Real Self Top Q&A

Kim:    Happy Wine Down Wednesday everybody.
Kim:    Okay, today we're doing a Q&A on RealSelf. Instead of a specific topic we looked up on RealSelf what the most common procedures are, the most popular and what some of the more common questions were.
Kim:    Right.
Dana:    So Mel is going to fire some questions at us and if anybody else has questions you can feel free to add them to the mix.
Kim:    I guess we'll back up for a second. A lot of people don't know what RealSelf is.
Dana:    Oh, good point.
Kim:    It is a really, really good portal website for people to go to to kind of get your answers. You can even post your own pictures. You can post questions. You can find out patients who we've done who've gone in there and posted reviews, so I guess we can explain RealSelf a little bit.
Dana:    Yeah. RealSelf is called a patient portal for plastic surgery, meaning it's a place where patients can go and log in and get a chance to pose questions to a group of doctors. For example, I get questions emailed to me every day and I can either choose to answer them or not. I tend to answer questions that either have something to do with the surgeries I like to do a lot of or questions posed by patients who are geographically pretty close by.
Kim:    Right.
Dana:    We have had patients where I've answered a question and then they've come in for a consult and we've ended up doing surgery. It's also a really good place for people to get information. Say, for example, you're not sure: Do I want textured implants or smooth implants? Do I want a lift, do I not want a lift? You can, like you said, go read about other patients' stories.
Kim:    Their experience.
Dana:    And see their pictures from week one, week two, week twelve and just kind of follow along to figure out how surgeries work for people.
Kim:    Yeah. There is a ton of questions on RealSelf.
Dana:    Oh, thousands, yeah.
Kim:    We're going to kind of pick out just a bunch of different ones that we think are really the top, number one most commonly asked questions. So fire away, Melissa.
Melissa:    All right. Starting with tummy tucks: How much weight can I lose from a tummy tuck surgery?
Kim:    Hmm. Weight.
Dana:    Yes. In actual weight, it's usually not any more than two to four pounds.
Kim:    Right.
Dana:    And that's a fairly large tummy tuck, but the effect of it-
Kim:    It's more feeling.
Dana:    For most people looks more like you've lost 10 or 15 pounds because it's taking a problem area and just getting rid of the whole problem area.
Kim:    Right.
Dana:    Especially for women after kids where you're in shape, you go to the gym, but you just have this loose skin, you're not going to be able to get rid of that any other way.
Kim:    Well there's lots of patients too, like they'll ask us, they'll say, "Well, should I lose five to ten pounds before surgery or will I feel like I've lost five to ten pounds after surgery." Usually the answer is: You'll feel like you did but on the scale you may not have.
Dana:    Right.
Kim:    Yeah.
Dana:    The other part of that question, even though it's not asked directly I get this a lot, is: Should I lose weight before a tummy tuck or after?
Kim:    Mm-hmm (affirmative). That's super common.
Dana:    The general rule of thumb is: If you have more than about 15 pounds to lose, you're better off losing it before. There'll be less stuff in your abdomen, we can tighten the muscles more. If you have any more looseness to the skin from losing more weight we'll be able to take care of it.
Kim:    Right.
Dana:    If you lose 10 or 20 pounds after a tummy tuck there is a chance that you could end up with a little more looseness.
Kim:    There could be excess skin again. Yeah.
Melissa:    Okay. Another question on tummy tucks is: Can you have a baby after a tummy tuck surgery?
Dana:    Yes.
Kim:    We have had people who have.
Dana:    Literally in the last two months we have had three of our tummy tuck patients come back having gotten pregnant in the first year after their tummy tuck. One was pregnant at her two-month follow-up visit. One got pregnant about six months after surgery and the other came back 18 months after her follow-up with a six-month old baby. I guess not surprisingly but a little bit surprising to me-
Kim:    Not ideally.
Dana:    They didn't look bad.
Kim:    Right.
Dana:    None of them need a repeat tummy tuck at all. There's a little more laxity to the skin and since the muscle repair usually holds things in pretty tight, some people actually end up getting a little stretching from side to side.
Kim:    On the side. Yeah.
Dana:    And it's tricky because it's not something that lipo can really take care of because it's just the lining of the muscles has stretched because the abdominal contents had to go somewhere. But luckily, yes you can have a full-term healthy pregnancy after tummy tuck and thankfully it doesn't usually undo the results too much.
Kim:    Right. Yeah.
Melissa:    And kind of the opposite of that, is it okay to have plastic surgery while menstruating?
Kim:    That's a good question.
Dana:    It is an interesting question, and I never thought a patient would actually ask that, but somebody asked that last week.
Kim:    But your pain levels usually are heightened.
Dana:    I do tell patients getting Botox and filler, try not to get it around your PMS or menstrual cycle because it does hurt more.
