News & Politics

Nip and Tuck

Considering breast implants? Liposuction? A nose job? Here’s what to know about four popular surgical procedures, including how to lower your risks. Plus, what men are having done.

Hardly a month passes that cosmetic surgeons don’t have a new tool with the potential to make us look better, and many options are nonsurgical: lasers, Botox, fillers.

But sometimes the change a patient wants still requires surgery.

The American Society of Plastic Surgeons says the top five cosmetic surgeries in America in 2007 were breast implants (347,524), liposuction (301,882), nose reshaping (284,960), eyelid surgery (240,660), and tummy tucks (148,410).

According to the ASPS, people in this area have more facelifts than Southerners or Midwesterners but fewer than those who live on the West Coast. Apparently, New Englanders don’t like their noses, because they get far more of them fixed than anybody else. Washingtonians get fewer nose jobs than those living in other areas of the country.

A New Look in Surgery

In the early 1970s, young women getting a new nose often emerged with identical, smallish, slightly turned‑up noses regardless of what the rest of the face looked like.

Today, patients and doctors are more inclined to improve a nose or any other feature in the context of the patient’s looks.

“We’re all coming to understand that ‘ideal’ doesn’t work on every face,” says James Bruno, a plastic surgeon in Chevy Chase. “Patients want to alter a feature they don’t like but still look like themselves afterward.”

Suzanne Kim Doud Galli, a facial plastic surgeon who practices in Reston and the District, agrees that a softer, more natural look is the trend.

“Practically every facelift patient comes in saying, ‘Don’t make me look like Joan what’s-her-name,’ ” she says. “The overlifted look is out.”

In 2007, Americans spent $12.4 billion on 12 million cosmetic procedures, an increase of 7 percent over the previous year. A lust for Botox, fillers, lasers, and the like accounted for most of the increase; the number of operations held steady among women and went up slightly among men.

Will our zeal for looking good continue now that the economy has weakened? Local plastic surgeons have noted a slowdown in big-ticket surgeries, but many say people are still coming in for noninvasive solutions. While some patients might delay having lipo or an eyelid lift, says Doud Galli, “it’s likely that others will say, ‘Since I can’t invest in the stock market, I’ll invest in me.’ We want the boost of looking good when times are tough.”

“I had my boobs done last year, and what a confidence booster,” volunteered a 27-year-old accountant sitting next to me on Amtrak recently. Would she have spent her money the same way this year? “You bet!” she said. “I only wish I’d done it sooner.”

What Men Want

Of the 12 million procedures in 2007, a million were on men, a 17-percent increase over the year before.

Men are discovering Botox: Getting it draws them into doctors’ offices more than any other procedure. After that, men go for lasers, especially treatments that remove unwanted hair from the back and chest. They’re also getting more fillers and more microdermabrasion, which takes off the top skin layer typically by spraying on and then sucking up tiny crystals.

In the past ten years, the number of surgeries on men has grown 3 percent. Nonsurgical procedures have jumped 886 percent.

“I do a lot of Botox and Juvéderm on men these days,” says Talal Munasifi, an Arlington plastic surgeon. He’s also seeing males who want their faces and jowls tightened with a laser treatment. “Women have always been able to get a facelift, but a lot of men don’t have any wrinkles in front of their ears where you can hide a facelift scar,” as many women do, he says. Munasifi says that lasers can do about a third of what a facelift can to improve appearance, with little or no downtime. He says men who have heard that lasers can repair old acne scars also are making appointments.

Men are leery of having work that will show, says C. Coleman Brown, a Chevy Chase plastic surgeon. When it comes to surgery, men get liposuction, eyelid surgery, rhinoplasty, male breast reduction (gynecomastia), and hair transplants, in that order, says the American Society for Aesthetic Plastic Surgery. “Men who come in for lipo tend to be very fit,” says David Kung, a Chevy Chase plastic surgeon. “They want to touch up an area they can’t seem to contour with exercise and diet.”

