as much material as he did?

(4) To what "new" liposuction technique do you refer?

To say that your case is "a bit rare" is an understatement. Careful preparation prior to moderate or large liposuction procedures is essential however to keep it's incidence as low as possible. I hope your recovery from his point is smooth.
John Di Saia, M.D.

The Patient's Response:

Dr. Di Saia, it was very kind of you to respond. Here are the answers to your questions. I hope they add clarification!

1) Yes, the physician is certified with the American Board of Plastic Surgery. If everyone is to be believed, I am truly the very first of his patients to have complications. I really believe it was a freak incident and have a good deal of faith in his skill. I am chalking this one up to poor judgement (and luck) on my part. I am not seeking fault with him.

2) No prior major bleeding problems. Heavy nosebleeds as a child. I did require a C-Section with my first child and had no problem with this. I might add that 10 days prior to surgery, the patients must begin taking tablets of C vitamins, Iron tablets AND Mephyton (small yellow tablets with 'MSD 43' written on them). I believe the Mephyton is to control bleeding. I was traveling quite a bit with my work up to the day before surgery. I admit to being a little haphazard on the pill taking (again, fault is mine!). I also had the blood clotting test (where they prick you and use the circle paper to measure your clotting rate). My rating was within the preferred range.

3) I met with my Dr. this am. He stated that 1 gallon of fluid was removed, approx 2 quarts of fat. He thinks he may have hit a major vessel. I have incredible bruising down to my ankles and he said it was due to the continued bleeding after surgery.

4) 'New' lipo technique is called 'Tumescent.'

I am feeling really very good now. I have not needed to take my pain pills since I returned home (and I only hit the demerol button twice on my IV when I was in the hospital so that is somewhat ok). With children, Tylenol is the wisest choice I think and has worked fine for me. I have not needed it in the last couple of days. I began to work from home on Wednesday and was very busy Thursday & Friday. Did a lot of running around this weekend with no problem. I will not return to regular exercise class for another week. I don't feel like gasping for air and I am sure no one at the gym wants to see blue legs! I myself am pretty much cured of my vanity, for others, I would say:

1) Ensure your surgery is scheduled in the morning.
2) Ensure you are eating correctly weeks before surgery (I say this because a blood analysis also showed my protein count to be in the 1.x range. I do not eat red meat and evidently I was eating too few quantities of chicken, fish etc . i.e. I don't believe my system was in great shape to handle this even if I thought I was physically ready.
3) Take all prescribed medication. Sounds like a no brainer, but otherwise intelligent folks like myself will still discount the necessity of it.
4) Seriously evaluate reason for surgery. I did it for shape, not weight loss. Anyone (personal opinion of course) who does it as a weight loss aide should be turned down. It is much easier to lose the weight via appropriate behavior modification/counselling than it is to incur surgery.
5) Get as much information on your Dr. as possible. (not a factor in my case but if this can happen with someone of my guy's reputation, I shudder to think what could happen with someone else!)

A Wrap-up:

(1) The surgeon seems well-qualified (a Boarded Plastic Surgeon).
(2) Her clotting time was normal, but she did have heavy nosebleeds as a child. Her previous surgery (C-section) went without a hitch. The pills were an added bonus. Not all surgeons give their patients Vitamins and hormones. The blood protein (albumin?) seems very low. It is plausible (but extremely rare in an American) that a dietary problem could have been contributory.
(3) A large quantity was removed (two quarts of fat)!
(4) Tumescent liposuction is not really a new form of liposuction (almost ten years old).

It seems that her care was appropriate from the information provided. Her course despite the appropriate precautions displays that even when procedures are correctly followed unexpected events can follow. The good news here is that these events are the exception rather than the rule. Most liposuction procedures are much less exciting than this one. A Parting Note: I doubt that the time of the operation really affected the outcome.
Thanks for the questions,
John Di Saia, M.D.

Question #7:

>I had tumescent liposuction on my abdomen and outer thighs on June 19. I'm thrilled with the results (finally), although I'm left with scars at the sights of each incision that was made. It's better than having the fat there, but I'm a little disappointed to be left with scars. Any advice on how to get rid of this? Each spot looks like a tiny black and blue mark.

An Answer:

Scars are to be expected with any operation. It is not a matter of whether or not scars will result, but how objectionable they will be. My opinion is that this is where training and skill come into play. You'll find physicians in many different specialties performing liposuction. Only in a Plastic Surgeon's training, however, will you find issues specific to the art of making scars as inconspicuous as possible. This is not to say that the work of a Plastic Surgeon will leave no scars, but we have been trained how to make them "pretty."