Kim:    Right. Yeah.
Dana:    You tend to bruise more and swell more. There was a study in our journal where they looked at patients getting breast reduction surgery and they did find that women who were in their teens and twenties who got a breast reduction did better and had slightly fewer side effects and problems after surgery when they weren't on their period for the surgery. But it didn't apply to every age group. It didn't apply to breast augs or surgeries other than a full breast reduction.
Kim:    That's interesting.
Dana:    In general, I would say you can have surgery when you're menstruating, and who wouldn't want to be on drugs when they have their period?
Kim:    Kill two birds with one stone.
Dana:    That's another pro right there.
Kim:    Yeah, we always kind of say that usually when it comes to the vaginal surgeries, we're like, hmm.
Dana:    Yeah, and I have-
Kim:    Because you might be bleeding anyway, so just kill the two birds with one stone.
Dana:    Absolutely. Yeah. I have had plenty of patients even try to plan their labiaplasty around their period, and sometimes they miss it and I have seen menstrual flow pre-op, post-op, intra-op. It's not really a factor.
Kim:    It's not something to factor in. Yeah.
Dana:    No.
Melissa:    All right. In regards to the scarring, how soon can you start using silicone scar sheets after surgery?
Dana:    Normally I would say it's going to be about two to three weeks for patients in my practice because we use Steri-Strips, the little tape strips, on the incision after surgery and we want to wait until those are gone. Most of the time when we take those off at two weeks if there's no scabs on the incision you can start scar strip therapy that day. Now it kind of depends on whether you're using a regular scar strip or Embrace scar strip.
Kim:    Or Embrace, yeah.
Dana:    Because the Embrace strips are meant to leave on for a week and if you're not sure if there's going to be a developing suture problem or scab, you may not want to waste your $100 scar strip.
Kim:    They're $400, aren't they?
Dana:    Well for a set that last lasts you two months.
Kim:    The set, yeah.
Dana:    Even one application can be between $50 and $100.
Kim:    Yeah, so bottom line, we start working on your scar.
Dana:    So here's my general recommendation: The moment you take off your Steri-Strips you can start using a scar cream, like Stratamed. It's a silicone-based scar cream but it's safe to put on open wounds.
Kim:    It's like an ointment.
Dana:    Not all scar creams are. That is something patients can start to use right away. When you're pretty confident you have no more scabs, usually by three or four weeks after surgery, then you can easily start using a scar strip.
Kim:    Right.
Melissa:    All right. And also: When can you go back to swimming after surgery?
Kim:    Oh, that's across the board.
Dana:    Pretty much the same timeline. Yeah. Any time you have an incision, you want to wait until the incision is healed, meaning there's no scabbing over the incision and it doesn't look like dry, flaky, brand-new baby skin.
Kim:    Right, which can kind of differentiate between different people.
Dana:    Sure.
Kim:    But usually about two weeks, right?
Dana:    Usually about two weeks. Now, if somebody's had a breast lift with implants underneath it, I'm a lot more strict about water exposure than somebody who has had liposuction and just has a couple of small incisions with no implants.
Kim:    Right. Because you don't anything, bacteria to get where the implants are.
Dana:    Absolutely.
Melissa:    Okay. So switching over to breast augmentation, there is a question: Can you do breast augmentations on asymmetrical breasts? Will it make them look worse or will it make them look better?
Kim:    Asymmetrical is almost everybody.
Dana:    That's the norm, yeah. No, we take measurements on everybody and it's really unusual for somebody to have the exact measurement side to side.
Kim:    You are the freak.
Dana:    Yeah, the exception to the rule.
Kim:    You are the exception to the rule if you have perfectly asymmetrical breasts.
Dana:    Most of the time getting implants doesn't necessarily change your natural symmetry. It can in certain patients tend to mask minor asymmetries.
Kim:    Right.
Dana:    Other times it can exaggerate them.
Kim:    Right. And accentuate it.
Dana:    And it really just depends on what it is. If one nipple points slightly up and the other one is more forward, that may be exaggerated after implants.
Kim:    Right.
Dana:    So it is good to be aware that everybody has these asymmetries and they don't necessarily mean you won't have a good-looking result.
Kim:    Right.
Dana:    Not everybody is a mirror image from side to side, in fact most people aren't.
Kim:    Yeah. And you don't always need implants for asymmetry. If somebody had like a C, D cup breast and an A cup, which we've seen where people go through puberty and it doesn't grow symmetrically.
Dana:    Absolutely.
Kim:    You can always do a little reduction and lift on that one side if you don't want to do implants to match it up.
Dana:    Yeah. We have patients come in and say, "Oh, well I asked for a breast lift on this one side to match the other and the doctor told me because of my size I would do better with larger breasts and I should do implants."
