The explosion in medical aesthetic technology has resulted in a market that is literally flooded with new products, devices and procedures, like Smart Lipo, all claiming to be the "latest and greatest" or the "next big thing."  A great deal of dedication (and caution!) is required to sort through all of the new (and often not-so-new) technology which is marketed simultaneously to aesthetic professionals and to the public.

I have not seen a single study that shows any advantage of Smart Lipo to traditional (tumescent) liposuction. But, there may be increased risk of complications, particularly since it seems this device is used by many physicians with absolutely no formal surgical training who are just entering the world of aesthetic medicine.

In my practice I use Power assisted liposuction.  These procedures are performed with tumescent liposuction.  The training of the physician is far more important that the procedure being used with these modalities and others.

Liposuction is the most commonly performed surgical procedure each year in the United States.  Surprisingly, the majority of physicians performing liposuction in the United States are not plastic surgeons; in fact, many do not have any formal surgical training whatsoever.  It seems hard to believe, but many physicians performing liposuction or Smart Lipo have had no more training in liposuction than a "weekend course."

I fear that some practitioners, and now consumers view liposuction as a "simple" surgery, since it does not involve making large incisions, and it requires little, if any, suturing.  Nothing could be further from the truth.

Liposuction, in my mind, is a very challenging operation that requires careful planning and preparation, and a great deal of care and finesse when it is actually performed.  It requires a three-dimensional understanding of the layers of human anatomy, an understanding that is second nature to a surgeon alone.

I think that it is often an inadequate understanding of anatomy (and perhaps, of the body's response to surgery) which leads to the poor results in liposuction and body contouring that unfortunately are so often seen.

Although many aesthetic cosmetic surgery procedures are not performed in hospital operating rooms, the fact that a hospital has granted a surgeon privileges for a given procedure ensures that the surgeon has met an accepted standard of competence.  It also means that your surgeon will be able to take care of you at a hospital, should any complications from cosmetic surgery arise.

If you are planning to have any type of cosmetic surgery performed, you should do your due diligence to determine if your surgeon has the appropriate credentials and experience.

 

Liposuction

There is no denying the fact that "before and after" images are the most powerful and effective means for a surgeon to communicate their aesthetic sensibility.  They give the prospective patient an immediate sense of what the surgeon envisions as a favorable postoperative result, and thus allows an individual to make a relatively quick decision as to whether or not that surgical practice is one that they should investigate further. 

Prospective patients have a host of issues to consider when evaluating pre-op and post-op images of cosmetic surgery patients.  An outspoken plastic surgeon who is known for some keen observations is often quoted as saying that "a photograph is merely reflected light."  Another telling maxim regarding cosmetic surgery photography is "almost anything can be made to look good from at least one angle."  Both of these observations speak to the fact that while such photographs should ideally communicate the true nature of a surgical outcome, there are inherent limitations to the two-dimensional nature of photography.

For this reason, as a consumer you should insist on consistency in preoperative/postoperative photography. The positioning of the subject and the size or 'aspect ratio' in the photographs should remain consistent.  If one photograph appears to be taken from five feet away and the other from eight feet away, there is no way to meaningfully interpret the "transformation."  The lighting and color saturation in all of the images should also ideally be identical, or at least comparable.  If the pre-op image is in shadow and the post-op image is well-illuminated, there is no way to determine how much of the postoperative "improvement" was provided by surgical technique and how much is just better lighting.  A bright flash can conceal a whole host of flaws.

