There are various methods of treating fat. In 2010, more and more women are having liposuction to remove fat from various parts of their body, and others have undergone stomach-firming tummy tucks. More recently, plastic surgeons along with scientists, have developed several new nonsurgical methods to reduce fat and sculpt the body.

Just to recap, liposuction treats fat deposits that are resistant to diet and exercise, such as saddlebags or the flanks, which means it’s not a substitute for traditional weight loss. In fact, diet and exercise are essential before and after the procedure to obtain the best results.  One thing for sure is that liposuction can’t eliminate stretch marks or cellulite, and it may even make cellulite more pronounced. Once the fat is taken out, we can’t predict or control how much the overlying skin will contract. In general, patients with good skin tone will experience tightening as the skin redistributes itself. But others with thin, soft skin may develop sagging in the areas suctioned.

About 20 % of patients request a redo following liposuction usually for unevenness or a lumpy look, in which case the plastic surgeon can usually do a touch-up by removing more fat. Another potential complication is “track marks”, the result of fat taken too close to the skin’s surface, which can be more difficult to treat. Also, if you gain weight after liposuction, you may find it collecting in areas on the body that have not been liposuctioned. The redistribution is unpredictable.

At the recent ISAPS 2010 Conference in San Francisco in August 14-18, plastic surgeons and others were developing alternative and noninvasive ways to remove fat, but for now liposuction is still considered the gold standard. A lot of work has been done in the exciting field of fat grafting which can be used for both cosmetic and reconstructive reasons. The plastic surgeon injects part of the body, usually the face or breasts, with the patient’s body fat (extracted from the abdomen, thighs, or buttocks) to smooth lines and fill hollows. Many of the injected fat cells don’t survive, and there can be loss of volume over time, so we usually overfill the area to compensate. But the final outcome may still look overdone, and if a patient gains weight, the grafted fat can grow.

In laser-assisted liposuction (LAL), fat is loosened with a laser before being suctioned out, which is why it can take twice as long to perform (same thing for ultrasound-assisted liposuction (UAL)). The laser is said to stimulate collagen and elastin repair in the overlying skin and to result in less bruising than regular liposuction, because it coagulates blood vessels. LAL may benefit older patients who have lost elasticity and may be best for relatively small areas without thick fat, such as under the chin. Some doctors are skeptical of using lasers this way, pointing out that there currently isn’t scientific data to support the claimed benefits. Also, you are potentially heating the skin to dangerous levels in order to achieve skin tightening (there have been some burns reported from LAL. There are several LAL devices, including SmartLipo, SlimLipo, ProLipo, and LipoLite. A new one, LipoEze, can remove large quantities of fat and presents no risk of burns, because the laser is positioned inside the suction tube away from the skin.

What about fat-melting injections? 
These shots sound good , but not to the FDA, at least for now. The agency has threatened legal action against medspas advertising fat-dissolving procedures called lipodissolve, lipozap, lipotherapy, injection lipolysis, or mesotherapy. None of the chemicals, drugs, vitamins, minerals, or herbal extracts in these injections are FDA-approved to eliminate fat, and the FDA cites “reports of permanent scarring, skin deformation, and deep, painful knots in the injected areas.” Studies are under way to find out which ingredients, if any, might work, and some injectable drugs show promising, though modest, results.

More recently, the least invasive fat removal option has been Zeltiq, a device applied to the skin, that chills fat cells, enabling the body to process and excrete the fat. Studies suggest that this treatment (also known as cryolipolysis) is for very fit people with isolated fat deposits, however, the procedure is slow, and the results take a long time, up to four months, to show. Zeltiq is cleared for localised fat reduction in Canada; in the USA, it is FDA-approved only for skin cooling during dermatological treatments, and doctors are using it off-label. I am currently not aware of its use in Australia.

Last of all, when do you need a tummy tuck? If the issue is simply extra fat, plastic surgeons generally recommend liposuction, but if there is very loose skin and muscle-wall weakness, which is not unusual in women who have given birth, then a tummy tuck may be preferable. This tightens the muscles and repositions the skin, forming a new belly button, as well as removing the fat. (A mini tummy tuck, which targets small amounts of excess skin and abdominal weakness, usually involves a shorter scar and recovery.)