Kim:    Just make them all larger, yeah. No.
Dana:    It's not necessary.
Kim:    Right.
Melissa:    Okay. Also pertaining to breast implants: How can breast surgery affect mammograms, or does it not affect them at all?
Dana:    Most of the time after breast surgery you're going to want to get a mammogram right before surgery, especially if you already quality for one. Now women in this country at age 40-
Kim:    40 and up.
Dana:    Should have a mammogram before surgery, or if you have a family member with breast cancer that was diagnosed before age 50, then you should get it ten years before they were diagnosed.
Kim:    Right.
Dana:    After surgery it's technically safe to get one within about three months, but given what they do to the breast during a mammogram, most patients are more comfortable about six months later.
Kim:    Yeah.
Dana:    If you've gotten one right before surgery you shouldn't need one for another year.
Kim:    Well I think on the question, it's more or less like can you actually see stuff.
Dana:    Well and that's the other part of it.
Kim:    Is it going to hinder what you see? But that could also ... It does vary between whether the implant is subglandular or submuscular.
Dana:    Well and whether you did an implant.
Kim:    Right.
Dana:    Let's talk about implant breast surgery and non-implant breast surgery. With implant breast surgery you're going to have to tell them you have an implant. They'll get something called Eklund views where they do a couple extra views on the mammogram and that allows you to see a little bit more breast tissue. Ultimately, you may miss about 5 to 10 percent of the breast tissue, but a normal mammogram on somebody without implants has the potential to miss a little tissue too.
Kim:    Right.
Dana:    They've done studies, there's no delay in diagnosis for patients with implants or being diagnosed at a later stage.
Kim:    They can also do an ultrasound too, to get like a double application.
Dana:    Absolutely.
Melissa:    So I guess that question: How does breast implants affect breast ultrasounds?
Dana:    They thankfully don't affect breast ultrasound.
Kim:    Right.
Dana:    You can usually see the implant and the pocket pretty well. If there's fluid around the implant you can see it. Sometimes you can see implant rupture, but there's nothing about an implant that makes it harder to look at on ultrasound.
Kim:    Right. Yeah.
Dana:    Same thing for MRI or any other studies. Now when we're talking the non-breast implant surgeries, if we're doing a lot of breast lift or breast reduction, then there is a risk for something called fat necrosis-
Kim:    Right. Can mimic.
Dana:    Where some of the breast tissue or fat doesn't get enough blood flow and it turns into hard scar tissue.
Kim:    Right.
Dana:    That can form hard lumps that feel like a cancerous lump, even though they're not risky for turning into that, and they can look like they have little calcium deposits on mammogram.
Kim:    Yeah.
Dana:    The good news is most mammographers can tell the difference between that type of calcification and a true concerning one, but there are some women who after fat transfer or lift-
Kim:    Right, we talked about that the other week.
Dana:    Might need more studies just to rule that kind of stuff out, especially in the first year after surgery.
Kim:    Yeah.
Melissa:    Okay. So switching over to another popular procedure: Brazilian butt lifts. When you get your Brazilian butt lift, could sitting frequently affect the results of the Brazilian butt lift?
Kim:    That's all timing for how soon after.
Dana:    Yeah, well it's how soon after and it's not so much the frequency of sitting, it's how long you spend and how you sit.
Kim:    Right. How you're sitting.
Dana:    If you're sitting perched on the edge of your chair, you're usually on the backs of your thighs-
Kim:    Or if you're sitting like I am.
Dana:    And that's not where we put the fat. If you're like this, lounging back, you're sitting directly on that fat.
Kim:    Right.
Dana:    Now 15, 20 minutes is probably going to have minimal effect on that fat, so if you're stuck for a car ride or if you're stuck for a short period of time you shouldn't panic.
Kim:    Right.
Dana:    But longer than about 15 or 20 minutes your body is going to start to notice the effects of that decreased blood flow.
Kim:    Right after or when, like timeframe?
Dana:    Well, within the first couple of weeks.
Kim:    Right.
Dana:    You want to try to avoid that more than 10 or 15 minutes of pressure on that area as much as possible.
Kim:    Meaning sleeping.
Dana:    Yes.
Kim:    Positions are totally different and everything else. Yeah.
Dana:    Sleeping on your stomach. Sleeping on your sides, unless you have a lot of fat transfer to the sides.
Kim:    But in the far future, it's I think more a question like: Will that always be the case?
Dana:    Absolutely not.
Kim:    [crosstalk 00:12:21]
Dana:    Most of the time, even though we tell patients three to four weeks, there's about a 12-week inflammatory cycle for anything in the body, 6 to 12 weeks, so certainly by 6 to 12 weeks you're able to sit as much as you want to and the results at that point are more related to swelling going away and not necessarily fat survival at that point.