You should also insist on seeing images from multiple angles, as this is the only way to get some idea of the quality of a surgical result in three dimensions when reviewing two-dimensional photographs, and to confirm that it isn't just from one direction that the result looks acceptable.  The photography set-up and photographic background should be consistent.  Images taken in the pre-op area in front of a bare wall with an exposed electrical outlet and the patient's gown pulled up but hanging down into the image should not inspire much confidence.  Body position and facial position should also be consistent.  I have seen breast lift (mastopexy) before and after photographs in which the patient's arms were at her sides in the "before" images, and then the arms were lifted above the head in the "after" images.  Raising the arms overhead produces an instant "breast lift," so it is impossible to objectively assess the effect of surgery in photographs where body position is inconsistent. Likewise, if the pre-op image of a facial rejuvenation surgery patient shows a sleepy-looking person in a hospital gown at 6:30 am on the morning of surgery, and the post-op image shows that person in full make-up at 2:00 pm on the day of a follow-up appointment several months later, you have absolutely no way of accurately determining what in the "after" photo is due to surgery and what is due to a good night's rest and some make-up.  You may not be aware that all board-certified plastic surgeons receive training in photography as they are trained as surgeons, so that they have a means to accurately document and communicate their surgical planning and the results of their handiwork.  I personally believe that a surgeon's photographic technique and documentation provides a person who is considering surgery a very clear statement of how organized, meticulous, compulsive and attentive to detail that surgeon is.  If I were a prospective patient I would not expect any of those qualities in the operating room if I did not see them in the "before and after" photographs.  I believe that consistency and quality in photography is a reflection of consistency and quality in one's approach to patient care.  All "before and after" images from this practice that are provided online, via e-mail and during consultation in the office are photographs of cosmetic plastic surgery patients treated by our doctor who have consented to the use of the images.  Absolutely no photo re-touching or digital enhancement is used to "improve" the images or to alter in any way the appearance of the surgical result.

Other Considerations:

When evaluating photographs, also keep in mind the fact that many examples you see of a particular procedure may not look like you.  Part of what makes the practice of plastic surgery so interesting and rewarding for me is the fact that no two patients are exactly alike, and thus each patient requires a fresh and personalized approach.  Rather than trying to dissect how a particular result relates to you personally, view it in terms of that patient's particular "starting point," and whether or not the surgical enhancement is aesthetically pleasing and natural-appearing.

Don't limit your investigation to an examination of photographs.  Review the content of a cosmetic surgeon's website thoroughly, and get a feeling for that doctor's individual approach and practice philosophy. Get a feel for whether the website is attempting to provide useful information or is just trying to sell you something. Determine if the priority is communicating the surgeon's aesthetic sensibility, or getting you approved for easy financing.

Also, another important source of information about a surgeon and a surgery practice can come from individuals who have had experience as a patient of that practice.  At our office we have many cosmetic surgery patients who are willing to speak to prospective patients about their surgical experience and their results.  If you are favorably impressed when you meet the doctor in consultation, ask to speak to someone who has undergone a similar procedure, and if at all possible someone who has a similar "starting point" or similar preoperative concerns.

Miscellaneous

Some surgeons perform what they call a "circumareolar" (or 'donut' or 'Benelli' ) mastopexy.  In my opinion there is absolutely no such thing as a "circumareolar mastopexy."  Removing skin around the areola may enable a surgeon to elevate the position of the nipple/areola complex perhaps 1-2 cm on the breast mound, but it DOES NOT lift the breast itself.  In most cases, unfortunately, it serves to distort the shape of the breasts, making them appear flattened at the top.  If the breast needs to be lifted, it absolutely requires some internal rearrangement of breast tissue to create a projecting, aesthetically ideal and lasting result - which in turn requires that vertical incision and vertical surgical scar below the areola (and sometimes in the inframammary fold as well).

If you want a breast augmentation without having an incision around the nipple there are other options.

The axillary or underarm area incision is ideal for patients with very youthful-appearing breasts, especially younger women with no history of pregnancy.  These patients often have a small areolar diameter, which makes the peri-areolar incision less than ideal, and smaller, perkier breasts - where the inframammary fold (and thus a scar in that location) can be easily seen.

The infra-mammary fold incision works very nicely for patients who do not have a marked color difference between areolar skin and breast skin, and who have adequate fullness in the lower pole of the breasts.  As full breasts conceal the infra-mammary fold very well, the scar is usually not visible when standing or sitting upright.  Ideally this scar is placed just above the inframammary fold on the lower pole of the breast, so that it faces down and therefore tends to be less noticeable. 

An advantage of the peri-areolar incision is that the color and skin texture difference between areolar skin and the adjacent breast skin conceals the resulting scar very nicely.  In many patients the scar is almost undetectable after only a few weeks.  This incision is commonly used in patients who have had one or more pregnancies and have a medium to large areolar diameter.

