The Brave New World of Cosmetic Surgery
By Laura Green
You may not need anything reshaped or shifted around – at least not right now – but isn’t it comforting to know what wonders surgeons can perform?
More and more women (men too) are choosing to have various features refashioned or readjusted – but cosmetic surgery, like any operation, is serious business. To bring you up-to-date on what can be done, what risks you run, and what’s new in the field, here’s a timely summary of techniques that have the potential to change your looks forever.
TAKING YEARS OFF YOUR FACE
Surgeons used to erase signs of aging by pulling and tightening the skin – leading to jokes about Hollywood beauties who underwent so many face lifts that they had to sleep with their eyes open. Now many doctors operate on underlying muscle and tissue to reduce sagging and smooth creases from the inside out. They say this technique, called the SMAS-platysma face lift (it’s named for the muscles involved), lasts several years longer than skin-only procedures:
In the traditional operation, the surgeon makes incisions all around the hairline, separates the skin from underlying fat and facial muscle, pulls it up and back, trims the excess, and sutures the skin in place. In the SMAS-platysma face lift, surgeons go two layers deep instead of just operating on the top layer. They tighten muscles and fibrous tissue beneath the skin of the face, chin, and neck. It’s somewhat like the difference between making a bed by neatening the spread, and pulling up the sheets and blankets as well.
In recent years, some women have begun getting face lifts in their late thirties and early forties instead of waiting until after fifty, when more work is needed and skin is less resilient. “It’s a lot easier to take a bit of skin from under someone’s chin at thirty-nine than to take out the turkey wattles at fifty-nine,” says John M. Goin, M.D., a Los Angeles plastic surgeon.
A new wrinkle in face lifts is the use of suction-assisted lipectomy (liposuction) on the neck and jowls. “With this technique,” says a New York City plastic surgeon, “we can obtain a cleaner contour of the neck and cheek lines.”
Blepharoplasty, the operation to remove the fat and excess skin that cause droopy folds above the eye and bags below, is often done at the same time as a face lift. Incisions follow the natural crease lines of the lid, so they are difficult to spot.
Sunglasses must be worn for about two to three weeks after surgery because eyes are swollen, bruised, sensitive to bright light, and prone to tearing.
Another procedure, used when eyebrows have descended or there are deep wrinkles in the forehead, is to make an incision in the scalp, two or three inches above the hairline, and pull the forehead up. This restores the level of the eyebrows and smooths the wrinkles. It’s a simple operation that can be done on an outpatient basis. Anyone who already has a high forehead, however, might be cautious about opting for this procedure, since it will pull the hairline back even farther.
Though a face lift leaves temporary swelling and bruises it’s possible for a vigorous patient to be up and about fairly soon. One San Francisco businesswoman met a new man for drinks in a cocktail lounge a week after an operation to have the lower part of her face and neck lifted. “I had little sutures all over, but I wore my hair so it covered them and just prayed that the wind wouldn’t be blowing when we left!”
“I hate a nose that looks like a nose job,” says Peter McKinney, professor of clinical surgery at Northwestern University Medical School. He believes it’s far better to remove small amounts of bone and cartilage than to do too much and have regrets. “It’s very difficult to build a nose back up-much easier to take a little more off later,” he says.
The goal, according to John E. Sherman, assistant clinical professor of plastic surgery at New York’s Mount Sinai School of Medicine and attending surgeon at Beth Israel Medical Center, is to end up with “a straight nose that is in balance with the rest of the face, as opposed to the old ‘manufactured’ nose that was overly reduced, with a pinched tip.”
During this procedure, called rhinoplasty, the surgeon works through an incision inside the nose to sculpt, removing bone and cartilage. After surgery, the nose is covered with a protective splint for a week to ten days. Postoperative bruises around the eyes fade gradually over two to three weeks, swelling of the nose subsides in about three months but may take up to a year to disappear completely. A Miami-based writer who had her nose shortened and narrowed says it was worth it to look, briefly, like a panda. “I wanted it done because I was generally gawky, and my nose was one of the gawkiest aspects of my life!”
CHOOSING A SURGEON
The first step: Get names from doctors you trust. “Ask your gynecologist who he or she would recommend,” suggests Gustavo A. Colon, associate professor of plastic surgery at Tulane University. Then check their credentials and those of the clinics or hospitals where they operate.
Doctors certified by the American Board of Plastic Surgery have completed a three-year surgical residency plus an additional two-year specialty residency in plastic surgery. Medical experts say certification by a specialty board is your best assurance that surgeons know what they are doing.