A significant number of men have a genetic predisposition for a pouchy neck, even in their twenties and thirties. The sag can vanish after a little lipo if the skin is still elastic. “It’s the kind of thing a man can do and nobody will know he had something done,” Brown says. “They’ll just think he looks good.”

A Word About Costs

Everything costs more in a major city, including cosmetic surgery. Lots of Internet sites post average charges for this or that procedure. Don’t pin your hopes on getting the same price someone paid in Boise.

There are two good ways to get a benchmark for costs. One is to call several offices to ask about the doctor’s fee and costs for the hospital or operating facility. Another is to check Web sites—some local doctors list charges.

You can’t know exactly what a procedure will cost until you and the surgeon have settled on what the operation will involve. A person getting a facelift very often has a forehead lift, a necklift, or eyelids done at the same time. The surgeon will bill separately for each procedure, and the operating facility will bill you by the hour. There also may be a bill for anesthesia; sometimes it’s folded into the facility fee.

Surprisingly, a prestigious McLean surgeon may charge the same as a young doctor in the far suburbs. Don’t assume any surgeon is out of your price range.

If you’re down to two surgeons, and the rates of the one you like best are steeper than you anticipated, talk with him or her. “I don’t like having my fees compared to another doctor’s,” says one surgeon. “And no, I won’t do three things for the price of one. On the other hand, if a patient tells me money is tight, could I help her out a bit—sure.” Especially if multiple procedures are anticipated. ➝

Staying Safe: What To Ask

While no surgery is risk‑free, studies show that cosmetic surgery is as safe as any other type of surgery performed in America. There is a battle going on in medicine over whether that statistic is still true if the surgery is done in a doctor’s office.

A decade ago, the safety of in-office surgery came into question after a series of deaths in Florida doctors’ offices. One study found that during a three-year period in that state, there were 13 office deaths and 43 complications requiring emergency hospitalization. Two things were alarming: Many victims were healthy patients having liposuction under general anesthesia. And in nearly all cases in which there was a bad result, doctors were board certified, although not always in plastic surgery. Other investigators concluded that Florida patients undergoing surgery in a doctor’s office were up to 12 times more likely to die there than if the operation were in a hospital or ambulatory surgical center.

Nobody really knows how many patients have problems during office‑based surgery. As recently as 2000 you could die in a doctor’s office in any state, and the doctor wouldn’t be required to report the death.

Some jurisdictions are starting to regulate office surgery. The District of Columbia requires any place where surgery is performed to meet the same accreditation standards as hospitals and ambulatory-care centers.

Because of the Florida cases, cosmetic surgery is safer. Blood clots caused some of the deaths, so patients now get stockings that compress, then release, the lower legs during any surgery lasting more than two hours.

Surgeons watch the clock more because it’s now clear that the longer a patient is in the OR, the greater the risk of complications. So you can have a tummy tuck and lipo on your butt and thighs—or get a facelift, necklift, and eye work. But no matter what you see on the makeover shows, you probably can’t get all that done in one marathon surgery.

Even so, ask questions. If anesthesia is involved, ask, “Who will be with me during and after surgery?” Hearing that a nurse “will be checking on you” isn’t good enough. A person can choke in seconds. Make sure someone will be able to see and hear you at every moment.

Because some of the Florida patients died from heart complications, professional groups for plastic surgeons are encouraging members to be certified in advanced cardiac life support. It teaches rescue techniques beyond conventional CPR and mouth-to-mouth resuscitation. Not all surgeons know it. Does yours?

If you are considering surgery in a nonhospital setting, find out whether it has resuscitation equipment and staff trained to use it. The question to ask is “What would happen if I stopped breathing?” If the answer is “We would dial 911,” your risk level just went up. Hearing “nothing like that has ever happened” and “we’re always careful” doesn’t alter that. Superb care will not prevent a freak drug reaction. Most plastic surgeons offer a choice of settings; choose one that has the tools to save your life.

Finally, ask a doctor: “Where do you operate?” At least one hospital should be on the list; if there is not, that’s a red flag. Hospitals check credentials and reputation before allowing a doctor the use of their facility.