Like many of these women you may find yourself choosing between these two procedures, or choosing both. Each has its own unique goals, and the procedures are often combined to achieve an even more attractive curvature.

Breast Augmentation Goals

The goal of breast augmentation surgery is to make your breasts bigger and/or fuller (more projected). Women differ so vastly in shape, size and frame that a number of options have been developed that offer something for everyone. You can choose from:

1. Silicone gel or saline implants
2. Textured or smooth surfaced implants
3. Implant placement behind the breast tissue or behind the pectoralis muscle
4. Round or tear-drop (anatomical) implants
5. Various sizes of implants
6. Different sites for the incision (breast fold, armpit or nipple areola complex)

Breast Lift Goals

Breast lift surgery is designed to elevate sagging breasts and restore their youthful, perky stature. Gravity, pregnancy and weight gain have a way of stretching even smaller breasts over time. Weight loss may leave breasts less firm and a bit saggy. Breast lift surgery involves elevating the nipples and tightening the breast skin to restore breasts to an attractive shape.

Breast Lift with Breast Augmentation Goals

The lift removes the excess skin and reduces sagging (pushes things “up and in”). The implant fills the remaining breast skin, adding contour and fullness where minimal breast tissue is insufficient (pushes things “out and down”). As you can see, the forces are opposing, and for that reason, there is a 20% revision rate for this procedure.

What Makes the Difference?

What makes the biggest difference in outcomes is that the most successful plastic surgeons use the following techniques and protocols:

1. Minimal blood loss, bruising and swelling by using electrocautery for dissection of the pocket, as well as, gentle manipulation of the tissues
2. Smaller incisions
3. No sutures for removal
4. Specialised instruments for accurate placement of implant
5. Adequate pain relief postoperatively
6. No drains or wraps to manage
7. Avoidance of blood thinning agents perioperatively (cease multi-vitamins, aspirin, NSAIDs etc.)

The earlobes are the lowest part of the ears made of skin and a small amount of fatty tissue in between. There are large variations in size, form and shape. The earlobes serve women (and men) as popular locations for placing jewelry. Often, the earlobes are pierced to fit various forms of ear ornaments ranging from studs to earrings which can occasionally set them up for trouble.

Excessive weight or trauma can easily overcome the strength of the earlobe tissues leading to a tear, which if complete, results in a cleft. Some people with rather thin earlobes who favour wearing heavy earrings, experience a gradual elongation of the ear piercing tract such that it becomes slit-like and often too large. Another problem is that the earlobes can be torn by accidental trauma. This split may be unattractive and renders the earlobe unusable for most jewelry. Sometimes, clip-on earrings can still be fitted and are used to camouflage the earlobe tear.

The repair of torn earlobes is relatively simple. The procedure is routinely performed in the office under local anaesthesia with an optional sedative. After planning and marking, a small amount of lignocaine numbing solution is deposited.  I favour a three-layer repair done under loupe magnification. But it is very important to remove the damaged ear piercing tract or to trim the edges of a cleft if the earlobe has been torn through completely. Then the three-layer closure consists of closing the outer layer of skin, the fatty tissue between the two layers of the skin and finally the skin in the back of the earlobe. Typically, the surgery must take great pains to avoid any notching at the bottom of the earlobe. The fine sutures on the skin are usually removed within 7 days. Small amounts of antibiotic ointment are applied at home for a few days ensuring cleanliness. The healed earlobe has usually a barely visible pencil-fine straight or zigzag scar line.

People often ask if the ears can be pierced again. They can but typically you should wait three months after the earlobe has been repaired. Preferably the piercing should not be done within the scar, as this can stretch and inevitably result in another cleft.

Your safety is of paramount importance when undergoing breast augmentation. Always have your surgery in an accredited hospital or day surgery facility. If you are young and healthy, then a day surgery facility is fine. If you are older and have health problems, then a hospital would be a better place to have the procedure performed because of the availability and back-up of an intensive care and other highly specialised health staff.

Accredited means that the surgical facility has passed a set of rigorous examinations to assure that the equipment and procedures meet standards for optimal safety. The hospital or day surgery facility should be fully accredited by the Australian Council on Healthcare Standards (ACHS) or a set of ISO standards that provide the highest standards of service. Patient health, safety and comfort should be the facilities main concerns and they should continually monitor and evaluate their performance to achieve this outcome. Another requirement of accreditation is to assure that personnel are trained, experienced and skilled health care professionals and procedures and equipment are in place to deal with any emergency from a power outage to cardiac arrest.

