The Ballerina Breast

Breasts come in all shapes and sizes, and few elements define the female form as they do. They attract, they feed, and they change. In the years that I have been focusing on cosmetic breast surgery, I have come to reinforce my long-held belief that shape is a lot more important than size when it comes to the bosom.

When breast implants were first used, the idea was to fill a small pocket with a large implant, and to have it be noticed. Augmentations were obvious, and at times a status symbol. They looked fake, but that was the point. And for the patients who had been struggling with padded bras and bikini breakdowns, this was a welcome alternative.

Over the years since their first use, implants have endured a rocky road. There have been recalls and revisions, saline and silicone, textured and smooth, and huge variations is size and projection. There have also been sweeping changes in cultural preference and social standards of beauty. As we entered the 2000s, the move to natural and holistic had its own influence on beauty goals; and I think it is finally catching up to me.

I have always considered small breasts to be beautiful. Full breasts are shapely, attractive, and very female. But there is something uniquely elegant, classy, and refined about a nicely shaped small bosom. One is not better than the other; they are just very different and equally enjoyable things.

The concept of the Ballerina Breast emerges in the wake of a return to natural, and in my opinion is a welcome breath of fresh air. The petite or slim figure is uniquely suited to a perky and petite upper body, and in some cases this is the most aesthetic possible outcome. Smaller implants also weigh less and cause far fewer complications, making maintenance much easier in the long run. And, as can be expected, they tend to look very natural and fly under the radar in most circumstances.

Why Don’t More Surgeons Use Small Implants?

As with most things in life, I find myself in the minority, on my own path with my own principles. I have been using small implants for most of my career, and have never considered them inferior. This is unique to me, as far as I can tell, much as I tend to place the implants above the muscle rather than under; but it is the product of a combination of true attention to aesthetics rather than pure force of habit. I, too, when I was trained, was told that one of the worst things that could happen after performing a breast augmentation was that the patient would say that she wished she had gone bigger. I prefer not to treat a fear. Furthermore, some patients want to stay on the small side, either because of functionality issues or professional limitations, as a matter of discretion, or simply because they like the way that looks and feels. The more I listen with attention, and the more I visualize with perspective, the more I believe that a lot of implants that I have seen are just not optimized to what they could be.

What Are The Features Of A Ballerina Breast?

The Ballerina Breast is a small teardrop shape, with a gentle slope on the upper pole and a round and subtle lower limit. It holds an unpadded bikini top in place, and can be pushed up to some degree, but it’s true quality is how it shapes the body with no extra support in place.

The line of a ballerina breast has only moderate cleavage. It works best with a deep V neck or fitted clothing. It is elegant and slim-lined, and appears effortless. An added benefit is that this silhouette conveys youth and femininity in its own dimension, and often defies the gravity that pulls large breasts down and makes them sag. In short, the ballerina breast looks like it belongs on a ballerina.

Are Smaller Implants Safer?

The larger the implant, the more it will impact the tissues, and the less possibility there is for a full return to baseline if ever desired. Large implants stretch the skin, but they also compress the breast tissue, and this can lead to permanent thinning of the breast. What does that lead to? The possibility that if the implants were ever removed, there would be less breast there than there was before the augmentation.

Very large implants can even flatten the chest wall, as they press on the ribs. Ribs are cartilage, which is harder than breast but softer than bone, and its shape can be changed. When I remove implants that are larger than 400cc, it is not uncommon for me to find a flattened or even scooped in chest wall under the breast, leaving a crevice where the implant was. This will not reshape itself over time, and often means that the patient will always need some sort of implant just to maintain normalcy in the shape of her torso.

In some cases where the trunk cannot support the weight of a huge implant, the augmentation itself can lead to issues commonly seen in patients who need a breast reduction: back or neck strain, chronic pain, need for very orthopedic bras, and long term difficulties with physical activity. This is not the case for everyone, and there are plenty of women with large implants who love them and live them to the fullest. But a small implant will usually have a lower risk of causing any of these issues, and it will also remain less detectable, if that is one of your goals.

Am I A Candidate For A Ballerina Breast Augmentation?

If you look at the vast majority of breast augmentation pictures out there, it is easy to start to believe that there is no such thing as a small breast augmentation. This is simply not true. While it is critical to size the implant width to the breast width, today’s implants offer so many choices and options in terms of projection in particular, that there should be little limitation as to whom could be offered this look.

It has happened to me many times that a patient comes to my office explaining that she has had four prior surgeries with three prior surgeons and she cannot understand why she just can’t get a smaller implant. Well, chances are that she probably can. And maybe that’s exactly what she needs.

Beyond Formula and Into Feeling : How to Optimize Cosmetic Surgery

How Art is Everywhere - And Hard to Explain

When I was in college, one of my good friends was an artist. Not only did he paint and draw, but he had spent a good amount of time studying art and learning the principles of design and aesthetics. Being the product of a regimented French school system, and having been on target for a life in the sciences, I had none of that exposure. When I looked at art, I expected it to represent literally what it showed. An apple is an apple. Does it look like one in this painting?

As I ventured through my first year of PreMed education, I realized that I had been studying science for so long that I had no idea what anything else really was. I browsed the list of offered courses and found 2700 classes that I could take. Most of which were not in science. Was there really that much you could do that was not science? Well, there was. And I wanted to do it all.

I changed my major to psychology to allow for the most flexible program. I then decided to dip my toe into design, and I took a class on contemporary artists. For weeks I sat there, watching them project images of colorblock paintings: one red rectangle on top of a blue square, four dots in a line, two lines down the painting, not quite centered. I couldn’t wrap my head around this. What was this nonsense? Who decided that these people were amazing artists? How were there entire books written about these works? Then I saw the ultimate offender: a solid white canvas. Just white. Um. What.

I decided to discuss this with my artist friend, beginning the conversation with a full-on accusation about the entire concept of design. He didn’t try to explain. Instead, he got some tickets to an art show and brought me to the exhibit. We walked around a little bit, observing some more traditional works and things that looked like themselves. And then there it was. A blank screen with some smudges on it. Nothing more, just smudges. I braced myself. I’m not going to get angry I said in my head.

“Okay. Please explain that to me,” I gently suggested. “It’s three smudges.”

He smiled patiently, stared at it some more, smiled wider.

“Yes,” he said. “But they are all in exactly the right spots.”

In the decades since that visit, I have come to understand the point of design, as well as the profound impact that it has on everything around us. The way that things are laid out and distributed not only determines what we consider attractive, but it can also affect our moods, our fears, and our spending patterns. We can become more productive in a less cluttered room, feel safer with symmetry, be attracted to someone who seems healthy and strong, and be confident when we feel balanced and in shape. The psychological impact of design makes the world turn, and despite being subjective, there are constants that hit us all the same way.

One of the most critical parts of a cosmetic breast surgery is the positioning and shaping of the nipple. For this portion, the patient is sat up to see how the breast falls, and then the nipple and areola are placed exactly in the right position. The surgeon often stands at the foot of the bed, and compares both sides, with the nurses and scrub technician confirming that they agree things are where they should be. For this, you don’t need much formal training. Things either look right or they don’t- you just know it when you see it.

This is the same thing that I try to explain to the medical students and residents that I train. While there are many aesthetic principles of which you must be aware in order to design things the right way, the bottom line is that proper designs just feel right. There is an instinct about it that lets you know that you have done things well. This is the principle that I use in all of my work.

Beauty Is Instinctive

It happens regularly that a patient will come in and say, “I hate my nose. I’m not sure why. I just hate it.”

