September 24th, 2011 drtim Recently, a wonderful patient of mine, September Sarno, put together a charity event for the S.H.A.R.E. organization in Beverly Hills. This is a charity for children with disabilities. She had organized a bachelor auction for which myself and my anesthesiologist, Dr. Michael Simon-Baker and 22 other single men in the city participated. It was an extremely fun night with over 450 people in attendance. For better or for worse, I was the first bachelor up on the runway. Each bachelor in the auction was asked to provide a theme through their walk and to describe the date for which the bachelor is going to take the winning bidder. This required a bit of brainstorming on my part because I have never done anything quite like this, neither has my friend and coworker, Dr. Michael Simon Baker. Of course, we were asked to wear tuxedos for the event. I had recently seen the movie Casino Royale and despite the fact that I do not have blonde hair like Daniel Craig, I looked nothing like Sean Connery, and I cannot even fake a good British accent, I decided to go with the James Bond theme. Thus, my bachelor date included me picking up the winning bidder in my vintage Jaguar Convertible and driving to a fine-dine restaurant for dinner. Naturally, I walked out to the James Bond theme song. My anesthesiologist, Dr. Michael Simon-Baker was perhaps a bit more creative. Other than being one of the best anesthesiologists that I have ever worked with, he is an amazing guitar player and singer. So, he had hooked up a microphone through the guitar to his chest and walked out playing and singing the song, “Your Body is a Wonderland” by John Mayer. On the end of his guitar, he had roses attached and will walk down the runway over to bidding women and give them roses. It was quite a spectacle and immensely entertaining night, and all for a good cause.
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September 17th, 2011 drtim Breast augmentation remains one of the most enjoyable surgeries. Perhaps one of the reasons it is so fun is that the results are immediate, well sort of… I saw a very pleasant woman today in the office who is one day after her breast augmentation with saline implants
under the muscle (submuscular). She was a B cup, and we chose to make her a big C small D cup. This patient reminded me that many patients don’t understand that going from A or B cups to C or D cups is a process. While the results invariably look spectacular on the operating room table, within hours after anesthesia the patient’s body puts of obstacles for the implants to settle. The muscle and soft tissues swell and the muscles tighten. The implants going up 2 cup sizes are often larger in radius than the nipple to fold distance. What does this matter? Well, the center of the implant should sit behind the nipple. However, when the implant radius is larger than the distance from nipple to fold, the ONLY way the implant will sit behind the nipple is for the surgeon to lower the fold surgically. However, that patient has lived with that fold for maybe 20 or 30 years. It WANTS to be there. It has ‘memory’. So, the fold is lowered, and on the table the implant is exactly where you want it. But then, the patient wakes up, the muscles tighten, the muscles swell, the implant rides up, and that fold you lowered tries to go back to its native position. This is where I believe wrapping and aggressive massaging can help. Some surgeons don’t believe that wrapping the upper pole of the breasts help push the implant down, others do. However, most agree that massaging the breasts aggressively and EARLY help the implant fall and prevent that fold from healing in its old position (too high). I encourage massaging after a couple of days if tolerable, with the patient squeezing the top of the implant to push it down. And in a month or two, they’ll start to settle. However, it is not unusual for the implants to stay ‘high’ for months! Patience! And beautiful breasts will come…
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September 14th, 2011 drtim 
Obviously, one of the goals in plastic surgery, and in particular breast augmentation, is to maintain a natural look. There are of course exceptions when patients want a naturally large beautifil breasts or unnaturally large beautiful lips, but most people seeking plastic surgery expect and want work done that is not obvious or have the stigmata of surgery. A good example of avoiding telltale signs of liposuction is scar placement. When patients have liposuction particularly in the belly and in the thighs, little incisions must be made to insert the liposuction cannulas. Although, these incisions are generally 1 cm or so in length, they do, like all incisions, leave some sort of scar. Thus, placing scars in camouflaged positions is always helpful. For example, a scar is simply placed within the bellybutton (which is a natural scar from the placental cord). Other scars could be hidden in underwear or bathing suit lines. For that reason, I ask patients to bring in either a bathing suite on the day of surgery that they like to wear. Therefore, we could place our incisions that hidden behind with the fabric of the bathing suite lines. However, another telltale sign is symmetry of scars. Whereas symmetry in aesthetics is important such as a symmetrical face, symmetrical smile, or symmetrical breasts, symmetrical incisions are a telltale sign of plastic surgery. Therefore, I find it very helpful to offset scars. For example, I do not place scars in liposuction symmetrical. I placed them on one point of the body several centimeters from the mirror image on its opposite side. Although, a small scar will develop, the result is that these small scars become much less noticeable and they are rarely mistaken for liposuction scars. Obviously, sometimes symmetrical scars are preferred. For instance, in a tummy tuck or abdominoplasty, great lengths are taken with intraoperative measurements to make sure that the scar is perfectly symmetrical along the bikini line. Here, in natural skin crease such as the lower abdomen, a symmetrical well-placed scar is less noticeable. Thus, great consideration is given every time a plastic surgeon puts a scalpel to a patient’s body.