Sometimes it’s reassuring to visit the accredited facility yourself. If you’re not comfortable with a surgical facility, don’t have the surgery there. What you want to see is modern, comfortable surroundings and caring and warm personnel. The operating room should appear state-of-the-art, spotlessly clean and equipped with the most up-to-date equipment. The recovery area should be immediately adjacent to the operating rooms. Some facilities provide overnight accommodations with one-on-one nursing care especially for patients who need overnight care for more extensive procedures.

The following checklist should help you “tie things up” when organising your breast augmentation:

1) Check date of surgery and pay scheduling deposit if required

2) Review surgeon’s financial policies and policies for refunds

3) Sign informed consent and operative consent forms

4) Schedule laboratory tests and mammography/ultrasound if required

5) Review medications to avoid and ones to take before surgery

6) Review post-operative instructions the night before surgery

7) On the day of surgery wear comfortable clothes, get someone to drive you home and be with you overnight, wear no make-up, and leave your jewelry and valuables at home

I am amazed how many patients spend more time shopping for a TV or washing machine than they spend selecting a plastic surgeon. Selecting your surgeon should be the single most important thing that you can do to assure an optimal result.

You should have a checklist of essential things to look for in a plastic surgeon:

1)   Certified by the Royal Australasian College Of Surgeons, the only college recognized by the Australian Medical Council that can train surgeons in Australia

2)   Be a Member of the Australian Society Of Plastic Surgery (ASPS) and the Australian Society Of Aesthetic Plastic Surgeons (ASAPS)

3)   Has hospital privileges to do breast augmentation at an accredited hospital or day surgery facility

4)   Subspecialises in cosmetic surgery

5)   Superspecialises in breast augmentation

6)   Recommended by a knowledgeable friend or doctor

7)   Curriculum vitae documents scientific presentations and publications

There are also a few less reliable points that I would like to address when choosing  a plastic surgeon. Advertisements and media coverage are paid for by the plastic surgeon and does not necessarily reflect how knowledgeable, competent or experienced they are. Your local doctor may not be in the know of who is best to do breast augmentation and may not have an interest in cosmetic surgery to find out either. Some just refer to surgeons who are their friends from medical school, are in the local area and thus convenient or who may be paid for by the surgeon to refer you. Never listen to recommendations from anyone who is an “armchair expert” or who has no in-depth knowledge of breast augmentation.

At the end of the day, look at the surgeon’s results to see how good they are. Be very careful with “glamour shots” that can deceive because of lighting, patient positioning and camera angle. They may even be “photoshopped” or airbrushed. Some surgeons may have models as patients that they have operated on their face but not their breasts (which was performed by another surgeon) and use them for advertising breast augmentation.

There are a further number of “red flags” that you should take notice of. These are:

1) Completed training in a specialty other than plastic surgery

2) Certified in an unrelated college

3) Not a member of ASPS and ASAPS

4) No hospital privileges

5) If you are given false or misleading information- claims that are too good to be true.

6) Unwilling to provide you answers to questions regarding credentials or curriculum vitae

7) When the office staff are not courteous, knowledgeable or don’t spend enough time with you and don’t tell you what you need to know. Beware of staff who give you all fluff, but no substance and don’t offer to send you any information. Always insist that the price be broken down into the following categories: surgeon fees , anaesthetist fees, costs of implants, operating room fees, hospital stay fees, laboratory fees, mammogram or ultrasound fees, any other fees. Ask how long the prices on the quote last for. Remember, there is no such thing as bargain surgery. Have you ever seen top-quality surgery for bargain price? How is the bargain surgeon able to offer such a good price?

When visiting the plastic surgeons rooms, look around and take notice of the little things. It should be a quiet, comfortable and modern, an atmosphere that reflects the good taste of the plastic surgeon. The organsation, function and flow of the plastic surgeon’s office is a reflection of the surgeon’s personality and habits. Think about it. If the office looks messy and unclean, doesn’t it reflect badly on the surgeon who accepts this scenario?

Most of the time, you will recognise a good surgeon without the surgeon having to tell you. If they have integrity, are caring and thorough, then this will definitely contribute to what you will get in the operating room and after.