At that point, the surgery training and the design training kick in. I can pick apart and analyze the issues, and help the patient realize why they are not happy with the shapes that they see. This helps with surgical planning and guides the process for what needs to be done. But ultimately, on the operating table, the work must continue until the overall design just looks RIGHT. This starts with the original plan based on aesthetic principles, and then gets modified to fit that patient’s face. The nose you draw in isolation is not the nose that will look best on that person. It is a version of the nose you drew that will optimize to this situation. Finding that version goes beyond formula and into feeling.

Plastic Surgery As An Art Form

In the decades since I renounced PreMed and became an artist/designer, then later returned to my first love of science and ultimately blended the two, I keep going back to the same art show exhibit. And every time I perform a surgery I think to myself: “Is that exactly the right place for that? Does that just look like it BELONGS there?” If the answer is not yes, then you’re not done.

There is a golden rule for aesthetics that dictates how to proportion things. It states that things look best when they are divided in thirds, and one part is one third, with the rest being two thirds. This is especially true for photography, where things looks good when the photo can be sectioned into 1/3 and 2/3 sections. If the bridge pictured here were in the middle of the frame, the photograph would look amateurish. I have always marveled at the fact that the human body is completely proportioned this way, throughout; and even more amazing is the fact that I learned that at Parsons and not in plastic surgery training.

One of my greatest joys in my work is improving or restoring my patients’ life or function. As a person who needs to be creative, I find tremendous satisfaction in the fact that every case is different, and every outcome can be customized. I have never made two noses look the same, or two sets of breasts fall the same way; because there is no one beauty standard. Not only do trends change and people evolve, but sometimes even the same person needs different things at different times in their lives. But the one thing that never changes is the total satisfaction of making it look and work just right, and seeing the beaming smile in someone’s eyes when they take a look in the mirror, then look up at you, and simply say, “Nailed it.”

FAQ

How Do I Know What Balance Is?

To some degree, balance is instinctive. You know it when you see it. But getting there requires training, and there are scientific principles in play. For example, the golden ratio dictates how we like things to be divided. This applies to photographs and faces equally. The rule is two thirds/ one third.

Is There a Perfect Shape For My Nose Or Breasts?

While there are design principles that guide our goals, it is crucial to remember that everyone is different, and needs a different result. Individual genetics and cultural difference should always be taken into consideration, because the same nose that looks perfect on one person may be completely out of place on another. There is a range of target shapes for every patient, and the goal should be to choose one that meets their aesthetic and functional goals, while respecting the principle of balance as a guide rather than an outline.

Cookie-Cutter Cosmetic Surgery

As with anything else, guidelines need to be applied to be optimized. The measurements and concepts are standardized to some degree, but they have to be personalized by patient in order to truly shine. This is the key to success: toeing the line between fitting in enough to not be obviously “done,” and looking good enough to stand out in the crowd. Balance is a delicate thing indeed.

Surgical vs. Non-Surgical Rhinoplasty

In the last decade, and with the advent of so many amazing injectable products, there has been a move toward non-surgical cosmetic procedures. Marketed with low (or no) downtime, lower cost, and lower risk these procedures become very appealing. But sometimes the appeal of the non-surgical option masks the reality of its ultimate success. Often, the conversation about the actual pros and cons is lost, as is the one about who is or is not a good candidate for the procedure based on their goals.

How Is Non-Surgical Rhinoplasty Performed?

As a general rule, non-surgical interventions on the nose involve injectable filler. While there are many versions of filler, most share the fact that they represent naturally occurring substances that the body degrades over time. Some are larger particles, some smaller, and some last longer than others. A few are permanent, but these are used less often.

Who Is a Candidate for Non-Surgical Rhinoplasty?

Because fillers do just that- fill a space- they can only make things bigger. You cannot shrink a hump, rotate a tip, or make a tip less bulbous with a filler. You can raise the area around a hump to catch up to it, add a point on top of an existing tip to make it look pointier, or make a round shape higher on the end of the nose to create the illusion of a rotated tip. But none of these elements represent true structural changes in the nose itself. You can also not straighten or narrow a nose with filler alone.

What is remarkable about non-surgical rhinoplasty is that, even though you are not chiseling a shape, for the right patient, the result can mimic having done just that. For patients of Asian or African-American descent for example, for whom in many cases the nasal dorsum is low, fillers are a wonderful substitute for a nasal implant, and have far fewer potential complications. They can also be molded to the needed shape, and adjusted in further applications. For the typical reduction rhinoplasty that involves a dorsal hump and bulbous or droopy tip, the options are more limited.

Isn’t Non-Surgical Rhinoplasty Cheaper and Safer?

For some patients, a really good illusion is plenty, especially since they can avoid an operation by creating that instead. While it is true that non-surgical rhinoplasty avoids an operation, the apparent and actual benefits do not always line up.

For one, cost can be grossly underestimated. A surgical rhinoplasty can range from $5,000 to $15,000, with a non-surgical one starting at $3,000 and generally staying below $8,000. But when you consider that the surgery is a one-time cost, and the alternative requires constant upkeep, then it really is not cheaper at all. Add to that the need for at least bi-annual office visits, and this really becomes a full time job to maintain. If you use permanent filler, then the results can last, but the material can not be removed if things do not work out as planned.

In terms of safety, there is an assumption that surgery is always more risky than something non-surgical. While surgery does involve cutting and anesthesia, properly chosen patients who are safe for surgery and treated in an appropriate environment with credentialed professionals are assuming less risk than people commonly imagine. Bleeding and infection are possible, but they are also possible with filler injection. Furthermore, filler injection has the risk of small particles getting into the tiny vessels around the nose and ultimately causing problems with blood flow to the skin or the eye itself. The risk of this goes up with the number and location of these injections, and a full non-surgical rhinoplasty usually means a lot of injections in a treacherous area. One could easily argue that it is less invasive, but at times more risky.

How Do I Decide On Surgical vs. Non-Surgical Rhinoplasty?

For patients who are seeking an overall reduction in the size of their nose, a significant straightening, or a complete reshaping of the tip, surgery is more likely to work for you. Smaller changes and softening of lines, or augmentation rhinoplasties that need to fill in or build up shapes, are good candidates for non-surgical interventions. What is crucial in your evaluation of options is to have a clear idea of what you can expect from the ultimate result. There are many things that filler can do; but once these are done, if having a nose that has a nice shape but is globally bigger is not what you are looking for, you may want to go back to the basics.

Odd Man Out - Why I Favor Breast Implant Placement Above the Muscle

When I was in training, every cosmetic surgeon that I worked with put breast implants below the muscle. The teaching was that this would contain the implant, isolate it from the breast, and offer more coverage on the upper portion. I was taught to perform the procedure that way, and continued in practice as one of many surgeons with that same training.

“Do Breast Implants Look Or Perform Better If They Are Under The Muscle?”

As I evolved in my own practice, I reconsidered many of the things that had been taught to me. Among them was the issue of where to place a breast implant. It had always seemed a bit strange to me that someone would take a device intended to mimic breast and put it where the breast does not exist. Yes, it is true that the muscle is under the breast, and putting an implant under the muscle does succeed in making the breast look bigger, but the breast tissue itself does not actually belong there.

“What Is The Benefit To Placing Breast Implants Above the Muscle?”

It also occurred to me that the muscle that is used for this purpose, the pectoralis major, normally lies flat on the ribs, tight and immovable. There is no space under this muscle, without cutting, ripping, and stretching it considerably. This same muscle also only covers about two thirds of the breast footprint, and especially after being pulled up to fit a large implant beneath it, it ends up only covering about half of the device anyway. What is more, even when maximally stretched, the muscle has the potential to contract, and this can cause a very socially awkward animation deformity that no one would want to display. The other issue with placement under the muscle is that, predictably, manipulating the muscle like that causes a significant amount of trauma to the area, and this leads to considerable postoperative pain, and longer recovery times. So why has this technique been the approach of choice for generations of surgeons? That is probably multi-factorial.