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September 10th, 2011 drtim 
Flat tummies can be achieved through abdominoplasty also known as tummy tuck. The idea of this operation is to not only remove excess skin and fat around the waist but to also tighten the muscles below the skin to correct what is called diastasis. In addition, they can often remove some of the striae or wrinkles related to pregnancy. Yesterday, in myBeverly Hills office, I saw a woman who had a prior scar from a previous surgery that bothered her. In addition, she had prior pregnancy. However, she was otherwise thin despite the laxity and belly bulge that she carried. Patients like this are perfect candidates for abdominoplasty. The operation typically takes three hours to three and a half hours and can improve one’s body tremendously. I often do abdominoplasty combined with liposuction of the flanks and back. Sometimes, rather than throwing this extracted fat away, it could be placed into the buttocks for what is typically called a Brazilian butt lift or butt augmentation, or it can be injected into the face to create fuller cheeks with fat grafting. Indeed, all of that fat that you wished away could be grafted (injected) into areas to make you more beautiful! One can plump up their butt, cheeks, lips, temples, and other areas that may have hollowed out from aging. In this particular patient that I saw, she also wanted beautiful breasts and inquired about a breast augmentation. While it is generally a reasonable idea to do a breast augmentation at the same time of abdominoplasty, it may be unwise to do breast lifts with abdominoplasty because the operative time is too long. In this particular patient who actually needed a lift, we decided to stage the mastopexy. In the end, it is always safety before beauty.
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September 10th, 2011 drtim 
In both my Beverly Hills and Glendora offices other than the need for beautiful breasts and breast augmentation, a close second request is beautiful lips. While there are a few ways to augment the lips using products ranging from AlloDerm to permanent implants, by far the safest and most natural approach is using hyaluronic acid. This includes products such as Juvederm and Restylane. However, the products alone are not magical unless you have a skilled technician injecting the product. To get a natural result, the anatomy of the lips and proportions of the lips must be recognized and obeyed. For instance, I cannot tell you how many women I see walking in the streets of Beverly Hills who clearly just have their upper lips injected. Not only it is a telltale sign of a lip augmentation, it is a telltale sign of bad lip augmentation. Many women feel the need to simply fill the upper lip (perhaps to save money) while ignoring the lower lip. In truth, both the upper lip and lower lip should almost always be augmented together. Proportions MUST remain natural. Usually, the lower lip is 1.5 times larger than the size of the upper lip. In addition, the curls of the lips under vermilion border must also look similar. That is, when you inject the upper lip on the vermilion border and curl it, it looks awfully silly when the lower lip does not have a similar pout or curve. In addition, the boundaries of lips are critical. Anything injected within 1 to 2 cm of the corner of the mouth will give a fake, trout-pout look. The main volume of the lip should be in the central third to the the central 50% in the upper lip. In the bottom lip, there is a natural cleft which should not be violated. In addition, when the volume is injected, it is to be layered such that more volume is given, the closer you go tothe philtral columns. When these approaches are taken, a significant amount of volume (Juvederm) can be injected into the upper and lower lip while still maintaining a natural look. I have injected up to 3 cc of Juvederm into lips and maintained a natural look such that people have no idea that they are augmented. For more about lip aesthetics, please visit my article at LA2Day.