The things you need to know to make better choices regarding breast augmentation are the following:

1) Match your desires with reality

The surgeon can only work with the tissues you bring him. If you want the best result, you have to balance what you want with what the tissues will allow you to have and what they can support over time. Also, no woman has two breasts that are the same, and no surgeon can create two breasts exactly the same. Cup size is extremely variable and inconsistent from one brand of bra to another and women buy a bra that they can fill  (or to push breast tissue where they want it to go to create a specific appearance), not necessarily a bra that fits. Last of all, the bigger the breast you request, the worse it will look over time and you can’t pick out a breast from a book or magazine and expect the same result unless the woman in the picture looked exactly like you before surgery.

2) Know about the implants

Breast implants are not perfect, don’t last forever, and require some maintenance. If you can’t accept these facts, don’t have a breast augmentation. If you do, then you need to think about:

a) Implant pocket location

Implants can be placed in front of, or behind muscle. There is less capsular contracture rates when the implant is placed behind the muscle and you can obtain better or more accurate mammograms too. Also, in thin women, behind the muscle is preferable because adequate tissue coverage is most important. Think when you lie in bed, if you are covered by a bed sheet only, then one can see the contours of your body a lot better, than if you were to be covered by a doona cover, they are less distinct. Having said that, an implant placed in front of the muscle will always more predictably control breast shape. How do you decide whether to go in front or behind the muscle? If you pinch the breast tissue in the upper pole and it’s < 2 cm, consider going beneath the muscle, otherwise, you run risks of seeing the edges of the implant.

One aspect that often gets overlooked is the way the pocket is created. Blunt dissection techniques are fast and efficient but create more tissue trauma, tear tissues, create more bleeding, and result in longer recovery time. Electrocautery dissection techniques use an electric current to seal blood vessels and are thus, less traumatic and have shorter recovery times.

b) Implant shape

Shapes of implants can either be round or tear drop (anatomical). There is a trend today of women wanting more upper pole fullness and therefore opting for round implants. Given that the breast is constantly evolving and that over time there is loss of upper pole fullness as the breast tissue “melts away”, round implants may be a good option for maintaining upper pole fullness in the long term. The other added advantage is that if it rotates, it doesn’t affect the shape of the breast. In contrast, a tear drop implant which is fuller at the bottom and tapers at the top, will give an odd shape to the breast if it does rotate. However, tear drop implants may be better in women who have odd shaped chests (either long or wide for example) because you can tailor the dimensions of the implant more specifically to fit the breast “foot print” on the chest. Tear drop implants may also be beneficial in women with mild sagging breasts who do not want scars on their breast from elevating the nipple. The tear drop implants have a “bucket-handle” effect on the nipple, elevating them to a higher position on the breast.

c) Implant surface (or shell)

The surface of the implant is made of a silicone rubber and can be textured or smooth. Textured implants have a lower risk of capsular contracture than smooth implants.

d) Implant “stuffing”

The stuffing or filler of the implant can be silicone or saline. Saline is salt-water and is harmless if the implant ruptures. It’s biggest disadvantage is rippling and that it takes up the ambient temperature, so that if you went to the beach for a swim, when you get out, your implants will feel cold. Silicone gel filler on the other hand is more natural, more predictable and it is safe. There are grades of silicone gel that range from “jelly” consistency to that of “gummy bears”.

e) Implant size

Remember, the larger the implant, the more tradeoffs and risks you’ll encounter, especially long term

f) Incision location

The scar can be placed in three areas. The breast fold incision offers the best degree of control for the wide range of breast types and is the the commonest type used by far. The periareolar incision (around the nipple-areola) usually heals well because it’s located in thinner skin but is limited and can’t be used if the areola is not large enough for access. The biggest problem is the increased exposure of the implant to bacteria if any of the breast ducts were to be cut. The armpit (axillary)  incision places no scar on the breast but takes longer to perform and harder to control the position of the breast fold.

3) Get well acquainted with the tradeoffs, problems and risks

Tradeoffs always depend on the details of each specific case, the characteristics of your tissues , the experience of your surgeon with different options. Every breast augmentation operation carries inherent risks and medical complications are not totally preventable by you or your surgeon. Remember, don’t have a breast augmentation unless you thoroughly understand and accept the potential risks and tradeoffs of the procedure.

