Real Self Top Q&A

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.

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. 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. 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.

How much weight can I lose from a tummy tuck surgery?

Yes. In actual weight, it's usually not any more than two to four pounds. And that's a fairly large tummy tuck, but the effect of it-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. 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. 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. 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? 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.
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.

Can you have a baby after a tummy tuck surgery?

YES. 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- They didn't look bad. 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. 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.

Is it okay to have plastic surgery while menstruating?

It is an interesting question, and I never thought a patient would actually ask that, but somebody asked that last week. I do tell patients getting Botox and filler, try not to get it around your PMS or menstrual cycle because it does hurt more. 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. 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? 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.

In regards to the scarring, how soon can you start using silicone scar sheets after surgery?

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 are 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. 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. Even one application can be between $50 and $100.
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.
Not all scar creams are 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. 

When can you go back to swimming after surgery?

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. 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. 

Can you do breast augmentations on asymmetrical breasts? Will it make them look worse or will it make them look better?

Asymmetry is the norm. Now, we take measurements on everybody and it's really unusual for somebody to have the exact measurement side to side. You are the exception to the rule if you have perfectly asymmetrical breasts. Most of the time getting implants doesn't necessarily change your natural symmetry. It can in certain patients tend to mask minor asymmetries. Other times it can exaggerate them 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. 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. Not everybody is a mirror image from side to side, in fact most people aren't. 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. 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. 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." It's not necessary.

How can breast surgery affect mammograms, or does it not affect them at all?

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 and up 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. 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. If you've gotten one right before surgery you shouldn't need one for another year.
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. They've done studies, there's no delay in diagnosis for patients with implants or being diagnosed at a later stage. They can also do an ultrasound too, to get like a double application.

How does breast implants affect breast ultrasounds?

They thankfully don't affect breast ultrasound. 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. 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; where some of the breast tissue or fat doesn't get enough blood flow and it turns into hard scar tissue. 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. 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 might need more studies just to rule that kind of stuff out, especially in the first year after surgery.

When you get your Brazilian Butt Lift, could sitting frequently affect the results of the Brazilian Butt Lift?

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.
If you're sitting perched on the edge of your chair, you're usually on the backs of your thighs and that's not where we put the fat. If you're like this, lounging back, you're sitting directly on that fat. 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. But longer than about 15 or 20 minutes your body is going to start to notice the effects of that decreased blood flow. You want to try to avoid that more than 10 or 15 minutes of pressure on that area as much as possible. Sleeping on your stomach. Sleeping on your sides, unless you have a lot of fat transfer to the sides. 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..

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?

So it's different for different patients. 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. 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 and 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. But I think the complication rates go way, way up when you're getting into super large volumes like that. Our patients want a little more athletic shape and some curve and a little lift, not so much size. 

How long does swelling and/or numbness last after a procedure?

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. 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. Many women will freak out because they'll gain five or ten pounds after surgery. Even with a breast aug. That's not uncommon at all. That goes away in two or three weeks. 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.
The more you wear your garment, the faster it will go away. But you do need to be prepared mentally for a little rollercoaster. 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.
 

What's the risk of not wearing your garment for long enough though? For instance for breast augmentation versus abdominal lipo?

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. Anything that's textured and is supposed to stick in place you want support for longer. 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.
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 or transition to Spanx and just wear that during the day. Roughly you want to wear your garment for at least three or four weeks

“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?”

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 uncomfortable, pull the trigger. For me, the biggest thing on impact with having children is two things. Number one: Some people really want to breastfeed.
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. 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.