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September 10th, 2011 drtim 
Today, in myBeverly Hills office I saw a young woman who was interested in beautiful breasts with a breast augmentation. Like most women who just come in for consultation for breast augmentation, she has already had a desired size and incision. Because many women in the city have friends or family members who have undergone breast augmentation, they often determine many of these factors based on their particular outcome. Furthermore, they have already gone to several plastic surgeons who have convinced them that one way is particularly better than the other regarding implant size, position, placement, etc. Of course, one of the dangers in applying someone else’s outcome to the way that you want your breasts done is that everybody’s body is different and everyone’s expectations are different. Thus, I find it very helpful to take a great amount of time talking to patients about the upsides and downsides of larger versus smaller implants, silicone versus saline implants, subglandular or submuscular positioning of the implants, and surgical approach including transumbilical, inframammary, periareolar, and transaxillary. For instance, a periareolar approach on a woman without skin may be a risk for poor scarring which will make certainly her and myself unhappy. Women with already excellent pre-existing breast fold would benefit from very well-hidden scar in the inframammary crease below the breast. Larger implants while can give somewhat of a lifting effect can also have problems such as bottoming out. Saline implants while they are less expensive and can be placed with a smaller incision than their silicone cousins can lead to visible rippling which patients may find unappealing. Thus, there are many factors that must be taken into consideration for breast augmentation. While the operation itself is not terribly technically challenging, the thought process leading up to the breast augmentation is often the most crucial element in predicting an excellent outcome. To make sure that I am on the same page with my patients, I often have them “try on” many different size implants under a sports bra and sometimes even see them in the office on a couple of occasions. Without doubt, the more time you take with patients and the more you explain options, the happier they ultimately are with their outcome.
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September 10th, 2011 drtim 
Last night, I had dinner with a facial plastic surgery colleague at one of our favorite restaurants in Beverly Hills. As usual, the conversation somehow shifted from what we were going to select on the menu, to breast augmentation, to the most recent difficult rhinoplasty case we have had. The nose, of course, is the centerpiece of the face. These operations can be very difficult if the expectations are not managed properly preoperatively. This dinner topic had brought up interesting point which is unique to plastic surgery. In aesthetic surgery, the outcome is determined almost solely by patient satisfaction. This is much different than other surgical specialties where the outcome is measured more by management of disease or pathology. For example, when a general surgeon removes a gallbladder, the outcome is determined by the resolution of symptoms. However, when a plastic surgeon operates on the body for aesthetic purposes, the outcome is determined mainly by how the patient feels after the surgery. Furthermore, most plastic surgeons such as myself are perfectionists and in fact outcomes are also measured by our own eyes. Of course, the best outcome is when the patient and the plastic surgeon are both extremely happy with the result. However, there are cases where the patient is extremely happy while the plastic surgeon finds bothersome imperfections. My colleague at dinner has tended to agree which leads me to believe that we are all, in some shape or form, obsessive of our work. In very, very rare instances, the patient could be unhappy with a particular outcome; for example, maybe a scar or a very mild asymmetry, and yet I know that this is clearly a very good result by all standards. When the patient is unhappy about something particular and yet the surgeon is very satisfied, this is the most difficult situation. It is nearly impossible to correct something when a reasonable imperfection does not truly exist. This is when patient expectations are critical in determining before a plastic surgeon operates. It is interesting that my colleague and I both came to the conclusion and reflected on our practice that we did turn down a significant amount of patients that we think have unrealistic expectations. I am convinced that the only way to determine whether or not you are a good fit with your patient is to spend a great deal of time with them and to truly understand what their desires and expectations are of the surgery.