Kim:    Right.
Melissa:    And then it's kind of a side note but not really, today I actually had a patient ask how much fat can be transferred, so how much can you take out and how much can you re-put back in for a Brazilian butt lift?
Dana:    Yeah. So it's different for different patients.
Kim:    Safety wise.
Dana:    Yeah. Safety wise the rules, at least in the state of Florida, are that you're not allowed to suction more than five liters of fat.
Kim:    Right.
Dana:    I know for a fact, based on anesthesia groups I've worked with in the past, there are definitely centers that will flat out lie on their op report-
Kim:    Yeah, and take way more.
Dana:    Take seven liters and put five of it back in. That is technically against the law because it's not proven to be super safe for patients who are going home after surgery. That said, aside from the legalities of it and the anesthetic part of it, there's only a certain amount of fat that the tissue can hold and so it depends on whether you've got tight skin, loose skin, whether you've been deflated or not. I would say you need at least 400 per cheek to make a visible difference for shaping, and you can put up to ... I've seen people put up to two liters per cheek.
Kim:    I think that's easier to understand.
Dana:    But I think the complication rates go way, way up when you're getting into super large volumes like that.
Kim:    Yeah. So more like a liter per cheek, right, would be the norm?
Dana:    That's more standard.
Kim:    Yeah.
Dana:    To me that's still on the high end for what our patients are asking for.
Kim:    Yeah.
Dana:    Our patients want a little more athletic shape and some curve and a little lift, not so much size.
Melissa:    Fair enough. This question is pretty much a frequent question for all procedures and it's about post-op swelling. How long does swelling and/or numbness last after a procedure?
Dana:    Sure.
Kim:    That is definitely across the board.
Dana:    Yes. It's obviously going to depend on what surgery you have and how much surface area of your body is involved. The more surface area the longer you'll be on the range of swelling. Lower extremities, like thigh lipo, tends to drag out more so than upper extremities or torso. But in general, the most swelling you're going to have you're going to see in the first two to three weeks.
Kim:    Right.
Dana:    That's because your tissues are inflamed and swollen, and your body releases something called anti-diuretic hormone, which basically makes you bloated and puffy.
Kim:    Right.
Dana:    Many women will freak out because they'll gain five or ten pounds after surgery.
Kim:    Even with a breast aug.
Dana:    Even with a breast aug.
Kim:    You look like you're pregnant, you have a bloated out belly.
Dana:    Yeah. That's not uncommon at all. That goes away in two or three weeks.
Kim:    Yeah.
Dana:    The microscopic amount of swelling in the tissues can persist for months, especially after aggressive liposuction or a tummy tuck, you can have swelling between the bellybutton and the pubic bone for six to nine months afterwards.
Kim:    Right.
Dana:    The more you wear your garment, the faster it will go away.
Kim:    Yeah, that's a big key component.
Dana:    But you do need to be prepared mentally for a little rollercoaster.
Kim:    A lot of people get frustrated and they get out of that garment way too soon and then the swelling will actually linger way longer.
Dana:    Yeah.
Melissa:    What's the risk of not wearing your garment for long enough though?
Dana:    So early on-
Melissa:    Like for instance for breast augmentation versus abdominal lipo?
Dana:    Sure.
Kim:    There's a lot of different variables in that because if it's a breast aug and you really need that garment for more support so the implants can stay in place and kind of keep everything where it is, or is it liposuction of the abdomen.
Dana:    Right. So to me, bras are most important when we're talking about complex revision surgeries where we're moving pockets for implants, we're lifting, we're tightening, we're rearranging a lot of things. There's a lot more potential for fluid pockets and for things to shift and move. A primary breast aug, I have many patients who after three, four weeks if they feel comfortable going without a bra, it's probably not the end of the world.
Kim:    It depends on the implant too.
Dana:    It does.
Kim:    You don't want somebody with a 410 running around without a bra.
Dana:    Correct. Anything that's textured and is supposed to stick in place you want support longer.
Kim:    Yeah.
Dana:    For lipo procedures as a general rule of thumb, you should not think about getting out of your garment before week three or four for longer than an hour or two at a time.
Kim:    Right.
Dana:    After that, depending on the surface area, the amount of fat suctioned out and how much swelling you have, you can kind of talk with your surgeon and figure out whether it's better for you to wear it part-time for three months.
Kim:    Or transition to something else.
Dana:    Or transition to Spanx and just wear that during the day.
Kim:    Right.
Dana:    Roughly you want to wear your garment for at least three or four weeks.
Kim:    We'll let them follow the directions that you got [crosstalk 00:16:42]
Melissa:    All right. I have a question from Cara on Facebook. She says: I'm planning to get a reduction done, however I'm torn between whether or not I should wait until after kids versus now as I am a long-distance runner and endure the misery with all the chafing that I get now. Thoughts?