Be aware that no law requires a doctor to have formal training in plastic surgery to do a face lift. All he needs is a medical license – and lots of nerve. “That’s why it is so important to ask if he’s board certified,” urges Dr. Colon. “And does he do a lot of operations?” Dr. Peter McKinney agrees that you should be wary. “You are not buying a toaster. Surgery shouldn’t be taken lightly.”
Both doctors recommend that you not rely totally on before-and-after pictures, because certain patients have such good bones and skin that a surgeon cannot help but make them look terrific. In addition, ask for names of patients to interview; they will probably tell you frankly what they like and dislike about their doctor.
What about doctors and clinics that advertise on TV and in other media? According to proponents, advertising makes information about plastic surgery available to people who might not get any from sources.
The American Society of Plastic and Reconstructive Surgeons, concerned that advertising not seduce or cajole, recommends that ads be limited to basic information about office hours and locations. Dr. John Goin, a former president of the group, dislikes ads showing elegant women in romantic or professional situations that imply that cosmetic surgery can change your life. Dr. Colon agrees: “Ads that imply ‘Come to us and get beautified and find the job you’ve been looking for’ may suck someone in to have surgery who hasn’t thought about it carefully. They treat cosmetic surgery as a commodity, like cornflakes, as if it were always safe and innocuous, with no problems.”
RESHAPING YOUR BODY
Suction-assisted lipectomy is a relatively new and increasingly popular way to flatten fatty bulges that nature giveth and that no amount of dieting can taketh away. The procedure is not an alternative to dieting; it can help women who are trim on top but have bulging hips, thighs, buttocks, and bellies. Someone cursed with saddlebags blessed with youthful, elastic skin that will quickly hug her post-lipectomy shape is the ideal patient. “The better the skin, the better the result,” says Gilbert Gradinger, a San Francisco area plastic surgeon and clinical professor of plastic and reconstructive surgery at Stanford University Medical Center.
The surgeon makes a half-inch incision, then inserts a hollow tube attached to a suction machine. The tube is maneuvered back and forth to loosen the and forth to loosen the fat, which is suctioned off with high vacuum pressure. Afterward, the area is tightly bandaged for several days. Some patients may need to wear long-legged girdles for a few months to help the skin shrink to size. But be forewarned: Lipectomy is not designed to eliminate cellulite dimples.
Surgical procedures as tummy tucks and seat lifts are usually done in conjunction with suction lipectomy, allowing surgeons to make smaller incisions and do finer sculpting than they could with surgery alone.
Abdominoplasty is often performed after childbirth or a large weight loss to reduce excess abdominal skin and tighten the underlying muscles. The surgeon makes a curved incision that swings from one hipbone down to the pubic bone and back up to the other hipbone. Another incision is made around the belly button. The skin is loosened from pubic bone to breast bone. Then the surgeon takes tiny stitches in the abdominal muscles, pulls the skin down, cuts away the excess, makes a new navel opening, and stitches the incisions.
“Think of pulling down a window shade. We pull down a layer of tissue to tighten the tummy,” says Fredrick Grazer, associate professor of plastic surgery at the University of California at Irvine. Before lipectomy, he says, abdominoplasties produced bellies that were too flat-looking. Today, surgeons use lipectomy to give a more natural look by recreating the slight vertical depression that runs down the center and around the belly button.
A twenty-nine-year-old aerobics instructor from Newport Beach, California, had abdominoplasty to restore her abdominal muscles after the birth of her second child. “I’m five feet tall and weigh ninety pounds. He weighed nine pounds,” she explains. Three months after the surgery, the incisions were barely visible. “I really did it for medical reasons, not merely for cosmetic ones,” she says. “But I do have a really nice, flat stomach now.”
Buttock lifts are seldom done because the scars show in a bathing suit and can stretch uncomfortably when you sit down. Surgeons can make incisions higher so they are less obvious, but the result is a flatter rear end, which may not be pleasing either. “Surgery sometimes requires a trade-off of one defect for another,” says Dr. Grazer.
Flabby, baggy upper arms can also be reduced by a combi-nation of suction lipectomy and plastic surgery. The drawback? A long vertical scar from armpit to elbow.