For one, surgeons like to keep it consistent. Once they are comfortable with a certain technique, it becomes a hard habit to break. Another reason is that, for decades, some of the complications associated with breast implants were attributed to contact with the native breast tissue. Having a barrier between the two was thought to prevent many types of problems, notably capsular contracture. But probably one of the most relevant reasons why this technique has been widely embraced is that, at the time of my training, the teaching was that the most common patient complaint after breast augmentation was that they had not “gone big enough.” As a result, surgeons placed the largest implants possible, and having that tight muscle layer to contain them actually did serve a purpose.

“Why Do Many Surgeons Prefer Breast Implant Placement Under the Muscle?”

In recent years, trends in breast augmentation have seen a remarkable shift. As I began to appreciate the relevance of placing a breast device in the breast plane itself, and as surgical techniques improved in terms of limiting complications from breast implant contamination with breast bacteria, the under-the-muscle technique has become less argued. That, coupled with recent trends towards natural results and teardrop shapes, has led to a revisiting of the procedures and a fresh perspective.

“Lead By Example - The Proof Is In The Profile”

There are circumstances where I would choose an under-the-muscle approach, such as when there is already a space made there and the patient is not having any issues with it. But on the whole, I prefer to go back to the basics and follow nature’s lead. As an art student and lifelong designer, my ideas and images of ideal forms are based in anatomy rather than habit; and my patients’ experiences dictate my preferences, even if this requires revisiting long-standing patterns. It is only through careful reflection and adaptability that we progress. And sometimes progress means going back to basics.

“Can Breast Implants Look Good Above the Muscle?”

Yes! Breast implants can look fantastic above the muscle. The key is to have them properly sized and positioned, and to choose the right type of implant for the patient. An oversized implant, or one with an imbalanced profile, will be harder to have sit right without the muscle literally holding it in place. But with the right choices and proportions, a well chosen implant can not only look fantastic above the muscle, but it can also move with the breast and simulate what it is supposed to simulate: more breast!

Why Is There Another Breast in My Armpit?

Ever wonder why your breast is supposed to be in front of you, but sometimes it ends up in your armpit? Well, there are two reasons why that may be happening.

The first possibility is that your breasts are too large or too wide for your frame. In that case, some of the tissue might end up extending farther out that the side of your body, requiring to be gathered back into your bra every time you get dressed. The other way that this can happen is that you have extra breast tissue that actually lives in your armpit itself. This is not an unusual place for breast tissue to live, but it can become a problem when it makes its own separate mound.

The breast naturally extends to the armpit, but it usually does so as a small thin tail of tissue. In some cases, a separate and large portion of breast can live right in the fold of the axilla, making it impossible to wear clothing or hang your arm comfortably down by your side. Much as with the rest of the breast, sometimes this tissue is mostly fat, sometimes it is mostly gland. Depending on the consistency and amount of tissue and skin, there are several treatment options available to you.

Why Looking Good on Camera Isn’t Just About Your Face

One of my good friends once told me that she always wears high heels when she is in online meetings. Although no one ever sees them, she knows they are there, and it just makes her behave differently. The heels also make her aware of her strength and femininity, and they officially feel “dressed up” for the occasion. They make her feel empowered, and she never fails to use that strength. Well, shoes are not the only thing that can have that effect.

In the last 7 months, more people have begun to work online and use electronic conferencing than ever before. Depending on their screen resolution and the nature of the meeting, this can add considerable social pressure to already challenging situations. It is also the reason why many people who used to love it have become slightly less avid fans of HD.

A few months after the COVID shutdown, there was a surge in cosmetic surgery procedures, to the point where this was chronicled in The New York Times. People started to notice the bags under their eyes, their double chins, and the wrinkles between their eyebrows. They spent most of their meetings staring at these features of their own faces and trying to figure out why they never noticed this before. Add to that the fact that most images that we have today of other people are air-brushed impossibilities of nature, and it can be hard to know what you are actually expected to look like. But, while our faces do in fact meet the world first, there is a lot more than just that that makes our impression on others.

Studies in non-verbal behavior will tell you that you say more with your body than you do with your mouth. One key element to how you communicate with others is your posture. Sagging or hanging over your shoulders can suggest that you are unhappy, bored, or lazy. It can also suggest that you are overwhelmed and cannot handle the job. Poor posture automatically defies confidence, ages you, and yes, hurts your neck and back in the process.

Posture is part habit and part anatomy. For example, women with very large breasts will find it almost impossible to achieve or maintain excellent posture, as they feel weighed down by a constant pull around their necks. People with weak core strength will also fall forward, leaving their backs with the disproportionate responsibility of holding up their trunks. Core restoration and breast reduction can help with either of these issues, as can targeted exercise routines where surgery is not indicated.

But posture is also psychological, and you are more likely to hold yourself high when you feel good about yourself. If there is something that makes you uncomfortable about the way you look or feel, it can translate into how you act and how you hold yourself. This is at the foundation of all aesthetics- the fact that feeling good about yourself can actually affect your performance and your general happiness.

One of my favorite things about being a plastic surgeon is watching that transformation occur for my patients. When I look back at some preop and postop photographs, many of them show that the patient is somber in the before, and smiling in the after. I try to be conscious about this so that the photos can effectively be compared to each other, and I never stage those looks, but they happen frequently on their own because of how people feel about themselves before and after their procedures. It is transformative to be constantly bothered by some small nagging detail, and then have it eliminated one day while you take a nap. It is even more empowering when the result is so natural that you can’t tell that anything was done in the first place.

A person’s mood shows on their faces, and their general comfort in their own skin radiates from every pore. Sometimes, confidence comes from the little things that only you know, but that make you feel particularly good about yourself. Sometimes it’s an accomplishment that you carry in your own mind. Sometimes it’s a connection with another person. Other times, it’s feeling amazing in a suit that fits you like a glove, or the first really great hairstyle you ever received. But regardless of where it comes from, confidence is emboldening, and sometimes the most so when it comes from your own little secret.

I once watched a woman buy a three hundred dollar bra while accompanied by her best friend. The friend asked her why she would do that.

“It’s not like people will see it,” the friend questioned.

“Maybe not, but I will know that it’s there.”

Am I Too Thin for Liposuction?

There is a common misconception out there that liposuction, and other fat reducing techniques, are made for patients who are overweight. It would make sense that a surgery that reduces fat would be optimized for patients who have a lot of it, and yet the reality is that these procedures were actually designed for people who have small amounts of extra fat. The key word here is “extra.”

The idea behind liposuction in particular is to target specific problem areas that stand out, and these areas are more likely to stand out when the rest of the person is trim. The other issue here is that the small problem areas on patients who are otherwise at their target in terms of overall size and shape, are usually resistant to diet and exercise, making them almost impossible to get rid of through discipline alone.

Fatty problem areas can occur for a variety of reasons. The first one is genetics. If you have ever observed a large multi-generational family, you will see that things like long legs, broad shoulders, and small feet can be patterned. The same can be said for extra upper eyelid skin, barrel shaped bellies, and double chins. The fat under the chin in particular is often pre-programmed, and it may appear as early as childhood in some people. While that bubble may look right on an older and heavier person, it is noticeably out of place on a young and fit person, and can make them look much older or heavier than they actually are.

The next contributing factor is hormones. Lifelong changes and events such as pregnancy will cause fatty deposits to form and solidify, often on the belly and thighs, and to varying degrees. Rooted in evolution, these deposits are intended to help feed new babies even in times when their mothers have little food. In an era where food is usually not an issue, they go from being purposeful storage units to stubborn unwelcomed bulges hanging over belt buckles, or unsightly side lumps in an otherwise smooth evening gown.

