Lisa Rinna Recently Had Her Lip Augmentation Reduced.

Plastic surgery is a part of celebrity culture today. From reality stars like Heidi Montag, Kim Kardashian, Pamela Anderson, and “The Real Housewives of…” to comedians like Joan Rivers and Kathy Griffin, to actors like Lisa Rinna, Nicole Kidman, Meg Ryan, Micky Rourke and of course stage performers like Cher and Kenny Rogers. All of these celebrities and hundreds more like them appear to have had cosmetic work done, and most, save Kim Kardashian and Cher, seem to have gone too far and pushed the limits of what plastic surgery is capable of.

The force behind this Hollywood celebrity trend to use plastic surgery beyond what is rational is a collective obsession with youthful perfection. That is, in American culture, youth is romanticized and physical perfection is idealized. The problem is that we are only young for a brief time in reality. Indeed, this evanescent quality is probably an ingredient of the fuel feeding this obsession. Combine this with the fact that very few, if any of us, are genetically perfect and you end up with a majority of the country somewhat unsatisfied with their appearance. Add to the fire, the pressure celebrities are under to be examples of perfection to those who consume their movies, TV shows, and music videos and you can imagine the desperate feelings these people have to hold on to this image of perfection or lose their celebrity status.

Further complicating the mix is that the personalities who go into that line of work tend to already enjoy some degree of narcissism with their coffee and you have a perfect storm. Nowhere do we see example after example of drastic measures taken by desperate souls to enhance or hold onto any shred of perfect youth that medical science might be able to offer. Likewise, nowhere else do we see so many sad cases of the fuel of this collective obsession with youthful perfection igniting the fire that ends in plastic surgery disasters.

As a plastic surgeon who believes very much that plastic surgery, and other cosmetic procedures such as Botox and facial fillers, can improve a person’s appearance and make them feel more confident, I cringe when I see the next star to step onto the red carpet with lips the size of sausages or faces pulled so tight they look like, as a friend of mine recently described, “a screaming skull.” Likewise, it sickens me to see a breast augmentation disaster such as putting 700cc breast implants in a petite woman of 5 foot 2 inches as was done to Heidi Montag, so she ends up making Barbie look comparatively proportional! These cases are not medical science being used to improve lives, they are a shameful mockery of the fine art of plastic surgery.

The most difficult thing for me to get my head around is the process by which a trained doctor goes through with these surgeries. If he or she is even remotely educated in plastic surgery, or even the pretend plastic surgeons who call themselves, “cosmetic surgeons,” these doctors have to know how awful these results are going to be before they even put the patient to sleep. As a plastic surgeon, my job is to improve on nature while balancing these improvements with aesthetic principles of balance, physical limits, and genetic realities. And a reality of being a plastic surgeon is knowing that some patients will come in with unrealistic expectations. I regularly have to sit down and explain in no uncertain terms, that there is such a thing as “too big” when it comes to breast implant size. It is very common for small framed women who have A-cup breasts to request breast implants that are simply going to make her look very top-heavy, cause stress damage to the skin, and create discomfort to the point that she will need to have them removed. When I explain the physical limits and the reality, most women normally understand and opt for smaller implants. In cases where they are still unconvinced and determined to have the larger implants, I apologize and tell them that as an ethical plastic surgeon, I cannot perform the surgery with the implants requested and we go our separate ways. And yes, occasionally they come back to me to have their “too large” implants removed.

I can feel for these plastic surgeons who have celebrities for patients. I can imagine they hear a lot of desperate stories about needing “that edge” in order to stay relevant in the fast paced world that is Hollywood, where one day you may be the toast of the town and the next you are wondering why you can’t even get an infomercial job. I realize there is tremendous pressure to push the limits because if you don’t someone else will. At the same time, we are doctors first and we have to do what is right by the patient, even if the patient is demanding what is wrong. We know that lips that look like two sausages painted red will look like hell, we know that 700cc implants can not be sustained in a petite woman of 5 foot 2 inches, we know that if you stretch the face back too far you will create a lizard mouth. We know this because it is what we do. Just as an engineer knows what you can and can’t do if you want a bridge to stay standing, a plane to stay in the sky or a computer to crunch ones and zeros and end up with me being able to type this article.