Kim:    Are you planning on having children really soon or is this just an idea in the future? Because if it's an idea in the future and you're that miserable, pull the trigger.
Dana:    Do it. Yeah. For me, the biggest thing on impact with having children is two things. Number one: Some people really want to breastfeed.
Kim:    Diehard. Right.
Dana:    If that's super important to you, I can't promise you it's going to happen after a breast reduction so that may factor in. The other thing is: What are they going to look like after I have kids? People's breasts are all over the board with how they respond to having kids. Some people get bigger. Some people get smaller. Some people get much more saggy. Some people hardly notice a difference.
Kim:    Exactly.
Dana:    I would say, again, if you have specific plans to have kids in the next year or two it may be worth waiting. If you don't, most patients find that they're going to enjoy their surgical results for a long time, even if they end up deciding to tweak something later.
Kim:    Yeah. Even if you do the reduction and then you get engorged and then it goes back, it's not going to go back to the way it was before.
Dana:    Correct.
Melissa:    So I have a quick question. If I have a capsular contracture issue, does it mean you should get your boobs redone?
Dana:    Yes and no. Capsular contracture is one of those things where kind of like beauty is in the eye of the beholder, capsular contracture is sometimes kind of amplified or downplayed based on the patient's perception of it.
Kim:    It's become a really tricky road with knowing what to do.
Dana:    Absolutely. And here's why: When you have capsular contracture your capsule is slightly thickened. If you have pain or tremendous asymmetry, it's probably something you want to address.
Kim:    Right.
Dana:    It's not life-threatening, health threatening, so there's no absolute need to have surgery.
Kim:    It's not an urgency.
Dana:    But it could progress and become more uncomfortable, so most patients will want to take care of it. If the capsule squeezes down tight enough and creates a fold in the implant, it could lead to implant rupture.
Kim:    It can rupture. The main things, I think, are like if you're in pain and it's bothering you every day, do something about it.
Dana:    Yes.
Kim:    If it looks kind of like it's deforming your breast, do something about it.
Dana:    Yeah. Now other people will have a mild case of capsular contracture or they won't like the hardness of the breast, but they'll like the way they look and that's a tricky situation.
Kim:    That's tricky.
Dana:    Because to fix capsular contracture, we have to remove the entire capsule of scar tissue, which leaves your breast with brand new, basically no support to the implant, and there is a chance that the implants could feel more weighty or your breast could look more saggy once we get the capsule out.
Kim:    Yeah. There's a lot of people who get used to it.
Dana:    Yeah.
Kim:    They get used to that high-volume and it being kind of hard and artificial-looking.
Dana:    And kind of tight.
Kim:    And then you take that capsule out and that's not really what it's supposed to look like and then they end up having a natural pretty slope to them and they're soft and they're like, "What happened to my boobs? I liked them the way they were." So it's a double-edged sword.
Dana:    It is.
Melissa:    She says: Thanks for answering. I need to make an appointment ... Again.
Dana:    Okay.
Kim:    Okay.
Melissa:    All right. Going back to some RealSelf questions, kind of in a different stream of things other than surgery but in regards to injectables, such as Botox. How long before can I shower after Botox?
Kim:    That's the best question ever.
Dana:    We laughed at this one.
Kim:    We were laughing at lunch.
Dana:    But then thought: Well somebody sincerely had this question. There's really no reason you can't shower immediately after Botox. I think in the question they were kind of alluding to: Well hot water makes your blood vessels dilate and could that cause Botox to spread?
Kim:    Yeah.
Dana:    That's a lot of 'ifs' and a lot of just something I don't think needs to be worried about. If you're paranoid about that kind of thing, wait four hours.
Kim:    Yeah.
Dana:    You know, but otherwise I don't think I've ever thought about the next time I shower after Botox ever.
Kim:    No.
Melissa:    Fair enough. Actually I had a question the other day about fillers and injectables and if they were to get fillers would it stretch out their skin so once the fillers went away would they need to re-tighten the skin or do they just have to continue to get fillers forever?
Dana:    No you don't have to continue to get fillers forever, but you can stretch out the skin if you overfill it.
Kim:    Overfill artificially, really artificially.
Dana:    I've seen women who really like an aggressive lip where they've smoothed out literally every wrinkle and so there's no looseness and that tissue doesn't always back back to normal after the filler wears off. But if you're just filing to a reasonable volume with a syringe or syringe and a half, it should go back to normal when the filler wears away.
Kim:    Right. And it does stimulate collagen. It's a hyaluronic acid, so it stimulates it a little bit.
Dana:    Sometimes.
Kim:    Some of them. It depends on the filler you're using.