A Little More, Please: Breast Augmentation

“I’m incredibly pleased with the results and have no regrets,” says Jennifer Lapine, 28, of Reston, who got saline breast implants in 2007. After nursing her son, she says, her breasts sagged and looked “stretched out.”

Most Washington women don’t go for the beach-babe look, surgeons say. To help patients decide how much they want to go up in size, Michael J. Olding, chief of plastic surgery at George Washington University Medical Center, says he has women try on different sizes of implants, then chats further and offers an opinion. “Their first choice often is more conservative than it has to be” in proportion to their frames, he says. More often than not, the final one is, too.

Lapine says that when she consulted with Eric Desman, the Alexandria plastic surgeon who did her implants, she was startled by all the choices to be made beyond size, such as saline versus silicone.

According to Olding, silicone looks more natural than saline, and most women opt for the new generation of silicone implants, two brands of which the Food and Drug Administration approved in 2006. For the 14 years previous to that, there was a moratorium on silicone implants. Thousands of women had sued implant manufacturers, saying that leaking silicone caused a variety of ailments, including infections, autoimmune diseases, and fibromyalgia.

While new silicone implants are less likely to burst or leak, the National Women’s Health Network and other advocacy groups note a lack of studies showing the new implants are safe in the long term. The FDA granted approval on the basis of studies showing the implants to be safe for two to three years.

If a silicone implant does leak, a woman probably wouldn’t know it because the implant keeps its shape. If a saline or saltwater implant ruptures, it deflates. The FDA advises women with implants to have periodic MRIs.

Regardless of which implant a woman chooses, studies show that up to 30 percent of women with cosmetic implants will need to have another operation within a few years. A common reason is the development of rippling or scar tissue, which causes the breasts to become oddly shaped or hard. Women who get implants after cancer surgery have complications and removals at a higher rate.

Implants make getting mammograms and detecting breast cancer harder. However, one study noted that there appears to be no increase in cancer deaths among women with implants.

Because Jennifer Lapine hopes to have another child, she had the incision done below the breast rather than through the nipple. Women with implants inserted via an incision hidden around the edge of the nipple are more likely to have trouble breastfeeding.

Another decision to discuss with a surgeon is whether the implant will go over or under the pectoral muscle. Over it, there’s less pain and quicker recovery. Under, less interference with breast exams and less chance the edges of the implant will show.

Lapine’s surgery was done in an outpatient setting. “When I woke up, a nurse immediately had me begin stretching,” she says. The next day she resumed her life, including driving her son to daycare. Lapine took a mild painkiller for two days. “The soreness felt like a pulled muscle,” she says.

Average cost for breast implants in Washington: $5,000 to $7,000 for silicone, $500 to $600 less for saline.

Fat‑Free: Liposuction

It’s easy to see why liposuction is popular with both sexes. Who doesn’t adore the thought of no more love handles, or jiggle‑free, sculpted thighs?

Doctors say the first thing to understand about lipo is that it isn’t an alternative to exercise or dieting. “It isn’t a weight‑loss tool. It’s good for getting the body in proportion,” says Dr. Kung.

Women often ask for lipo on the stomach, thighs, and hips, where female fat is genetically programmed to land. A woman, Kung says, can be “fanatical about exercise and still not be able to get rid of fat there.” With men, it’s love handles and flanks.

During liposuction, fat cells are broken up by an energy source, then sucked out through a tubelike cannula. They’re gone for good.

Smart Lipo uses a laser light to rupture fat cells. Other liposuction devices employ mechanical energy or ultrasound (“vaser liposuction”) to liquefy cells. Twenty years ago, when lipo was new, surgeons got a workout: They pushed and scraped the cannula through fat using their own muscle. No type of lipo is superior, Kung says. He uses all of them, depending on what he thinks will work best for the patient.

The FDA has given Kung permission to try a liposuction technology that uses water to dissect fat. It’s been used in Germany, and Kung says that evidence indicates that it causes less bleeding than other methods. “I don’t do lipo in an office setting; I don’t think it’s the safest place for it,” Kung says. “But if I were going to, this is the one I’d use.”