One thing I always stress with my patients is that when all is said and done, a stranger should never be able to look at you and “know” you’ve had plastic surgery. Whether it is breast augmentation, lip augmentation, a tummy tuck or a facelift, all should be subtle enough to look perfectly natural. Sure, if you go from an A-cup to a C-cup overnight, your friends might notice, but to the world, you should just look shapely, balanced and aesthetically pleasing to the eye, not like a freak of nature. Similarly, a facelift should simply take 10 to 15 years off your face, not make you look like a new person. You should look like pictures of yourself from the past. If you look at Joan Rivers now and Joan Rivers from 15 years ago, it is like they are two different people. On the other hand, if you look at Cher now and Cher 15 years ago, she looks the same! That’s plastic surgery done right!

The collective obsession with youthful perfection will probably be a part of the American cultural reality for the foreseeable future. Perhaps, just being a little more aware of it and reminding ourselves and our children to actively work toward being less influenced by it and more happy with our own realities is the answer. Sure, a good plastic surgeon can improve on nature a bit, fix some of the effects of time and make your day-to-day life a little happier because you smile more when you look in the mirror. But youthful perfection is not something we are capable of producing and someone needs to see that Hollywood gets the memo.

There’s even a $7,000 entry-level course being taught for anyone with an M.D. degree to learn how to perform breast augmentation. At the end of this weekend course, someone with only modest surgical skills could learn how to balloon up the breast tissue as you would for liposuction, and do a very limited pocket under the breast and over the muscle for a large incision in the breast fold and then put an implant in and sew it up.

What does surgical judgment, experience and aesthetic judgment count for?  By the time I had started my cosmetic breast practice, I had performed hundreds of a much more difficult procedure: breast reconstruction. This gave me a great deal of experience with the sub muscular pocket and the beginnings of the concept of the muscle brassiere. In addition, with breast reconstruction, you are usually trying to match and adjust the opposite side.

So is judgment and experience important?  Just this last week, among the other cases cited were breast cases: bilateral and augmentation, unilateral augmentation, and then a mastopexy bilateral Salt removal and replacement bilateral implant removal incised exchange.

Just as an outline of the process of breast augmentation and lift:

1. Preoperative marking
2. General anesthesia
3. Incisions
4. Making the sub muscular pocket with muscle support
5. Placement of a sizer to expand the pocket to fit the breast implant
6. Sit the patient up for visual assessment for shape and volume
7. Make necessary adjustments to the size
8. Temporary sutur breast lift
9. Sit up for assessment
10. Remove sutures
11. Second temporary breast lift
12. Sit patient up for assessment
13. 3rd Temporary breast lift
14. Set up okay just markings
15. Remove skin
16. Suture closures
17. Set up for final check of finished lift and augmentation to make sure it is aesthetically correct.

These steps were for a complicated major breast lift and augmentation with asymmetry.  There are many different surgical steps with a lot of decisions to be made at every step. The reason you can’t just throw some markings and then cut on the dotted line is for every change in volume, there are changes in dimension according to the skin tension. This is different according to every person.

There’s a lot more to cosmetic breast augmentation, breast lifts and breast surgery than just putting a little bag under the skin. Cosmetic breast surgery has a steep learning curve that takes years to master.  This is especially true if one is performing symmetry surgery or revision surgery, which is complicated three-dimensional surgery.  It is definitely not for the gynecologist with time on his hands who has just taken a weekend course.

Now there is a very clever funnel invented by Dr. Keller called the Keller Funnel which accomplishes several purposes with something that looks like it belongs on the Food Network’s TV show Ace of Cakes!

First of all, it allows introduction of the implant with a true no touch technique the implant can be dropped into the funnel and then gently squeezed through like decorating the top of the cake. The surgeon doesn’t touch it and it doesn’t touch the patient’s skin or breast tissue while it is being introduced in the pocket. This eliminates the main source of potential capsular contracture which is residual bacteria on the skin or in the breast tissue of the patient

Secondly, this way of introduction puts less stress on the implant so that is less likely to break during introduction or later due to the stress placed while putting it in

And lastly, this method allows for smaller incisions and faster introduction minimizing scar tissue and lessening the time that the patient is under anesthesia

I am very pleased to now be using the new Keller Funnel that allows us to improve the quality of breast augmentation. At Advanced Concepts in Plastic Surgery we continue to select the best of new technology. The Keller Funnel is an example of this by making breast augmentation better, safer, and minimizing future complications.

