Plastic Surgery Choices (cont.)

"In general, for any of these cosmetic procedures, weight loss prior to surgery is preferred to weight loss after surgery. That's true for any plastic surgery procedure, cosmetic or plastic."

MEMBER QUESTION:
When do you have complete healing with breast augmentation?

ZINS:
It depends on what exactly we mean by complete healing. And by this I mean within several weeks most patients are reasonably comfortable after breast augmentation. They may have minor discomfort at this time, but certainly in two to four weeks they should be resuming normal activity.

However, if the patient develops firmness of the breast this can lead to discomfort relatively long after the procedure. Therefore, if the patient has continued discomfort months or even several years after surgery, he or she should return to see their surgeon. Firmness of the breast, or capsules, can result months or even years after surgery. Therefore, if an individual has the gradual onset of new discomfort, months or years after surgery, I would recommend that they return to see their surgeon.

MEMBER QUESTION:
Could you go into some detail about removing dark bags from under eyes?

ZINS:
Well, of course I would have to see the patient to understand certain specifics. But, generally bags under the eyes are due to one or a combination of several things:

• Excess fat
• Excess fat combined with lax or excess muscle
• Excess skin
• Darkness under the eyes can be the result of sun damage or can be an inherited type of abnormality

Darkening under the eyes can first be treated by products used at home, such as Retin-A or Retin-A in combination with bleaching creams. If this is unsuccessful, a variety of peeling techniques can be used to remove pigment.

MEMBER QUESTION:
Four years ago I had a chondrosarcoma on my shoulder blade and as a result had a total scapulectomy. Since having this surgery I have experienced a tremendous pull and drag effect on my left breast (which also happens to be two sizes larger than the right breast). I realize I no longer have the support that I previously had. My question and theory is this: If I reduce the size of my left breast with reduction surgery will this in turn reduce the heaviness that I am experiencing on the left side? I would be eternally grateful if you could provide me with your opinion.

ZINS:
Certainly large breasts cause patients a number of problems. These include back pain, strap mark grooves, infections under the breasts, as well as neck pain. However, pain is a very subjective thing. If your breast size is a D cup or greater then reduction in the size of the breast may well have a positive effect on the pulling or discomfort you're describing. This may or may not be related to your previous surgery, but I would suggest that you return to your surgeon if the scapulectomy problem is an issue.

"Certain growths can be readily removed by superficial techniques that require superficial removal only with a minimum scar."

MEMBER QUESTION:
I would like to remove two moles from my face for purely cosmetic reasons. One is in an obvious spot and I want to minimize scarring and discoloration. The moles are raised (one on my cheek and the other by my temple/hairline) and approximately the diameter of a pen cap. Do you recommend I see a dermatologist or a plastic surgeon for this type of procedure? Is scraping, cutting, or freezing best? Also, can you give a general guideline of the cost of such a procedure?

ZINS:
My prejudice would be that for any cosmetic result a plastic surgeon is the best person to see, because of his or her attention to surgical detail. Of course, there are good dermatologists who remove moles, and if other friends or family members have had a good experience with a dermatologist, this would be acceptable. However, in general, plastic surgeons are technically superior in surgical techniques.

The mole would need to be examined to determine the best method of removal and removal with a minimum scar. Certain growths can be readily removed by superficial techniques that require superficial removal only with a minimum scar. Other growths require an excision or scar for complete removal.

Cost is dictated by the size of the lesion, the number to be removed, and the surgical technique required for their removal. Because of this, specific prices would be difficult to give you without more detail.

MEMBER QUESTION:
Please give me your opinion on the effectiveness of Thermage versus eyelid surgery.

ZINS:
Of course I need to talk in generalities when not being able to examine the patient. Eyelid surgery is done for a number of reasons. Most commonly, in the upper eyelids the problem is predominantly excess skin, and sometimes excess skin and fat. This is so readily treated by surgery and the result so consistent I would be hard pressed to even consider any other technique.

In the lower eyelids, the problem is generally fat visibility, excess fat, lax cover of the fat so the fat is prominent, and sometimes loose muscle or excess skin. Again, these problems are most effectively treated by eyelid surgery and Thermage would be ill advised. Thermage has been most successful in the forehead and to some degree in the cheek area, although these results are inconsistent. Therefore, I would approach Thermage with significant circumspection.