 

Breast Augmentation

 

This is a very common situation after pregnancy, and also is seen in many patients who naturally have full and somewhat droopy breasts but who have never been pregnant.  As you obviously are aware, a number of surgical options are available.  A breast lift (mastopexy) will remove some skin and in most cases some breast tissue as well (in order to tighten and re-shape the breasts internally), so your lifted breasts will most likely seem somewhat smaller, even if you still fit a D cup bra.  A reduction can be performed if you would like to transition from a D to a smaller C-cup (or even a full B-cup) breast profile; it is essentially a breast lift plus more extensive removal of breast tissue.  Both procedures relocate the nipple/areola complex to a youthful position at the top of the breast mound.

 

In either case you may or may not end up with upper pole breast fullness, which is something most patients want from their breast rejuvenation surgery.  If you pinch the breast above the nipple/areola complex and  there appears to be a fair amount of breast tissue there, then you may be fine with a lift or reduction alone.  If there is not much breast tissue there, then in most cases a lift or reduction will not improve that situation in a lasting way, and you'll have to think about whether or not to have an implant placed to create that aesthetically ideal upper pole fullness.

 

Mastopexy (breast lift) and augmentation can frequently be performed simultaneously, but in some patients with larger breasts it is best to perform the mastopexy first and then several months later perform the augmentation.  Reduction and augmentation, as odd as it may sound, are sometimes performed simultaneously as well.  It sounds counterintuitive, but what is being accomplished (ideally, if the appropriate surgical technique is used) is removal of excess lower pole and lateral breast tissue, and simultaneous augmentation of the upper / medial aspect of the breast by means of implant placement.  It is critical in these surgeries to be very conservative with the size of the implant, as too large an implant will quickly stretch out the lower poles and produce a 'bottomed out' appearance.  Which generally results in another trip to the operating room to tighten the lower poles, usually by the removal of additional lower pole skin.

 

So the most important consideration in planning the surgical rejuvenation of your breasts is determining: (1) whether or not you will have upper pole breast fullness (above the nipple/areola complex, especially the upper cleavage area) with a lift or reduction alone, and (2) whether or not you are willing to consider the placement of modest-sized breast implants for the purpose of creating upper pole fullness if it is determined that there is not enough natural breast tissue to create an ideal, youthful shape without implants.  This assessment can be reliably made by a board-certified plastic surgeon who has plenty of experience with cosmetic breast surgery.  As your doctor examines you he or she will take a number of measurements, simulate a breast lift or reduction, and assess whether or not you need an implant to provide you with lasting upper pole breast fullness.

 

Make no mistake about it: this is a complex surgical issue, both in the planning and in the performance.  Make sure that your board-certified plastic surgeon shares your aesthetic vision for the result you have in mind, and that he or she is able to show you numerous photographic examples of the surgery you are considering.

Breast Augmentation

 

Mastopexy (breast lift) and augmentation can frequently be performed simultaneously, but in some patients with larger breasts it is best to perform the mastopexy first and then several months later perform the augmentation.  Reduction and augmentation, as odd as it may sound, are sometimes performed simultaneously as well.  It sounds counterintuitive, but what is being accomplished (ideally, if the appropriate surgical technique is used) is removal of excess lower pole and lateral breast tissue, and simultaneous augmentation of the upper / medial aspect of the breast by means of implant placement.  It is critical in these surgeries to be very conservative with the size of the implant, as too large an implant will quickly stretch out the lower poles and produce a 'bottomed out' appearance.  Which generally results in another trip to the operating room to tighten the lower poles, usually by the removal of additional lower pole skin.

 

So the most important consideration in planning the surgical rejuvenation of your breasts is determining: (1) whether or not you will have upper pole breast fullness (above the nipple/areola complex, especially the upper cleavage area) with a lift or reduction alone, and (2) whether or not you are willing to consider the placement of modest-sized breast implants for the purpose of creating upper pole fullness if it is determined that there is not enough natural breast tissue to create an ideal, youthful shape without implants.  This assessment can be reliably made by a board-certified plastic surgeon who has plenty of experience with cosmetic breast surgery.  As your doctor examines you he or she will take a number of measurements, simulate a breast lift or reduction, and assess whether or not you need an implant to provide you with lasting upper pole breast fullness.

Breast Lift