Dana:    It depends on the filler and sometimes just that needle poke can stimulate some scar tissue formation so some patients' lips don't go all the way back.
Kim:    Yeah. It really should just go back to the way it was if you're not doing it overkill.
Melissa:    Fair enough.
Kim:    I love the 'fair enough'.
Melissa:    So pinpointing on a topic we haven't talked too much about but it's a big trending procedure now is vaginal rejuvenation, including internal and labiaplasty.
Dana:    Absolutely.
Melissa:    One of the most common questions, because it is now a trend, is: Is my labia normal?
Dana:    We get this question all the time.
Kim:    We are going to talk about this really.
Dana:    Combined. Yeah, we'll have a whole topic on this ...
Kim:    This is ...
Dana:    We're getting everybody warmed up to it.
Kim:    This is literally like the 50% of the clients here is breast and vaginal rejuvenation.
Dana:    It's a lot.
Kim:    It is a hush-hush topic and we are treading on eggshells with it, but we're going to talk about it eventually.
Dana:    Absolutely.
Kim:    There is no normal.
Dana:    The answer to it is there's a very wide range, just like the concept of a bell curve where the average takes up a pretty large chunk of society and then there's about those two percent at either end that are either really exceptional and have like this little tiny labia that you can't see anything and then there's the other end where there's a lot more tissue.
Kim:    We call it a redundancy.
Dana:    Both of them are normal, but they're just not on the same end of the spectrum. I think these days our society has gotten a little pushed, a lot pushed, in the direction of thinking that the aesthetic ideal is normal.
Kim:    Right.
Dana:    That's not true. Most people who come in for labiaplasty have a normal labia, but it doesn't mean it's aesthetically their ideal or that it's comfortable for them.
Kim:    There's a lot of hate out there for it. I mean, these poor girls. There is definitely legitimate concern, they have definitely issues. They have things that are causing every day in their life issues.
Dana:    We tell patients that are worried about how others are going to perceive it, and I tell people who ask me: Like why would anybody ever want to get that done? If you don't know why it could be a concern, just be grateful you don't have that problem.
Kim:    Right. Yes. That's it. Count yourself lucky.
Dana:    Yeah. The people who I do the surgery on who feel like they need the surgery definitely have a life change from having the surgery.
Kim:    Absolutely.
Melissa:    And then there's a question as well on like the length of time that you have sutures. Are they permanent? Do you have to get them removed? Are they dissolvable? What kind of options do you have?
Kim:    We talked about this at lunch too.
Dana:    Yes.
Kim:    I said the average person thinks 'suture' means removal.
Dana:    Yes. Most of our surgeries are done with absorbable sutures that eventually dissolve completely and they're all usually buried underneath the surface of the skin, meaning you don't see them and they don't have to be removed. Now some people's bodies will not want to dissolve the sutures and in some cases they can end up poking through the skin and in that case they would need to be removed, but for the most part they'll dissolve under the surface. Even the labiaplasty sutures are superficial on the surface but they'll dissolve and flake away after about a week.
    For certain surgeries I do prefer to use the type of suture that comes out, mostly for eyelids-
Kim:    Eyelids, yeah.
Dana:    And facelifts and small areas like that. Those generally come out within-
Kim:    Five days.
Dana:    A week. Five to seven days.
Kim:    Yeah.
Melissa:    Okay. Fair enough.
Dana:    The thing is, if somebody's leaving sutures in on the surface longer than about ten days, you're going to get those little train track marks.
Kim:    You'll get marks.
Dana:    Don't let somebody do that to you.
Melissa:    Okay. So I have a question in regards to mommy makeovers. On RealSelf they have a description for what a mommy makeover entails. What would you consider to be a mommy makeover here in our office?
Dana:    To me, a mommy makeover is any surgery that a mom feels like she wants to have to get herself back to where she felt like she was before kids.
Kim:    And it doesn't have to be somebody who had babies.
Dana:    It doesn't. Many women through menopause and just over time will have some of the same changes to their bodies.
Kim:    Yeah. Changes, hormonal changes.
Dana:    For our practice we definitely consider breast and tummy mommy mommy makeover.
Kim:    And vagina.
Dana:    Labia for sure. And many people will start talking about inner thigh lipo or outer thigh lipo just because your body's tendency to put weight in certain places changes over time.
Kim:    Yeah. Anything that really hormonally changes or as we age.
Dana:    Yeah. So the mommy makeover is not a specific surgery, it just is a grouping of surgeries that-
Kim:    Because I've had patients who have come in and be like, "I think I'm the mommy makeover but I'm not a mom." I'm like, you're still a mommy makeover then.
Dana:    Yeah.
Melissa:    And then in general, one of the other questions that's always asked is: What is the cost of procedures? Is it more to get a breast augmentation? Is it more to get a tummy tuck? How do you feel about vaginal rejuvenation cost? Some of the other costs.