Not all plastic surgeons use drains after plastic surgery, so why do I?

Before I began using drains when performing breast augmentation the breasts would tend to swell more.  When there is more swelling, the breasts will be more sore.  It could take a month or more for this swelling to come down and can be quite uncomfortable. Because I see it as part of my job as a plastic surgeon to reduce as much pain as possible, I began experimenting with drains as a way to relieve this swelling after plastic surgery.

Generally 60 to 200 CC’s of fluid will come out over the course of 2 days.  Some of this fluid is actually blood which would have to be reabsorbed if it is not removed.  Blood gathering around the implants can accelerate infection.  Blood also seems to be a factor in capsular contracture.  Patients that developed hematomas are more prone to capsular contracture.  I have never had a patient develop an infection where I have had to remove a breast implant.

So in my opinion drains speed healing, make people more comfortable, and help decrease capsular contracture.  Seems to be worth the inconvenience of having a tiny drain for a day or two. At Advanced Concepts in Plastic Surgery I really try to make all plastic surgery procedures as painless and as comfortable for the patient as possible.

Silicone breast implants were the most common implants for much of the history of breast implants.  Then about 15 years ago Connie Chung ran an expose which claimed that implants were responsible for all kinds of health problems.  This led to lawsuits a huge windfall for lawyers and the subsequent ban on silicone implants.  Shortly after this, the ban became worldwide.  This lasted for years until more than 100 clinical studies showed that breast implants don’t cause cancer, lupus, scleroderma, or a host of other problems.  Eventually, a federal judge threw out the lawsuits, declaring them junk science and sent the lawyers packing.  This led to the present re-introduction of silicone implants and their approval by the FDA.  Interestingly enough, most of the rest of the world re-introduced them many years ago.

Saline breast implants have always been available and continued to be available as a choice.

Apart from the differences in history and reputation, what’s the actual difference between the two?  Both are made of a silicone shell.  One has silicone gel inside; the other one has salt water.  But how do they act in the body?

Silicone breast implants are softer squishier and move better.  They are less likely to cause wrinkling, rippling, malposition, and sagging.  With larger sizes more than 400 cc silicone implants perform better and are less likely to cause severe sagging.

Saline breast implants are more likely to be felt under the skin because the shell is thicker.  This is not a problem for average or slightly heavier women.  In thin women, this can be an issue.  This also applies to wrinkling and rippling.  If there is enough tissue to cover the implant well then said implants do very well.  The other issue is that when the implant fails, as all implants do eventually, saline implants go down completely within a day.  When silicone implants break, the material stays in the pocket or implant space and allows more time until replacement surgery.

Fortunately now the type of  breast implant used is a woman’s choice.  Her body type and her concerns all influence her choice.  In my practice Advanced Concepts in Plastic Surgery in Sacramento, I have performed breast augmentation surgery on many women who made their own choices of either saline or silicone breast implants and were very happy with the results.

Over the years at Advanced Concepts in Plastic Surgery of Sacramento various measures to decrease this exposure have been adopted. These includes our state-of-the-art surgery facility strict attention to sterile technique, better skin preparation as well as rinsing the pocket with Betadine, antibacterial solution, IV antibiotics, no touch techniques, (trying to avoid touching skin) and changing gloves for implant insertion. All of these have been beneficial to a certain extent but the percentage of contracture is still never zero. Research goes on.

So what can be done if someone gets capsular contracture? Recent research shows that a class of drugs called Leukotriene Inhibitors which have usually been used for asthma have been effective in reversing these changes. These drugs include Singulair and Accolate. Another method to help reverse this problem is Low Level Laser Light. This activates cellular energy and seems to help soften the scar tissue especially when it is combined with constant pressure during treatment.

As a last resort a second surgery removing the scar tissue and removing the implant can be done with good results. If done early, this is a simple operation and involves less downtime, discomfort, or recovery than the original procedure.