5) Know about the recovery

The more tissue trauma caused by your surgery, the longer and more difficult your recovery. That is why it takes longer to recover from a pocket created behind the muscle. Excessively large implants can produce excessive stretch marks that cause more discomfort and temporary or permanent sensory loss. Most women return back to normal duties within four weeks and athletic activities by six weeks.

There are generally three groups of women who frequently consider breast augmentation:

1) Nature “missed a beat” during breast development

This usually occurs during puberty where the breasts may not develop at all or slightly, resulting in a “bowling pin” type of a look. Apart from making one feel inadequate because their is a disconnect between the narrower chest to the wider hips, it also makes it difficult buying clothes that fit. Some people revert to using fillers and enhancers but they can never seem to compensate, are temporary measures, and they never feel a natural part of you. Breasts can also develop unevenly during puberty, causing both difficulty in buying and wearing clothes, as well as, making one feel abnormal or a “freak”.

2) Nature “took  a toll” during pregnancy and breast feeding

During these times, the breast enlarges and deflates repeatedly. This cycle stretches the breast skin especially in the lower pole, resulting in stretch marks. After breast feeding, the breast tissue itself may “melt away” (especially in the upper pole), sometimes to a size less than before pregnancy. However, the skin never shrinks back to its original size, therefore, the breasts will appear saggy (think of the skin like an overstretched elastic band which frays at the edges).

3) Nature “didn’t match desires” of women who want to enhance the shape and appearance of their breasts

Some women want to be the best they can be. Others have developed unattractive breasts or have uneven breasts that makes buying clothes difficult. Still others want to “marry” or improve the balance between their chest with their hips.

Women who fall into any one of the above groups have every right to want to optimise any aspect of their breast appearance. If this involves breast augmentation, then she needs to also think about:

2) The Procedure

3) The Surgeon

4) The Facility

Remember that no choice(s) is perfect and that every choice has trade0ffs (you need to know them) as well as benefits. Therefore, choose carefully.

Breast implant surgeons in Australia have been warned not to use silicone gel-filled breast implants manufactured by the French company Poly Implant Prothese (PIP). The company’s marketing, distribution and export of these products has been suspended (it has since filed for bankruptcy after running up losses of 9 million euros). The company exported ~90% of their breast implants to 66 countries worldwide including Australia.

The Australian Society of Plastic Surgeons (ASPS) contacted the Therapeutics Goods Administration (TGA) on the 1^st April, 2010, upon being informed about the recall. The French medical device regulatory authority (AFSSAPS) had recently carried out an inspection of PIPs manufacturing plant and found that most implants manufactured since 2001 had been filled with an unauthorised silicone gel which differs from the originally approved material.

According to AFSSAPS, the implants do not appear to cause different complications than those usually seen with other types of breast implants pre-filled with silicone gel. However, the agency reported a higher frequency of rupture and local inflammatory reactions.

To understand this a little bit better, think of breast implants like “water balloons”. The balloon is the “shell” and the water (or stuffing) can either be silicone gel or saline (salt water). The silicone gel can be viewed further like maple syrup in terms of its consistency (viscosity) varying from runny to a very thick, sticky form. Some of the silicone gels used recently are even firmer having the consistency of jelly or even “gummy bears”. Now one explanation why PIP implants have had such high rupture rates is that the unsuitable gel could damage the shell which contains it and thus could leak more easily than the approved gel.

Although I have never used PIP breast implants in any of my patients, unfortunately, there have been between 35,000 and 45,000 women worldwide who have had an implant supplied by the French company since 2001. It is recommended that breast implant surgeons should not implant these devices any more and they should quarantine any stock. For patients who have any concerns about their PIP silicone gel filled breast implants, my advice would be to contact their breast implant surgeon and get annual ultrasounds performed if necessary.

The Food and Drug Administration (FDA) in the US has issued warning letters to six medical spas and a Brazilian company, saying they made false or misleading statements that “lipodissolve” procedures are safe and effective, or otherwise misbranded the products.