Dana:    It's really tough to give a general ballpark for different things because even liposuction, somebody getting liposuction to the abdomen, if I'm going to spend an hour under anesthesia for one patient and somebody else has more fat and that's two hours under anesthesia it can change the cost of the surgery by a thousand or two.
Kim:    This question is my nemesis.
Dana:    I would say if you're walking into a plastic surgeon's office and you're going to have a procedure under general anesthesia, you should expect to pay at least $5000 and it could be close to ten depending on your choice of implants or if you're doing multiple areas of liposuction.
Kim:    It's hard. It's hard to say.
Dana:    It's difficult.
Kim:    I get it all the time where people are like, "But I just need to know cost before I get in there." I'm like: It's just not that cut and dry because anybody across the board thinks they know what they're supposed to get when they get it and then they come in here and it's a totally different plan.
Dana:    Yeah.
Kim:    When everybody gives numbers on the phone, it's so vague. But like if people are out advertising and they're saying: Breast augmentations $3500. One, either don't go. Two, they're just telling you what the surgeon's fee is.
Dana:    Yes.
Kim:    It's a gimmick to get you in the door. If you're looking up and numbers stay consistent across the board, then that's probably what it is, but if you're seeing these high peaks and lows, try to stay in the middle somewhere usually.
Dana:    Mm-hmm (affirmative). Yeah. More expensive doesn't always mean better. Cheapest is not always the best deal.
Kim:    We love that one phrase. What is it? Oh god. Ryan always says it. Is it: Good surgery is not cheap and cheap surgery is not always good, whatever it is?
Dana:    Oh yeah.
Kim:    But yeah, it really is true.
Dana:    Yeah. So being somewhere in the middle is probably the smart way to go. That gets back to why RealSelf can be helpful because they give so many different surgeons' averages for surgeries that it really takes out a lot of that guesswork and you can really see an average.
Kim:    They really do. They show a lot of the across the board average of like what's a neck lift cost? What's a tummy tuck cost? They're pretty consistent.
Melissa:    So when patients have questions before they come in, would you recommend them to go to RealSelf to ask questions or find answers or do those kind of things?
Dana:    I think it depends on the question. There are patients who will post pictures and say, "What surgery do you think I need?"
Melissa:    Right.
Dana:    That can be a good way to start, but I think unless a surgeon is touching your tissues and feeling what component is stretchy skin versus fat, it can be hard to give a true opinion and to be accurate about what you're recommending.
Kim:    I have to so bring up that lead that came in this week.
Dana:    Oh, okay.
Kim:    I think that's frustrating.
Dana:    Go ahead.
Kim:    Okay.
Dana:    Go ahead.
Kim:    I answer all the leads in the practice for when you email or you send anything in. I am your ... I'm your person behind the computer. But typically we can answer questions if you send in a photo and you say: Okay, this is my scar on my face. What do you think can happen? We can give you a couple of different variations saying lasers, maybe a scar revision. It's still vague. But if you send a picture of your cheek, like this big, and just say, "What can you do about this?" And it's not really descriptive. We had that this week. "Give me all the different options and all the different costs and then maybe I'll fly in to see you." That is so impossible to do because you don't know really like what you're dealing with by looking at a little quadrant of a cheek. You don't know what anything is really. I mean, that's very hard to do.
    So the recommendation is to say: Hey, it is best either one, submit better pictures that show much better areas and then we can give a better kind of idea of what can be done, or come and have a consultation because ultimately that's what the consult is for. It's an hour-long appointment for the doctor to assess you in person to kind of check things, to give the prices, to go over pros and cons.
Dana:    Well and it's not always about which procedure is the best fit for you because sometimes I could say: Oh, a C02 laser is going to be the best for that ...
Kim:    And it's not going to be the best for them.
Dana:    But if it doesn't fit into your lifestyle because of sun exposure or downtime, then it's kind of a waste and talking in circles.
Kim:    It's really getting to know the patient. Definitely you can do inquiries and you can send things in and you can get kind of an idea. We do FaceTime consults. Patients will submit their photos and then have actually a consultation with Dr. Goldberg and that's still being a little bit more efficient than just an email.
Dana:    Mm-hmm (affirmative).
Kim:    Yeah.
Dana:    But for general questions or if you're not even sure you're ready for surgery, RealSelf is definitely a great site.
Kim:    It is good.
Dana:    Surgeons will answer very specific questions.
Kim:    It kind of helps you to feel out the different surgeons you might be interested in too, as to how they respond to you and so forth.
Dana:    Yeah. It's good too because if you get ten responses and eight surgeons say the same thing, then you feel pretty reassured that that's a decent plan for you.
Kim:    Exactly.