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August 24th, 2011 drtim 
Despite what you may think, the desire for beautiful breasts and breast augmentation did not originate in Beverly Hills! In fact, the first augmentation mammaplasty (breast augmentation) wasn’t even in the United States. In 1895, Austrian-German surgeon Vincenz Czerny performed what is considered the first breast augmentation. Impossible, you say! Silicone implants weren’t developed until the 20th century. Indeed, it wasn’t until 1961 when the American plastic surgeons Thomas Cronin and Frank Gerow, and the Dow Corning Corporation, developed the first silicone breast prosthesis. The very first breast augmentation using silicone followed one year later. So how did Vincenz Czerny create larger breasts without these wonderful devices? Well, here’s a hint: he didn’t use anything not found in the human body. Vincenz Czerny actually used the patient’s own tumor growing in her back! The tissue of this tumor was a lipoma which is a benign (not cancerous) growth of fat. (Note this is NOT the same as autologous fat grafting.) This benign growth was transplanted from her back to the defect where he removed a breast from a more aggressive tumor. What followed later were various experiments and disastrous consequences from the hands of many different surgeons using products like paraffin injections, ivory, ground rubber, glass balls, , ox cartilage, wool, gutta-percha, formaldehyde polymer sponges, polyethylene tape strips wound into a ball, and polyester. How archaic, you say! Well, consider this. As early as 2000 British surgeons were using breast implants filled with soybean oil! Shortly thereafter, studies have shown a link between leaking soybean oil implants and cancer or and birth defects. At the time of the warning, approximately 5,000 women in Britain had already undergone breast augmentations with these implants. Now, we have cohesive silicone gel implants. And while they are not perfect, they appear to be very, very safe after countless studies investigated by the FDA. For more on silicone implants and their safety, refer to my LA2DAY article here.
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August 22nd, 2011 drtim 
Breast augmentation and the high demand for beautiful breasts remains one of the most popular plastic surgery procedures in Beverly Hills. With so many breast augmentations, breast augmentation revisions also becomes commonplace. Breast revision surgery may include any number of things ranging from removal and replacement for bigger (or smaller size), capsular contracture (see prior blog for details of this problem), breast asymmetry, removal of saline implants for silicone, rippling, bottoming out, and deflation. Of these, capsular contracture is probably the most common reason for a breast augmentation revision. In cities where bigger is generally deemed as better in the breast worlds (Houston, Dallas, southern California), bottoming out is a rather unpleasant prevalent sequel of large implants. Basically, this is when the weight of the implant causes the implant to migrate down and give an illusion of a nipple to high on the breast. While bottoming out is usually related to larger implants, it can happen to anyone at any age, and a lot of it is related to natural tissue elasticity properties of the individual. That is, smaller implants in a thin girl with poor elastic properties of her skin can also develop this phenomenon. To correct this, one may just wear wired bras for a prolonged period of time if the bottoming out is quick and after surgery, or, may need revisional breast surgery to resuspend the implant above a recreated breast fold. In fact, many of the complications one sees with breast augmentation can be corrected without surgery with good follow up care and compliance. So, every time I plan on performing a breast augmentation on a patient, I stress that THEIR post op care and compliance heavily influences the ultimate cosmetic result. Massaging and attention to post op care by your physician, particularly in the first 6 weeks of surgery is crucial!
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August 17th, 2011 drtim Today in my Beverly Hills office I performed a lip lift. A lip lift is exactly what you suspect it is. Usually, it refers to the upper lip being raised surgically to a higher position. Most people when they age ask for fuller, plumper lips. While it is true the volume of the lips slowly diminish, volume loss of the lips is not the only result of an aging face. The upper lip also elongates. In youth, 3-4 millimeters of the upper central teeth are visible with the open, parted mouth at rest. Look at every billboard on Sunset Boulevard! The most common sexy facial pose is the mouth opened at rest. And what do you ALWAYS see? Yup. Upper teeth. But, as the face ages, the upper lip gets longer, and the once visible upper teeth become hidden. And in turn, the lower lip also drops, and the BOTTOM lower teeth become visible at rest. Look at the two pictures posted with this blog. Young, full lips with a VERY short distance from nose to lip, versus the old aging mouth. In the photo of the the older woman, you see no upper teeth. Instead you see lower teeth. And indeed, the upper lip has elongated. This is the tell-tale sign of an old mouth. Juvederm and Restylane CANNOT change this. They can only plump the lip. And often, plum lips that have elongated with age look fake. Our brains know better. So, to truly rejuvenate the mouth, one should at least consider a lip lift. It takes 30 minutes and can be done in the office. And the results are significant.
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