After the surgery has been performed however, it is prudent to lets the scars "declare" themselves. The body will heal in stages. Normal scars become the most noticeable in the first weeks and months to "settle down" over the first year. I would keep the areas out of the sun to avoid changes in pigmentation and let your body "re-model" the scars the best it can. After this period of time, look at the areas. For those that are objectionable, excision and careful closure may be indicated. It is pertinent to note here however that in this case you "trade" one scar for another. Most often the new scar will be less objectionable than the first, but you can't ever be 100% sure.
Thanks for the question,
John Di Saia, M.D.

Question #8:

>I noticed all the mail from females...but I'm a 50 year old man in relatively decent shape except for love handles which I've had even when I was downright skinny. How effective is liposuction in cases such as mine?

An Answer:

Liposuction in males (as well as Cosmetic surgery in general) is becoming more popular. The "Love Handles," as you might expect, are amongst the most common areas in which treatment is requested in men. The results here really depend upon the laxity/elasticity of the skin over the area and the amount of fat to be removed. If the skin is elastic (and/or the amount of fat to be removed is small), suctioning is more successful. The skin "tightens" around the area following surgery and the appearance is good. If the skin is lax, then a skin fold can form following surgery which tends to be less attractive. Wearing of a "wrap-around" type garment is very important following the procedure to keep the skin flap juxtaposed to the underlying abdominal wall.
Thanks for the Question,
John Di Saia, M.D.

Question #9:

>1. Is there a procedure that can remove stretch marks or improve their appearance?
>(My return question) -Where are the stretch marks?
>(Her reply) - On my hips and buttocks and I have had them since I was a teenager. I am 5'7 and 130 pounds. I have never been overweight but have fluctuated between 5-6 pounds in both directions.

An Answer:

Stretch marks are a problem for which there are a limited number of solutions. When they are on the abdomen (particularly when they are just over the pubes), an abdominoplasty may be useful. It rarely removes them all though. These types of stretch marks tend to appear after pregnancy

In your case, they are on the hips and buttocks. Removing them surgically trades the marks for scars (rarely worth it). There is experimentation currently underway with regards to the utility of certain lasers here. At present, it is not known whether they will be helpful. They could make the marks worse.

In general, I would recommend keeping the areas out of the sun to keep pigmentation changes to a minimum. Bleaching creams may give you a slight lightening in the color which may make them less conspicuous.

Thanks for the question,
John Di Saia, M.D.

Question #10:

>Dear John,
>I appreciate your home page and information very much. I found your page before I went ahead with the breast augmentation. I breastfed my son for two years and wasn't pleased with the way my breasts had become so I had the operation in July (two months ago). I am unable to speak to my plastic surgeon at this moment and I'm worried.

>My implants are placed above the muscle, I went from 32A to 34B. Actually I did not fill up the 32A bra cup but that was the size I wore. I am asian, 5ft3, 44kg. I have thin, delicate skin. I am experiencing sensitivity and tenderness in my nipples and still sore in the area near the incision of my right breast (lower side of breast). My left breast is all right, except for the sensitive nipple. What can I do to minimize this discomfort? Is this temporary, and will it go away? I am not in great pain, just not comfortable and I'm worried.

An Answer:

You put me in an awkward position as I really don't know how your surgeon performed your surgery. I would advise that you call him or her Monday morning. If the pain is progressive or you see redness in the breast you may wish to call him tonight.

To address your tenderness, some women following implantation have sensitivity as the breast projects into the bra/clothing more following surgery. Sometimes the placment of a cotton ball over the nipple for the first few months is helpful.

Incisions can be uncomfortable and "tingly" and even itchy on occasion especially early on (first few weeks to months). Massage of the area of the scar can be helpful.

It is common following breast augmentation to have sensory changes. Usually this amounts to a small decrease in sensation. Fortunately, in 85% of patients the sensation returns to normal. 15% however will have some permanent change. The degree is usually very mild.
Thanks for the question,
John Di Saia, M.D.

An Interesting Reply:

Dear John,
I'm very grateful for your reply, thank you so much. I'm so relieved. There are very few plastic surgeons or medical specialists in Malaysia and because of this, most of them have an "authoritarian" attitude, like if you consult me, we do it MY way. I did not have much choice on prodecure,what implant size, how many cc. etc. Here most of us patients leave it up to the doctor. Which is why I found your homepage informative and helpful.

I haven't told anyone I had breast augmentation, only my husband and parents know. And my father was not happy that I went through with it. Nobody talks about breast augmentation here, it is a "hush-hush" topic.For example sex is taboo, that sort of thing. So I couldn't discuss with anyone.

I always find interesting the differences in different cultures regarding cosmetic surgery. It is surprising to me that the surgeons in Malaysia seem to cater not a bit to the desires of their patients (by the looks of this)!

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.



©1996-2004 John Di Saia, MD... an Orange County California Plastic Surgeon       John Di Saia, M.D.