Melissa:    So I have one more question from Cara. She says: Is it nearly impossible to get a percentage of a reduction covered by insurance, as she's been told in the past that has happened.
Kim:    We have done so many efforts in the past to get that covered.
Dana:    Yeah. I just gave up. We used to take insurance and the last four breast reductions that I submitted for all got turned down and they were all thin young women with enormous breasts.
Kim:    Enormous. Rashes, sores, grooving.
Dana:    They fit all the criteria for the insurance companies. They had doctors' notes to document.
Kim:    Yeah.
Dana:    And after weeks of us getting work and submitting things for the insurance companies to take two months and then say 'no', it was really aggravating.
Kim:    Yeah.
Dana:    And then if they do approve, they make you take off a specific amount of tissue.
Kim:    Yes.
Dana:    So if you want to go from a DD to a C, you might not be able to do that.
Kim:    They may say you've got to go to an A, B.
Dana:    They may say, "You've got to get 400 grams, I don't care whether you end up a flat A cup after that, you're getting 400 grams." And it's all based on scales and numbers, so it may not accurately represent how much tissue needs to be removed.
Kim:    And then they can also give you a preapproval.
Dana:    And then take it away.
Kim:    And you can go get your surgery and you can get it done in a hospital setting or whatever it is, and then deny it and then you get a huge bill later and it's usually more expensive.
Dana:    That happened to a handful of patients for us for upper eyelid surgery and then we stopped submitting for those too.
Kim:    Oh yeah.
Dana:    So there are still a couple of options. There are surgeons who do take insurance and you can work with your family doctor and a plastic surgeon to try to go down that road, but just expect you might spend three to six months trying to seek approval and you might not get it.
Kim:    And still not get it. But some people say that's worth the effort.
Dana:    You can submit on your own. Some insurance companies will do out-of-network benefits or they may cover the insurance at a facility but not the surgeon's fee, but it tends to get very dicey and these days I find just the insurance companies are really tight-fisted, so it's tough.
Melissa:    All right. So to wrap up, because there's so many questions out there, but what I want to know is: What is each of y'all's favorite questions to hear from a patient? Like what's one that comes up all the time that just sticks in your head like that, that you feel like is a rational question to ask or maybe it's not, doesn't seem normal.
Dana:    I don't know if we talked about this but a lot of people say like, "When will I be back to normal after surgery?"
Kim:    That's a good one.
Dana:    I tell people there are three phases of recovery: There's the sort of bedridden/you should stay at home phase, which can last anywhere from two to ten days, depending on the surgery. Breast aug, it's going to be two or three days. Full body makeover, it's going to be two weeks.
Kim:    Right.
Dana:    Then the next phase of recovery comes when you can do some light cardio; for most patients that starts between two and four weeks after surgery. No matter what surgery you have, you're pretty much through most of the swelling and restrictions and everything by about 12 weeks. But I've had patients feel sluggish and not like they have their full energy back for six months after surgery.
Kim:    I would say another one, the biggest question out there, is: Death from anesthesia. There's handfuls and handfuls of people who don't pull the trigger to have surgery because they are afraid of anesthesia. I think that's always a big question.
Dana:    It is. No one can guarantee 100% that you're going to wake up safely from surgery.
Kim:    Right.
Dana:    There's just no way to guarantee that because stuff happens. But there are so many steps you can take to minimize the dangers of anesthesia.
Kim:    Right.
Dana:    Getting full clearance ahead of time and getting an EKG, making sure your blood work's okay and you're not anemic.
Kim:    Which we do. We're kind of OCD about our clearance.
Dana:    Yeah.
Kim:    Which a lot of people aren't. Some people don't even really ... If you're young and healthy they're like: You're good to go.
Dana:    Yeah. But we've found a couple of patients who have severe anemia that might have tipped them over to having a complication, maybe not life-threatening, but ... The type of anesthesia also matters and how long you're under anesthesia. We tend to try to stay away from inhaled gases and muscle paralyzers because they tend to be harder for people to recover from and thankfully for the surgeries we do, they're not usually necessary.
Kim:    Right.
Melissa:    Fair enough.
Kim:    There's are so many questions I get asked every day.
Melissa:    There's so many questions.
Kim:    Oh my gosh. As you just said that I was like ... Going off.
Melissa:    Well and this opens the door to anybody who watches this post being streamed live to ask any questions you have.
Dana:    Absolutely.
Melissa:    We're always here to answer. We keep up with our social media so if you ask a question on there we've got you covered. But really it's anything anyone wants to know, we're free to talk about it and have that conversation.
Kim:    Yes.
Dana:    Absolutely.
Kim:    That's why we're here.
Dana:    All right.
Kim:    All right guys. Enjoy your Wednesday.
Dana:    Thanks for joining us.
Kim:    Take care.