Hormonal changes occur in men as well, but with a different deposit pattern. Men will commonly form fat pockets at the neckline and around their sides. This is one of the reasons why, even in men with stable weight and healthy lifestyles, neck and belt measurements generally trend up over time, and disproportionately to their overall size. This then leads to the neckline overhang and the muffin top effect that force the purchase of larger clothing sizes, and prevent the confident wearing of a fitted T-shirt on a Sunday afternoon.

The last element is a challenging one: nature. The fact remains that the human body is beautiful, but beauty is also culturally and temporally defined, and we have come to a place of airbrushed perfectionism that seems impossible to attain. The truth is that this perfect is not in fact natural. The images we see in magazines and social media of flawless skin and chiseled abs do not occur spontaneously. Yes, those models work hard, eat right, and exercise devoutly. But a lesser known fact is that many of them also avail themselves of aesthetic procedures for the finishing touches. There are unique women who have full breasts and Disney-worthy waistlines, but they could all fit in one elevator. There are men who have washboard bellies and rippled arms, but there are more of them with very strong bodies and a few inches to pinch around the waist. The good news is that there are also simple procedures available that can shape those edges and eliminate those inches, if that is the look you are looking for.

Liposuction was designed to be a body contouring procedure, and it does just that. It sculpts and shapes the lumps and bumps that distract and defeat. And yes, that fat is then gone forever. You may make new fat, but it will preferentially go elsewhere. That is why small amounts of liposuction are very successful, and very large amounts can sometimes lead to imbalances if the patient gains a significant amount of weight afterwards.

Liposuction is safe, controllable, and it produces results. The conversation about less invasive procedures is a long one, but suffice it to say that if any of those techniques could replace liposuction, they would have by now. In the right hands and with the proper support staff, the procedure is reliable, effective, and often touted as “one of the best decisions I ever made.”

Out of all of the patients that I have treated, the happiest by far are those who had breast reductions, upper eyelid blepharoplasties, and small volume liposuction. For the latter, the conversation often starts with them announcing to me that their friends have no idea why they would even consider plastic surgery. “Am I even a candidate for this? No one understands what I am complaining about,” they say. But whether or not anyone else notices it, they do. And they definitely notice it when they wake up one morning and that annoying little bulge is no longer there.

“I look down at my waist and I laugh,” said Mr. S at his postoperative visit. “I mean, I just laugh out loud.”

Sometimes it is the little things that make a big difference.

What is Elective Surgery, and Why Is It Off-Limits Right Now?

In the world of surgical procedures, there are two modes: emergency and elective. By definition, emergency surgeries are those that must happen now, or at the very least sometime in the next 8 hours. Elective surgeries are procedures that should happen at some point, but do not have a similarly urgent timeline. While there are still timelines for many of these elective surgeries, they are often movable and imprecise.

In the current COVID-19 climate, all medical resources are critical. Ventilators, hospital beds, nurses, surgeons, and supplies all require conservation and redirection in order to properly address the current crisis. What’s more, every patient who undergoes a major surgical procedure that then requires a hospital stay (whether planned or not) will use a significant amount of all of those resources, at a time when they could be used to save someone critically ill. Desperate times call for prioritization.

This concept is relatively easy to understand in the scope of cosmetic surgery; but it is harder to grasp why knee replacements and hernia repairs have also been temporarily ruled out. The fact is that all of those procedures use resources that cannot be spared until there is a clearer view of what this extreme situation demands. With regard to cancer surgeries, this may seem almost extreme- how can a cancer operation be indefinitely delayed? The short answer is that the delay is not intended to be indefinite, and decisions are being made in real time as to what can and cannot wait.

The magnitude of this situation cannot be understated, and its effects reach all people and all activities. But it is at times like these that we can be our best selves, and exercise both our optimism and our patience. Whether or not everything is on hold, communication need not be. We may not be able to schedule a procedure for tomorrow, but we can discuss it, prepare for it, plan it, and support each other through the uncertainty of timing. And when the rooms open up, it will be a tremendous relief that we can go back to business; but more importantly, it will also be proof that things have improved enough that all of those resources are no longer needed in the eye of the storm. It is then that we will begin to feel the ease of things, and enjoy the strength that we built in the meantime while partnering from a distance.

Breast Reduction Surgery: The Ultimate Weight Loss and Lifestyle Procedure?

The first thing that I tell patients about breast reduction surgery is that is it a life changing operation. It is relatively rare that you do one thing in a few hours that impacts your world in so many ways. But while most women realize that a breast reduction can make your breasts smaller and lighter, they may not know how many other aspects of your body and world can be affected by this change. And they definitely do not realize to what degree your weight and overall health are usually impacted.

ONE- Proportions

When patients ask me what size their breasts should be, I hesitate to answer. For one, every body is different, and I am a big believer in proportions. A slim woman who is very tall and has wide shoulders may be able to carry a larger size, while a narrower woman with small hips may be better off with smaller breasts. One thing is for sure: they were not handed out evenly, and most of us are on one side or the other of the breast proportion spectrum.

One of the complaints I get from my breast reduction patients preoperatively is that they "can't buy clothing." They might be a size 4 in pants but an 8 in tops, so what happens when they want to buy a dress in one piece? Or, could you imagine, a bathing suit? It becomes almost impossible. What is worse is that wearing something too small on big breasts can look unprofessional or unattractive, so the default usually falls to the larger size- which can then look frumpy. When the rest of your body is small and only the breasts are large, that larger size doesn't fit you right anywhere, and you start looking like you are wearing someone else's clothing. Downsizing to the right one resumes that proportionality, instead of having your entire wardrobe dictated by something that only represents 10% of your entire person.

TWO- Weight

Even if you are not wearing clothing two sizes too big, very large breasts have the effect of making you look heavier than you are. Whether standing still, walking around, or sitting across a table or desk from someone, you will seem heavier than the scale suggests. Bringing that size into range of the rest of you allows the overall impression to be more accurate. In the end, most patients who get a sizeable reduction can look like they lost 20 pounds without having done anything at all. This is similar to the effect of removing a double chin through liposuction. A small patch of fat in the wrong place can suggest something very different about the rest of you, and an oversized top half can be even more extreme.

THREE- Age

Whether large or small, breasts that sag suggest older age. Gravity being what it is, the larger the breast, the more likely it is to hang low. When performing a breast reduction, the goal is to minimize size but also maximize lift, which has the side effect of rejuvenating that entire area. Once reduced, the shape of the breast must then be rearranged, and this is the perfect opportunity to create something perky and light. Nipple position is a critical component of the operation, and the nipple is almost always raised back to its ideal aesthetic location. Finally, when moving the nipple, the areolar is generally resized and also reshaped, leaving the door open for a little artistic license and customization. This is where the design aspect comes into play; and in the right hands, it completes the cosmetic renewal. Can you say "mono-kini?"

FOUR- Cleavage

One of the things that is most difficult for people who do not have large breasts to understand is that the larger the breast, the less likely it is for the breast to be in the right place. Large breasts tend to pull on the skin and the ligaments, ending up hanging rather than sitting up in place. The more breast tissue there is, and the heavier it is, the more likely it is to hang down low. As it pulls, the volume that once was in the upper part of the breast falls below the fold, and you can eventually end up with most of the breast on the belly rather than the chest.

When performing a breast reduction, it is important to recognize that the breast tissue has fallen below where it belongs. The goal is not to just remove some tissue and pull the rest up by the skin. Skin has no inherent structure, and it will just fall back down again in time. Plus, if the skin falls after the nipple has been moved, you can get a "bottoming out," where the nipple is up and the breast is down, looking as backwards as it sounds.