MEMBER QUESTION:
How risky is it to remove cheek implants that were inserted 12 years ago?

ZINS:
I would first ask why the person would like the implants removed. Are they malpositioned? Are they too big? Do they appear to be enhancing the appearance? If there is a problem with the implants, then removal would be reasonable.

Cheek implants can be placed initially through a number of incisions and sometimes are fixed in place with screws, making their removal more difficult. Therefore, before they were removed, I would suggest that the patient obtain the operative report from his or her previous implant operation. If the implants were not fixed with screws, removal is generally uncomplicated. But the patient should understand that he or she would lose the effect that the operation has created on their appearance.

MEMBER QUESTION:
I can't let my job know about having eyelid surgery. How long after will a person be bruised?

ZINS:
That varies according to the type of operation, the complexity of the operation, which eyelids are being operated on, upper eyelids or lower eyelids, and whether anything else is being done at the same time. Generally, patients' black and blues will be able to be concealed at 10 days to two weeks after surgery.

MEMBER QUESTION:
Is there a procedure to broaden shoulders?

ZINS:
Not that I know of. Anything's possible.

MEMBER QUESTION:
I have a question about a 2"- to 3"-long scar on my face that is 40 years old. I had eight stitches on my cheek, but the wound got infected several times. The scar is dimpled. Is it possible to have it repaired or made less obvious, even though I've had it so long?

ZINS:
Anything's possible. Without seeing you it is possible to review the scar; however, scar revision turns the clock back and the scar initially, over the next several months, will be visible. Scars that are many years old tend to be much fainter, but if there is a significant indentation, pucker, or other irregularity, consulting a plastic surgeon for correction is quite reasonable.

MEMBER QUESTION:
I was told that if you have a face-lift that nothing can be done with the neck. And that is why you see women all wearing turtlenecks. Is this true?

ZINS:
This is totally untrue, and the source of information is not well informed. Actually, virtually anytime that I do a face-lift the neck is also treated. In general, with regards to aging, the neck is often the first area to age. In fact, isolated treatment of the neck only, through incisions under the chin or through incisions that we use for a face-lift, is frequently utilized.

In the case of a revision face-lift, that is, in a patient who's had a face-lift and is undergoing another face-lift years later, often the neck has held up better than most other areas of the face. In short, the neck is an ideal area to treat to improve or reverse aging.

"There's been tremendous amount of media attention on plastic surgery in general, and cosmetic surgery in particular. The potential negative effect of this attention is to trivialize the importance and the seriousness of these operations."

MEMBER QUESTION:
I get skin tags on my eyelids, my neck, under my arms, on my back, and worst of all, on my upper inner thighs. If I get them removed, will they just grow back? I know my family doctor can cut them off, but I don't want her cutting near my eyes, and she doesn't feel they are medically necessary to remove, so I might as well see a plastic surgeon since she thinks my concerns are purely cosmetic, even though they can be irritated (especially on my thighs). Your advice, please?

ZINS:
Skin tags are readily removed in any location by a most simple procedure, and eyelids would pose no problem. The skin tags shouldn't return, but if you have formed many skin tags previously, you may form some more.

MODERATOR:
Are there any special concerns for those with darker skin when considering plastic surgery?

ZINS:
Darker-skin people have a tendency to form thicker scars, although this is unusual in the eyelid area. There are also techniques in properly selected patients who can have the surgery done without a skin incision and rather an incision in the conjunctivi, or inside the eyelid. This incision is generally used in patients who have fat excess in the lower lids only and minimal excess skin.

MODERATOR:
Dr. Zins, before we wrap things up, do you have any final words for us?

ZINS:
I think perhaps the best question we had today was your first question on how to choose a plastic surgeon. There's been tremendous amount of media attention on plastic surgery in general, and cosmetic surgery in particular. The potential negative effect of this attention is to trivialize the importance and the seriousness of these operations. Therefore, choosing the best-qualified person to do your surgery is the most important decision that you'll make with regard to a cosmetic surgery procedure.

Plastic surgery is a very diverse field, and good plastic surgeons may perform many operations well but not necessarily all operations well; therefore, the experience of your surgeon with the specific problem with which you are dealing is most important.

MODERATOR:
Our thanks to James Zins, MD, the chairman of the department of plastic surgery at The Cleveland Clinic, for sharing his expertise with us.

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