Lipodissolve involves drug injections intended to dissolve and remove small pockets of fat. Lipodissolve is also known as mesotherapy, lipozap, lipotherapy, or injection lipolysis. The drugs most often used for lipodissolve procedures are combinations of phosphatidylcholine and deoxycholate, but sometimes ingredients such as vitamins, minerals and herbal extracts are included in lipodissolve mixtures, according to the FDA. The agency said it is not aware of any credible scientific evidence that supports the effectiveness or safety of lipodissolve for fat elimination.

Also, some of these companies have claimed that lipodissolve can treat certain medical conditions, such as male breast enlargement (gynaecomastia), benign fatty tumours called lipomas, excess fat deposits and surgical deformities. Once again, the FDA is not aware of any clinical evidence to support any of these claims.

Furthermore, FDA officials have received reports of negative side effects from people who have tried the procedure, including permanent scarring, skin deformation, and deep painful knots under the skin in areas where lipodissolve drugs were injected.

What’s my take on things? Whenever a new beauty product or service comes out, the bell curve tends to indicate how any population will respond to the new technology. Starting on the left side of the bell curve, group 1, are  the innovators (usually geeks and nerds) which are few but brave people that are willing to try things that are on the cutting edge. They are followed by group 2, the early adopters, that love and embrace new stuff and ideas that helps them improve their self-esteem. Then, there is group 3, that picks up new ideas a little more slowly and the next, group 4, that completes the mass market (3 and 4 make up  the middle third of the bell curve). The last one, group 5, are the laggards, who usually have very little interest in such things.

I feel that cosmetic patients should place themselves in groups 3 or 4, as this allows enough time, usually 12-24 months, for risks and complications of these products and services to manifest themselves. After all, there is no reason for you to be the guinea pig, is there? The simple rule is: buyer beware! Wait until the jury is out before you decide on a product or service and do your own due diligence.

The Cougar phenomenon is an interesting social event. The term “cougar” is being popularised by TV series and dating services specifically targeting older women interested in younger men. But are mature women who date younger men really predatory felines, or is this just a new name for something that’s been happening for years? Just think of the following:

1) Mae West and Cary Grant  in “She Done Him Wrong” (1933) when she utters the classic line “Why don’t you come up some time and see me?”

2) Anne Bancroft and Dustin Hoffman in the now classic film “The Graduate” (1967).

3) Judy Garland and Liz Taylor had husbands or partners who were much younger than them in yesteryear.

4) Todays equivalents are Demi Moore and Ashton Kutcher; Goldie Hawn and Kurt Russell; Reese Witherspoon and Jake Gyllenhaal; Julianne Moore and Bart Freundlich; Madonna and Guy Ritchie; or Susan Sarandon and Tim Robbins. 

5) And scores of other films: “Notes on a scandal” (2006); “Prime” (2005); “Y tu mama tambien” (2001); and “Class” (1983) where Jacqueline Bissett, in a passionate lovemaking scene in an elevator, utters the famous line “Which do you prefer…going up…or going down?”.

What better proof that love is priceless at any age? Older women may have a powerful Oedipal pull on the psyche of a young man. Thus, while older women-younger men relationships have been rare and socially frowned upon, they have always developed.

So why are they more evident now than in past periods? One reason may be that romantic and sexual relationships are more open today. Older women and younger men who had such relationships might formerly have kept them quiet for fear of social disapproval and ridicule. Another reason is that people in the modern world do not age as badly as they used to. Improvements in diet, exercise and medical care mean that post-menopausal women often look more healthier and more beautiful today than in previous years. Injectables and cosmetic surgery have also done a lot to stave off the evidence that women are no longer of reproductive age. Lastly, cougars see things more differently now than ever before. They are well educated, career women who are financially independent. They see older guys as boring who are usually going bald and carry a lot of baggage too (and I don’t mean physical either!). They may no longer get along with guys their age. A younger man makes them feel like they’re in their 20s all the time and younger men have a lot more energy. That just says it all, doesn’t it?

So what do cougars seek in cosmetic procedures to either make themselves feel happier or to make them more attractive to date younger men? A third of women over the age of 40 hate the following body parts: tummy 50%; thighs 15%; buttocks 7%; and breasts 7%. According to a recent survey conducted by Harris Interactive on behalf of RealSelf.com, the most popular cosmetic treatments were tummy tuck 39%; liposuction 36% , face lifts 24% and laser hair removal.

These women just want to “feel as good as they look” and I, for one, applaud them!