For a breast reduction to be successful, the tissue that is left behind must literally be relocated to the upper portion of the trunk, and the cleavage line reclaimed. It may seem counterintuitive but the bigger the reduction, the more likely you are to grow your cleavage line by having the surgery performed. This involves a certain amount of redesigning and a clear 3D perspective on anatomy, but when properly executed, it leads to a remarkable transformation- and often a bra-optional lifestyle to boot.

FIVE- Diets Optional

Most of my breast reduction patients complain that they try everything but cannot lose weight. As you can imagine, if you had two 10 lb. weights around your neck, it would be hard for you to exercise too! For these women, simple things like going for a jog seem prohibitive. I hear stories all the time about women who wear two and three bras at a time while going for a run, because they can't contain their chest in any meaningful way. Getting a breast reduction when you need one can change all of that.

On average, a breast reduction patient in my practice will lose anywhere from ten to twenty pounds in the first six months after surgery. This is because she can actually exercise now. This is also because she can see her body, and the apparent weight loss from the surgery itself gives her a first look at what could be if she keeps that train going. For women who have been struggling with their weight, this can be a first step to a lighter life; but most importantly, it is a springboard to the final benefit: a complete change in lifestyle.

SIX- A New Lifestyle

A few years ago, one of my breast reduction patients told me that when she went home after surgery, her son was shocked to see that "Mommy, you grew!" She obviously had not gotten taller, but she was standing up straight for the first time in years. She was also walking differently, because she now had breasts that were not only proportional and lighter, but more symmetrical. For decades, she had had one much larger than the other, and it pulled her not only down, but to the side. She had the deep shoulder trenches from orthopedic brassieres, dents in her chest from industrial strength underwire, too-big-tops, and a hunched neck that required daily pain medication. Not fun.

After her surgery, this lovely woman suddenly walked tall, straightened out, and started a new workout regimen. She got so much healthier that her early high blood pressure went away and she no longer needed medication. The back pain also resolved and she no longer needed pain medication either. And she was finally able to buy clothing that fit, which meant that she could shop anywhere and benefit from sales. Huge amounts of money saved. It was a total life transformation.

Other Things to Know

Breast reduction is sometimes covered by insurance, depending on your plan and whether or not you meet the criteria. It is usually an outpatient procedure, with a well tolerated recovery. Most patients who were trying to lose weight prior to their reduction will have an easier time meeting those goals after the fact.

BE FREE

While many plastic surgery patients are happy with their results and feel that it was worth the effort, women who have had breast reduction surgery are among the most satisfied. From weight loss to body rejuvenation to saving tons of money on bras and bikinis, the overall effect is generally transformative in every way. Happy is the woman who can wake up pain-free, go for a jog, and then throw on a summer dress without a bra and get on with her day. This brings new meaning to the concept of women's liberation. Be free, ladies, and thrive.

The High Cost of Free SIicone

These days you can find silicone almost anywhere. It’s in the hot pads we use for cooking, the gel we use for scar healing, and the industrial lubricants that the contractor uses for some of his building projects. Silicone is versatile and ubiquitous, but there is one place where you can find it that it does not belong: hanging out free in the human body.

One of the reasons why silicone has been so widely adopted is that it has long been considered inert, meaning that the body does not react to it. As more and more silicone products were developed, the medical community supported their use with the belief that the human immune system had no reaction to the material, making it safe as an implant product. If the body didn’t react to it, then the rate of inflammation and infection would be low, and therefore problems would rarely occur. Unfortunately, after decades of use, this concept is now being called into question. But even if you assume that there is reactivity to silicone, some forms are more problematic that others.

When we think of silicone for medical use, breast implants are the first thing to come to mind. But there are many other forms that silicone can take, and many other places it can end up. From eyelids to buttocks, in the form of liquid or solid, silicone has been making an appearance in multiple places here and abroad, often with dire consequences. So why is this such a problem? And why are we using so much silicone if it causes us so much trouble? Let’s try to demystify this issue once and for all.

1.      Solid silicone implants

Solid silicone is a block with a specific shape. This type of silicone is used to make things like chin or cheekbone implants. The product remains hard, and is often used to substitute things like bone. Like any foreign body, a scar shell called a capsule forms around it, and this contains the implant and serves as a barrier to the rest of the body.

Because solid silicone has no liquid or gel component, even if the implant cracks, there is nothing in it that can run around the body. This means that removing it is usually pretty easy. Even if it is stuck to the capsule, it can be removed with the capsule shell and this takes everything out in one go. The problem with the solid state is that it is very firm, and this makes it less desirable for areas that are not meant to be solid like rock.

2.      Silicone gel

When you want something semi-solid for softness but that also remains contained fairly easily, gel is the answer. Silicone gel has a relatively solid consistency, but it also has a softness and fluidity that make it ideal for simulating human tissue. The degree of “cohesiveness” in the gel refers to how linked the molecules are, or how solid it feels and how much it holds its shape. At this point, technology allows us to dial up or down on the softness, depending on what we are using the implants for.

Some of the other places that silicone gel can be found is in calf or buttock implants. Often, these implants also have a thin, pliable, solid shell and the gel is used to fill the shape. The solid shell contains all of the product, and a capsule forms around it as usual. The problem with these implants is that, depending on the level of fluidity of the gel, if they burst, the insides come out. Therein lies the main issue.

Once silicone gel is no longer contained within its shell, it is basically free, in full contact with the human tissues. That’s where things get hairy. The gel is sticky, taffy-like even. This makes it incredibly difficult to clean up. It sticks to everything it touches, irritating tissues and causing inflammation. Removing it becomes a huge problem, and this is where the real trouble starts. Most of the time, in order to really get it out, you have to remove the sticky gel, the shell, the capsule, and any tissues that came into contact with it. What a mess. This is one reason why many surgeons in the Unites States do not perform these procedures. When it goes bad, it’s bad, and very hard to cope with.

3.      Liquid silicone

Here is where things get really sticky. Liquid silicone was also long thought to be inert. As a filler material, it offered the option of being clear, malleable, and easy to inject. It also had the property of infiltrating the tissues like gelatin into a sponge, by filling every nook and cranny evenly. This was very tempting to practitioners who were looking for some bulk without having to make an incision and insert a block of construction material. But the same thing that makes liquid silicone so good as a filler material also creates a medical nightmare when things are less than fantastic: it cannot be removed from those tissues.

Imagine wiping up liquid Jell-o with a sponge and then putting that sponge in the fridge and letting the Jell-o set. Now take the sponge out and try to remove the Jell-o from it. It’s totally impossible. This is what happens when liquid silicone is injected into a buttocks. The stuff sets into the fat and muscle, never to be retrievable again. If it has the misfortune of getting inflamed or infected, then the misery has just begun.

Whether or not you believe it is inert, silicone gel is still a foreign body to the human body. It can get covered in bacteria and become infected. If it is not inert, then it can cause an inflammatory response without any infection present, stimulating your immune system to fight it off and attack. When this happens, your body will make a lot of scar tissue, causing tight and painful areas where the battle has taken place. In many cases, these infections and/or inflammations can make the person sick; and they can strike at any time and with any degree of frequency. What is worse is that, not only is there no specific medical treatment for this condition, there is no way to predict how bad it will get nor how often it will get there. This is where the black hole of misery begins.

One area where liquid silicone sometimes makes an appearance if the eyelid. People looking to fill in the divots under their eyes will sometimes get persuaded to go for a permanent solution. While some forms of liquid silicone are approved for human injection, these are intended for use in ophthalmology procedures, not for cosmetics. Injectable medical-grade silicone only comes in these small amounts in the U.S., but it is not made for wrinkle repair. When it sits quietly, all is well; and the results can be terrific. But if it decides to get upset, it too cannot be removed without removing a large piece of that same eyelid. The other thing is that the inflammatory response is usually so great that a different kind of scar tissue forms, called a granuloma. This too must come out for treatment to be complete, because it harbors small amounts of the silicone that the immune cells were not able to destroy. All in all, this can become a true disaster right in the middle of your face.