MORE BEAUTIFUL BREASTS
The most common cosmetic surgical procedure is not a nose job or a face lift but breast enlargement. The woman in her twenties or thirties who has waited long enough to know that nature will never give her big breasts is the most typical breast-augmentation patient. According to Gary Brody, clinical professor of plastic surgery at the University of Southern California, who has been performing breast implants for twenty-two years, surgeons now know that breasts will tolerate larger implants than was once thought possible. As a result, women are having their breasts made larger than ever. (New York City plastic surgeon Lawrence Reed points out that larger implants are used more in California than on the East Coast… but, even so, he says, “no one has ever come back to be made smaller!” About four or five patients a year ask Dr. Reed to exchange an existing implant for a larger size – a fairly simple procedure.)
During the operation, one incision is made just above the lower curve of the breast and another along the lower border of the areola, the dark skin surrounding the nipple. The surgeon lifts the breast away from the chest wall to create a pocket for an implant – a flexible plastic pouch containing silicone gel or saline solution. The operation leaves only small scars that even the skimpiest bikini covers.
When breasts sag, they can be lifted with an operation called a mastopexy. The surgeon removes a crescent-shaped section of excess skin from the lower part of the breast, then raises the underlying breast tissue and moves the nipple to a higher position. This operation leaves a curved scar at the base of the breast, another scar from the base to the nipple, and a third surrounding the areola.
Unlike augmentation and mastopexy, breast reduction isn’t considered purely cosmetic, because enormous breasts can cause stooped shoulders, backaches, and chest pains. Therefore, medical insurance sometimes covers the cost. The most common operation is called brassiere-pattern skin reduction. Working through horizontal incisions about two-thirds of the way down the breast, the surgeon removes tissue, skin, and fat from the sides and bottom of the breast. The nipple, part of the areola, and the underlying tissue are moved upward. After this, skin on both sides of the breast is brought to the center to enclose and contour the smaller breast.
Reduction mammoplasty leaves extensive, permanent scars, but since they are in the folds of the breast and around the areola, they are easily concealed by clothes and bathing suits. Breast reduction may also interfere with the ability to breast-feed.
The major advance in breast surgery, according to Dr. John Sherman, is use of the body’s own tissue to help in reconstruction after a mastectomy. “By incorporating an abdominal lipectomy,” he explains, “excess skin and muscles can be elevated in one operation to reconstruct the missing breast. The occasional complications caused by use of a silicone or saline prosthesis are eliminated, and the breast looks and feels more natural.”
Because most plastic surgery patients are basically healthy people, it is often possible to have an operation performed outside of a hospital and go right home to recuperate. Dr. Colon estimates that having outpatient surgery and spending the recovery period at home can cost 50 to 70 percent less than checking into a hospital for a few days to undergo the same operation.
A clinic should be fully equipped, not only to handle medical emergencies but also to provide follow-up care after the surgery. Someone on the clinic staff should call patients the evening after surgery and the next day to check on their progress. Patients should have a clear list of post-surgery dos and don’ts and easy access to a person who can answer questions by phone.
Even surgery performed under general anesthesia can now be done on an outpatient basis because of changes in hospital regulations and the availability of anesthesia in private offices according to Dr. Sherman. “These procedures include suction lipectomy, eyelid lifts, and mastopexy,” he says. “Among other operations, face lifts, rhinoplasty, brow lifts, and breast augmentation can be performed under local anesthesia and without a lengthy and expensive hospital stay.”
WHAT CAN GO WRONG?
Although any surgery involves a certain amount of risk, plastic surgery is less risky than most operating-room procedures because patients start out healthy. Also, most of the work is done on the face and upper part of the body-areas that have a larger and richer blood supply and therefore tend to heal quickly.
When surgery is done in an office or private clinic (away from the germ-laden hospital environment) and under local anesthesia, the chances of infection and other complications are notably lessened.
Nevertheless, risks do exist, and the more extensive the surgery, the more opportunities there are for something to go wrong. Nerve damage is possible, and any patient can have poor scar formation. In some cases, scars must undergo additional surgery in order to be excised.
After breast augmentation, there is a chance that internal scars may form around the implant, compressing it until it becomes too firm. When this happens, a second operation may be necessary.
The complication most closely associated with cosmetic surgery is excessive bleeding. It can cause a hematoma – an accumulation of blood – which may have to be surgically removed. To minimize the risk of excessive bleeding, most doctors advise that you refrain from taking aspirin or any aspirin-containing products for three weeks prior to surgery. There is also an increased risk of bleeding among patients on the Pill, so you should consult your doctor about the advisability of switching to another birth-control method.
Depending on the type of surgery, activities such as jogging and swimming may be taboo for some time afterward. Carefully following the convalescence regimen outlined by your surgeon will minimize postoperative complications.