Lipo often is combined with other surgical procedures, such as breast implants. If lipo is being done for only a small area, the trend is to keep the patient awake, perhaps with a drug to allay any anxiety, then to numb the affected areas.

Expect scars where the cannula goes in. Doctors do their best to hide them in skin folds, and they do fade.

Whether lipo is painful, and how sore you are afterward, varies by individual. To reduce swelling after surgery, patients wear a compression garment for about two weeks. It can take up to six months to see the real, final contours.

The risks involved with lipo include possible scarring, infection, and an uneven or rippled result. Between 5 and 10 percent of all patients need a second, shorter lipo session to make small adjustments—should one side not be even with the other, for example.

Average cost: $3,000 to $4,000 per area of the body, but a discount often is offered if several areas are being done at the same time.

A New Nose: Rhinoplasty

You may think you have the world’s worst schnoz, but what people want changed doesn’t vary much, says Potomac plastic surgeon Diane Colgan. She runs through the typical complaints: “My nose is too large, too wide, has a big bump, a tip that’s too broad, it’s boxy, it’s bumpy, or I can’t breathe.”

While Colgan says she has older patients who want rhinoplasty, it’s typically younger people who come in for this surgery. “After you’ve lived with a nose for 30 years, you’ve probably gotten used to it even if you don’t like it,” she says.

A girl who inherited Grandpa’s unfortunate nose can have rhinoplasty starting at age 15, Colgan says. Boys’ faces take longer to mature, so they must wait until 16. “Often, teens want to do it before they leave for college,” she says.

Doud Galli is both a plastic surgeon and an otolaryngologist. “It’s important to me that a nose not only look better but breathe better,” she says.

Doud Galli says many people are born with a deviated septum, which means there is an obstruction on one side of the nose. Often undetected, it can be the cause of snoring, difficulty breathing, and sleep apnea. “Some people go through life with chronic sinusitis and never realize it might be because of their nose,” she says. If there is a medical reason for rhinoplasty, health insurance will cover all or a portion of the cost.

The surgery takes one to three hours. Most patients take at least a week off work. At the end of that time they look presentable, although it can take a year or more for all the swelling to go away completely, Doud Galli says. She operates under general anesthesia, and patients go home wearing soft, silicone splints.

Average cost: $7,000 to $8,000.

The Mommy Surgery

Despite a tummy tuck’s reputation for an uncomfortable recovery, the procedure is increasingly popular, especially among women yearning to have their prechildbirth figures back.

In a tummy tuck, the surgeon removes stretched‑out skin. If there’s bulging fat, that goes, too. Most women also need the muscle under the skin tightened, says Dr. Bruno. That’s the uncomfortable part: The incision goes from hip to hip.

“My goal is to put it low, in the bikini line, in the same place as most C‑sections,” he says. “It’s a long incision, but fine. With time it will be a thin, faint scar.” For women who have a cesarean scar, one goal may be to excise any rough‑looking scar tissue with this fainter scar.

Sometimes plastic surgeons get asked to do a tummy tuck right after a woman has delivered a baby by C‑section. It can be done, but a new baby and the hormonal swings after delivery make life hard enough without throwing in a second operation and a larger wound, Bruno says.

More often, tummy tucks are combined with liposuction in one or two areas, or with a breast augmentation. The combination is known as a “mommy makeover,” preferably done when a woman’s family is complete. Says Bruno, “It doesn’t make sense to go through surgery if you’re planning to be pregnant again and stretch out the area.”

A tummy tuck by itself requires two to three hours in the operating room under general anesthesia. Most patients go home with a drain, a tube inserted in the wound or in a small incision made for it. This decreases the risk of having fluid collect between the muscle and the skin. The drain stays in for several days. Other risks: infection and blood clots, so patients wear compression stockings and are encouraged to walk as soon as possible.

Expect to be on a prescription painkiller for seven to ten days, gradually tapering off. Patients resume normal activities in two to three weeks but shouldn’t expect to be back at the gym for six.

Average cost: $8,000 to $10,000.

This article first appeared in the February 2009 issue of The Washingtonian. For more articles from that issue, click here.