Whether in small or large amounts, free silicone can unpredictably become a life-long problem. Any tissues taken out in order to take out the problem silicone will ultimately need to be replaced. This means that treatment can be long and require multiple stages or surgeries, and end with disfiguring scars. Patients who get large amounts of free silicone injected, usually in other countries, will find it difficult to get any kind of treatment once seeking care here, because the interventions required are often dramatic and with unpleasant outcomes. The alternative is living with chronic pain and deformity, as the granulomas become hard and lumpy, the opposite of what you wanted for either look or feel.

Consider as well that once the gel gets out of that shell, it essentially becomes the free silicone that no one wanted to inject in the first place, whether or not there is a capsule barrier present. This is the big problem with breast implants, when silent ruptures mean free silicone without the patient even knowing it. What started as a contained soft addition becomes a clumpy mess of gel and granuloma, often with small bits traveling around the chest wall. Removing it becomes an arduous search and destroy mission, one that many surgeons shirk away from performing. While this situation is usually not as bad as the buttock epidemic currently under way, it can be just as miserable for its bearer.

FREE SILICONE – The VERDICT

Thousands of people get lured every year into having silicone injected into everything from their buttocks to their labia, often with the promise of lasting results with no surgery and no downtime. It takes very little time, costs very little money, and seems to hold the answer. But if you stop to consider this for a moment, it may occur to you that if this were the real easier and cheaper answer, it would have replaced surgery long ago. It hasn’t. Also consider that most of the time, free silicone injections are occurring in motel rooms rather than credentialed physicians’ offices, and payments are in cash only. This too should set off all of the alarms.

In the end, there is usually a reason why certain things are not done very often. Sometimes it is because they are difficult and require expertise. Other times, and more usually, it is because somewhere along the way the community figured out that it probably wasn’t such a great idea, and people stopped doing it. The best litmus test is this: If a Board Certified plastic surgeon won’t do it, and you rarely see successful before and after stories about it, you probably don’t want to chance it yourself.If it were such a good idea, there would be more of it going around, and you would have at least a handful of friends who could show you how happy they were with their results ten years later; as opposed to the horror stories you find online and in blogs. In aesthetics, as in life, you often get what you pay for; and short cuts often lead you right off the cliff. There is no buying your way out of that freefall, and it’s no

How to Spot a Fake!

Ever consider buying a really expensive handbag, and then realize that you could get something that looks almost exactly the same for a fraction of the price? Ever buy a really expensive handbag on a deep discount only to then realize that it’s not authentic? Well, don’t feel bad. It can be very difficult to spot a fake if you don’t know what you are looking for. That is why they have things like the Goyard Guide to help you figure out if what you are seeing is really real.

The same principle holds true for cosmetic surgery. Before and after shots are sometimes compelling to the point of being mesmerizing, and they often seem nearly impossible. What you might not realize is that many of these pictures are not representative of what that person actually looks like. There are countless photo-taking and Photoshop-ing tricks that can significantly affect how those pictures come out. Even where you stand when you take the picture can make a huge difference in how it represents what you are capturing.

So how to spot a fake? Here is your quick and dirty guide… Then take the SELF-TEST to see if you can spot the fake!

Tip #1: COLOR

Colors can make skin look fresh and bright, dark and dusky, red and angry, or green and sickly. Small changes in “HUE” can suggest well-being or age, depending on which way you skew it. Always look to see that something pink or green that was not supposed to change looks the same on the other side. Take a look at the picture below for example. The eyes are different colors, but they are not supposed to be. In this case, the color difference is more of a light and dark issue than a red/green issue, but the difference in color is a great tip off that the picture is a little skewed.

Tip #2: LIGHTING

By far, the most influential aspect of a photograph is the lighting. Bright lights wash out details like fine lines and wrinkles. Brightening a photo with the computer can decrease contrast, or make the colors blend more together, and therefore look more even. Always look at the lighting on the before and the after. If they are not the same, chances are things are misrepresented. In the picture here, the eyes are different colors because the lighting is darker on the left. Darker lighting means deeper folds, more prominent wrinkles, etc... Always look for bright spots and dark spots, and any glare that just washes out the problems. This will be your first clue.

Tip #3: SATURATION

Saturation is the intensity of color in a picture. Basically, it describes how much paint is on the canvas. High saturation can make things look rounder or fuller, more plump. Lower saturation can make things look drab and less vibrant. See here the lips- much plumper on the right. Higher saturation is like putting an extra coat of lipstick on, without even touching the subject.

Tip #4: ANGLE

Do this experiment on yourself: hold your camera up high and take a picture of yourself facing up at it. Now take the same selfie with the camera in your lap and facing down. Totally different right? Not only does the angle change how the light bounces off things, but gravity also either pulls your face back to freshen you up, or forward to make things sag. The angle in which you take the picture can really make things look different. Always consider how the person is standing or holding their head. It can be a game-changer.

Tip #5: CLOSENESS

Because of the way that photo lenses work, there is an optimal distance at which to stand when taking a picture. Any more or less will change the photo itself, in a way in which zooming in or out will not fix. Without getting too technical, it’s all about the geometry of the light, or the way it bounces off your object and onto the lens. If you take a picture of someone’s breasts while standing close to them, they will look huge. Stand back six feet, and they will shrink up, without anyone doing anything to them at all. The close photo gives things a “fishbowl” appearance, almost like a panoramic view. Standing back lets the different elements in the photo even out and equilibrate. When considering that photo, try to see if any particular element seems a little blown up, or out of proportion. It may be exaggerated.

Tip #6: FACIAL EXPRESSION

Back in the day (I will date myself here), before and afters routinely showed the before with someone frowning or serious, and the after shot had a glowing smile. Infomercials are still famous for this, as you watch the before eggs sticking to the pan that no one will ever be able to clean, and the perfect after eggs slide onto a plate with three strawberries and a single sprig of mint. The intention is to suggest that everything was miserable before the treatment, and now we are all just giddy with contentment.

What has happened lately, interestingly enough, is that this has shifted a bit. Because there is such a huge focus on rejuvenation, and therefore wrinkle-reduction, after shots rarely show anyone smiling. Why not? Aren’t they just delirious after their Botox treatment? Well, the answer is that those happy-lines are in fact wrinkles. Showing someone smiling will remove much of the evidence that they had their faces appropriately treated. Smiling can not only bring out your laugh-lines and crow’s feet, it can also reveal your double chin and the bags under your eyes that normally only show in the morning before your coffee. Always take into consideration how the movement of facial muscles may affect how the skin folds around them.

Tip #7: POSTURE

For body shots, posture is everything. Stand in front of a mirror, then turn sideways. slump down your shoulders and hang your neck. Now curl your pelvis under. Ugh. Very “before”.

Now stand up straight, bring your shoulders back, and stick out your butt. Now tighten your abs. That’s better! Now twist at the waist- WOW!

Right there, you just created your own before and after with no surgery at all. Shoulder posture totally changes the way the breasts lay, and overall core positioning can push out your gut or pull it right in. How your legs are placed also has an effect. Stand forward with your shoulders and hips square. Meh. Now rotate just a little to the side and cross your feet in front of you. Very slimming! These are the tricks the stars use for their red carpet looks. These are also perfect before-and-after tips for why one look might look very different from the other.

Tip #8: CLOTHING

We all know that the clothes we wear can really change how we look. But they can also change what we think we see. The height of a collar can make a neck seem shorter and more chunky, or taller and slimmer. Low-waisted clothing reveals more of the belly, and it shows the definition of the midline. A higher waist will smudge out that line break between the narrowest part of the waist and the wider hips, and this could obscure the contour. When the before shows a high waist or chunky belt and the after has a streamlined (and sometimes Spanx-ed) profile, this may be part artifact and not all fact.

Tip #9: MAKEUP

Makeup is a very common tool for before and afters. In general, people look better in makeup. You can make or erase shadows, plump lips, brighten eyes, and take away shine. In this photo, the makeup colors look similar but the makeup is used very differently. The eye-shadow on the right brings out the eye and makes it look much bigger. The lipstick on that side goes beyond the lip line, and the color is brighter. This makes the lip much fuller. Shadows on the nose also make it look thinner and make the nostril look smaller. No, really, look closely. They fooled you!!

Tip #10: TONE

Finally, let’s talk tone. Ever notice how sometimes you read an email, and even though you can’t hear the person’s voice, you can feel their tone? Tone is a huge factor in photography. Think of it as the background music of the shot. In this photo, the left side seems sadder than the right, although at first glance the woman appears to be in the same mood. But if you really look at it, you will see that on the right side she is almost, sort of, subtly, smiling. The corner of her mouth is just a little up, the corner of her eye a little lifted, and the muscles in her face just a tad bit animated. She is a little happy. Not enough to tip you off, but just enough to make you feel it. The woman on the left had a bad day. The one on the right is feeling just fine. Almost happy. Definitely confident.

So how do you tell the tone of a photo? Easy. How does it make you feel? That’s your answer.

The verdict: Photos can show us things that are and things we want to show equally. When considering your cosmetic options, be an educated consumer. Surgery on your body is higher stakes than buying that almost-handbag, and the advertisements are more aggressive. Remember that the before and after shots you see are the best that person has to offer, and also represent what they imagine is a great result. Make sure your goals line up with theirs. But more importantly, when looking at those pictures, all designed to make you say “wow,” know how to spot these tricks. An excellent surgeon will doctor her patients, not her photographs.

Why Everyone Needs a Plastic Surgeon on SpeedDial

Life is full of Boo-boos. They happen to everyone all the time. But before you decide to just "butterfly" it and run, consider this: there's probably a plastic surgeon nearby who could patch up that boo-boo and get it looking much much better down the road.

Plastic surgery has come a long way since its inception last century. Wound care technology and surgical techniques, along with breakthrough lotions and potions, now have us in a place where the idea of a scar is a very different thing than it was for our grandparents. What's more, since a scar is not mature for at least one year after injury, there is actually a lot that can be done over a long period of time to ensure the best possible outcome. You just need the right coach.

The idea of a plastic surgeon evokes Botox and breast augmentations- yes, we do those. But what most people do not realize is that we also fix cuts, burns, broken bones in the face, nerve injuries, and hand wounds. We repair bellies, cover open wounds for other surgeons, and shepherd our patients through full body rejuvenation in a way that no other specialty can. 

So whether life hands you a surprise party, the aftermath of pregnancy, or a bump on the head that "came out of nowhere," know this: the boo-boo lady is your lifeline to timely expert care, and your best chance at destroying the evidence of a bad day

You're Not Alone... Why No One's Bra Fits Well

You’ve probably heard the statistics: 80 percent of women are wearing the wrong bra size, and they don’t even know it. But many of these women have been wearing bras every day for decades. How, exactly, could they be so clueless? If you had the wrong size shoe, you would probably know it. So how could something so intimate be so off-base?

The Problem With Sizing

The problem with bra sizing lies less with the wearer than with the sizer. Bras have only been around since the 1930s, when corsets went out of fashion and people started making underwear as we know it today. The original idea of bra sizing focused on how much ptosis, or sagging, a woman’s breasts had. This proved to be minimally useful, so the "A,B,C,D" letters were eventually re-adapted to assess breast volume more than position.

How Traditional Sizing Works

The way that bra sizing works is as follows: The chest wall is measured in circumference just below the breasts. The breasts are then measured in circumference at their peak, and both numbers are recorded. If the difference between the two numbers is one inch, then the cup size is A, if it is two inches, the size is B, and so on. This approach is simple and direct, and seemingly adequate, but ultimately totally inefficient.

The Missing — And Most Important — Measurements

The problem with this approach to bra sizing is that it fails to take into account many things. For one, the most important measurement of any breast is the base diameter, or the width of the breast. As a plastic surgeon, this is the most critical assessment I make on any breast exam during a consultation. The base diameter of the breast sets the stage for any implant-based surgery by letting the surgeon know how much real estate she has to work with. Similarly, the width of the breast should guide what covers the breast. Much as a foot fits into a shoe, width can make or break its success; cup sizing as we know it takes no account of this.

Bra cup sizing also fails to recognize the height of the breast, and more importantly, how low it hangs. If you measure the circumference of the breasts at their peak, but the breasts are sagging to the floor, you are likely to underestimate how much breast really lives there. In some patients, most of the breast tissue lies low on the abdomen rather than on the chest up above. In extreme circumstances, this could mean that more than half of the patients’ breast tissue eludes the cup size measurement entirely, and remains unrepresented. This may be part of the reason why the original cup sizes came with a disclaimer that they were in fact not useful for very large-breasted women.

Gravity

Now let’s consider gravity, the enemy of perkiness. Most breasts will sag over time, but some will sag more than others. The more a breast sags, the flatter it appears to be. The flatter it is, the less it can project forward away from the body. If you go back to the cup measurements, and you visualize the measuring process, it becomes clear that perky breasts will stick out more than flatter ones. And they could easily measure out to a larger cup size even if the breasts they represent are in fact half the size of the sagging ones.

Finding the Right Bra

It is now becoming clear that bra cup sizing is in fact quite arbitrary. So what about the professional lingerie houses that offer personal sizing? Are they the answer? Yes and no. As long as we have the current system, finding the right size bra will continue to be similar to finding the right size pair of jeans. The sizes will serve as a guideline, but it is only once you identify the perfect brand for you that things will really fit into place. It’s helpful to look for the model a brand uses—does she have similar characteristics to you, in terms of breast width and size?

The reason why lingerie houses may be more successful in fitting you than a regular underwear house is that they have a clear sense of how their items are sized, and they often have a variety of styles that incorporate different widths and projections to compensate for client variability. Still, this option remains a mere Band-Aid to the real problem: bra sizing was created by people who thought of breasts as small, medium, and large, once they were freed of their corset baskets 80 years ago.

Developing a New Bra-Sizing System

As a dedicated cosmetic breast surgeon, I spend a lot of time thinking about breast shape, size, and proportion. I also spend a lot of time consulting with patients, most of whom are never really comfortable in their bras. It is my plan to devise a realistic bra sizing system in the near future, one that can be standardized and represents relevant measurements for each woman. Conceptually, this is not that challenging. The real question is, if this system were developed and proved to be useful, how would anyone get the world’s bra manufacturers to make the switch?

Seek Support Without the Wire

Old habits die hard for a multi-billion dollar industry, but there is hope that if enough women learn how to find the right bra, seeing the difference it could make may incite a revolution; cup size would finally become an antiquated custom. In the meantime, embrace your B, whatever that means, but lose the wire. The only thing worse than the wrong width bra is one with a metal band set to the wrong diameter. Technology offers us revolutionary new materials that can change and conform as needed, and support without the remnants of a corset. Support is possible without metal, and shape is easier with stretch. Until the day that bras are actually made to fit real breasts—and I believe that day is coming—the only chance we have at comfort is adaptability.

ho·me·op·a·thy ˌhōmēˈäpəTHē/

I am not generally that big on lotions and potions. Few things truly work as well as they should, and even fewer come without significant side effects. For scar therapy, you can't argue with the data on silicone and sunblock. But for the other nemesis of cosmetic surgery, unsightly and uncomfortable swelling, there is Arnica.

Arnica is a homeopathic medicine derived from a plant whose mechanism is not well understood. What is well understood is that it has an impressive ability to limit swelling, bruising, and pain after physical stress. Many athletes routinely take it to help ease the burn after a strong workout. Today, Arnica Montana is a mainstay of plastic and aesthetic surgery.

While we are not sure exactly how it does it, Arnica can do many things. It can speed up healing, relieve pain, decrease the pressure and discomfort felt by swelling, limit inflammation, and in fact fight infection. The two chemicals it may work on are called helenalin and dihyrdohelanin- two potent warriors that attack inflammatory cells, bacteria, and even some cancers. There are rare reported side effects from it, and most people do experience a significant benefit from its use. Furthermore, it's cheap, easy to use, and at this point easy to find.

So why doesn't every surgeon use it? Among plastic surgeons, Arnica is a frequent flyer. Because so much of what we do is elective, we have the benefit of presurgical planning. But the medical world is beginning to hear our cry, and fortunately gentle remedies like these are taking hold. Coupled with Bromelain, an enzyme found in pineapple juice that decreases inflammatory prostaglandins, Arnica is indeed becoming very popular in head and neck surgery and some orthopedics. 

Now before you run out there to stock up, remember that ,as a general rule, self medicating is a bad idea. Don't take anything without discussing it with all of your doctors. Many people do not realize that all these over the counter "vitamins" and "herbs" are indeed drugs. They too come from plants, they too can have side effects, they too are not for everyone, and they too can interact with other substances. Keep perspective and keep it simple. And with the right homeopathy on board, you'll also keep it cool.

When Looking Young Starts to Get Old

Every once in a while, as you gaze at one of your favorite celebrities who just really hit the big-time, you start to wonder.... what in the world did she do to herself? She still looks sort of like herself, but somehow things just seem off. Even stranger, you know she is young, and she seems a little less wrinkled, but she also oddly looks a lot more like an older woman than she did a few months ago. How does that happen?

In the wake of an injectables revolution, one must consider the old adage- all things in moderation. Fillers and toxins are fantastic aesthestic tools, and when used properly, can yield tremendous results. But if things get out of hand, they can really backfire. 

For one, some lines are meant to be on your face, and completely removing them makes things look a little strange. For example, nasolabial folds (aka, laugh lines) should be soft and not make you look like a wooden puppet, but if you really flatten that entire upper lip area, you start to look like a doll and not a human. What's more, complete flattening makes the lip look longer, and that looks more masculine. And anything masculine on a woman will start to look old.

There are several areas of the face that have this same limitation when overly smoothed, but this is not the only potential pitfall with injections. At this point, so many people are so overdone that the overdone look has its own stigma. You can spot the look from across a room, and it has the connotation of an older person trying to look young beyond what is possible. The interesting thing about this is that, when a young person starts to look done, she will start to look like the older woman trying to look young, and will then start to look OLD! The more tells there are, the worse this gets, until eventually you just can't tell who is who anymore.

The good thing about most of these methods is that they do wear off, so if you go too far there is usually room for reprisal. But if enough needles have been enough places, scar tissue will form, and this is a one way situation. Patients may not realize that  no cut does not mean no scar- it only means tiny needle shaped ones. A couple of them twice a year won't do much in the long run, but if you've used five syringes in your cheeks every quarter for ten years, there is in fact no turning back. And at that point, sometimes surgery is the better answer after all.

In treating patients with fillers and Botox, I always consider what the natural younger version of them should look like. The intention is to slow time and preserve identity, all the while without letting anyone know that you are doing anything. Beauty extremes seldom succeed, and there is also just so much your skin can handle without fighting back. Be aware that this type of fight generally isn't pretty.

But Will It Leave a Scar? The Top Ten Tips

It happens all the time.. I talk to patients about their surgery, including their scars, I tell them the scars will always be there. And then they ask me: "But I thought I was having plastic surgery?"

Any time you cut through the skin full thickness, you will get a scar as a result. Scarring is your body's way of healing and closing a wound. Scars happen, and nothing can prevent them from happening. BUT, the degree to which they are visible varies widely. Not seeing a scar doesn't mean that there is no scar there. That being said, while scarless surgery does not exist, invisible scars can be a reality.

1. The main factor in scar formation is genetics. If you are someone who scars a lot, then that will often be your fate. If you "heal well," you are already ahead of the game.

2. The second key to good healing is a proper surgical repair using all of the plastic surgery principles of optimal wound healing. This is operator dependent.

3. Optimize nutrition. You scar what you eat. If you have the right stuff going in, you are more likely to do the right things on the outside.

4. Follow instructions. Most patients underestimate how much their instructions can impact how their scars will look in the long run. If you are told to put on cream, use it. If you are recommended to massage, do it. All of these things have an impact; and even if each is a small factor in and of itself, the combined effect and longevity of use can create huge differences.

5. Keep it clean. There are situations in which wetting a wound is a bad idea. But unless you have been told to keep it dry, washing is a good idea. Infection, even on a small scale, can cause a lot of inflammation. Inflammation is the enemy of a good scar.

6. Keep it dry. When it's not being washed, a wound wants to be dry. Excessive wetness, including things like using too much ointment, can create goopy messiness. None of this will help the layers form or the bugs stay away.

7. Avoid the sun.

8. Avoid the sun!

9. Get ahead of problems early. If you think you have a thickening scar like a keloid, or if your scar is itching or burning, go see your surgeon. There are many problems that require early intervention for good treatment, and many interventions that often have success. Get in early for best results.

10. No lotions or potions. As you watch your scar mature and agonize over every change, people around you will have many suggestions for what to put on it. Some will seem reasonable, and others more like strange brews. Bottom line is that if it wasn't recommended by your doctor, it's likely to muck up the pot. Keep it simple.

Scars are unavoidable. Good scars are the goal. 

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But Can You Wear a One-Piece?

When my patients ask me what size they will be after surgery, I struggle with the answer. They want me to use one of the conventional letters (A,B, DD) but these are not exact measurements (read more about why bra sizing makes no sense!). What's more, these letters do not reflect the fact that there is no one size for all.

When assessing what size to make someone, whether bigger or smaller, it's all about proportions and balance. Everything looks different depending on what it is next to. When you make the breasts bigger, the belly looks smaller, and vice versa. That seems pretty intuitive. But what is not always so immediately obvious is the fact that the same size will look different on different people. The exact size breast on a smaller, shorter, narrower woman will appear tiny on someone six feet tall and broad shouldered. The ultimate size has less to do with the bra cup in a vacuum, and everything to do with the overall proportions of the patient. If you're not looking at shoulders, hips, and height, you're not really sizing things up properly.

In terms of clothing size, most women have an overall size. The best candidates for plastic surgery are those who know and maintain their size, but have one element that is off proportion to the rest. For example, someone who has full hips and wears a medium overall but can't fill a B cup bra. That person will always have trouble finding clothing, and spend most of their dress time padding up. Another example is the mom who is a overall size small but has a weak and bulging belly that just can't crumple into a pair of regular jeans. Imbalance.

Imbalances can be obvious or subtle. The best way to know if you are imbalanced is to go one-piece shopping. If you can't buy a one piece or a bikini in a set, you are probably imbalanced. This is not an issue if it doesn't bother you, but if  you're buying three sets of swimwear because nothing works as it should, it may be time to consider your surgical options. In most cases, the target is clear and the goal can be attained. The trick then is not to overshoot; and if you really want to hit a home-run, find a surgeon who can get that "fake out" result for you. If you get to the size you should have had to begin with, no one will question whether or not you came that way. If it fits, it fakes. Just another happy day at the beach. :)