As you and I know, there is a ton of information available to the public about plastic surgery. The good thing about this is that patients can be very well informed about something that they are interested in.
The flip side to this is that many people come in wanting one operation when they need another. For me, as a plastic surgeon, this invokes the art of changing directions, or – in the current vernacular – pivoting.
From breast augmentation to facelifts, here are the top three procedures that cause the most issues for patients during their consultations, hands down.
1. Tummy Tuck vs. Liposuction of the Abdomen
When one of my nursing staff puts a woman in an exam room and tells me that she wants liposuction of her stomach, but that she has had three children, my antennae are up even before I see her. Women who have had children generally have several issues (and, yes, I generalize here). Sometimes there is an increase in the fat of the abdominal wall, and you don’t have to have had children for this to be the case. Usually, there is also some degree of skin excess or skin laxity and separation of the rectus abdominis muscles (the sit-up muscles), otherwise known as a rectus diastasis.
The women who are good candidates for liposuction of the abdomen have only increased fat and perhaps just a small amount of skin looseness. Liposuction will work because the only issue is the fat. In most women who have had children (or who have had significant weight loss), the muscle separation needs to be repaired, and the excess skin removed. If only liposuction is done for them, the skin will become looser, and the shape of the abdomen, due to the rectus diastasis, will not be improved. Liposuction alone could make the abdomen look worse.
Moving from liposuction to a tummy tuck is a standard pivot. The takeaway here is that if you have had children or significant weight loss, you probably need more than just liposuction.
2. When a Breast Lift is Needed Along With an Augmentation
I see a lot of women who want to increase and improve the appearance of their breasts. The majority come in requesting breast enlargement with implants, and that is precisely what they need. However, some women have significant sagging of their breasts and just want implants, when what they need is a breast lift with implants. Time to pivot.
There is a misconception (even among some plastic surgeons) that if you put a large enough implant in a sagging breast, it will lift the breast, and all will be well. Unfortunately, the result of such a venture is that you have a larger, sagging breast. One way of looking at the breast is that there are two parts: the skin that surrounds the breast, and the breast tissue that fills the skin. If you have significant skin excess, a lift is needed to get a good shape. If you are seeing a plastic surgeon who suggests that your significant sagging can be corrected by a large implant alone, keep looking.
Generally speaking, if the level of the nipple is below the crease below the breast, you are probably looking at a breast lift. Perhaps you’ve heard of the pencil test? Well, if you fail the pencil test, chances are you need a breast lift. That said, some women are borderline in terms of their sagging, which may get by with implants only. However, they will not have as much fullness of the upper breast. And, yes, some women say they need a breast lift who do not. This is a much easier pivot, as you might imagine!
3. Why You Might Need a Facelift if Your Neck Is What’s Bothering You
To understand this redirection, it is helpful to understanding something about facial aging. One of the main side effects of aging in the face is the downward movement of cheek fat. As we age, under the forces of time and gravity, facial fat descends. The result is a loss of fullness in the cheeks with sagging along the jawline and the creation of jowls. (Do you see where I’m going here?)
Frequently someone comes in asking for a neck lift. When I ask them what they don’t like about their neck, they will point out the looseness of the skin, the muscle bands in the front of the neck, perhaps some fat beneath the chin, and their jowls. OK, they were suitable for a neck lift except for the last part, the jowls. Correction of jowling requires that the facial fat that has descended into the jowl area be put back up into the cheeks from whence it came. This will require a facelift which corrects the contour of both the face and the neck. (All of my facelifts include neck lifts.)
The other reason to consider a facelift rather than just a neck lift is that the face and neck age together. If you correct just the neck, when facial contouring is also needed, there can be a real disconnect between the well-contoured neck and the aging face. It can make the aging in the face more noticeable, not less.
Bottom Line: The Best Results Come From the Right Procedure
The real concern I have in talking to patients about these redirections is to avoid the feeling that I am up-selling them: recommending a more extensive operation than they are requesting. That’s a real pet-peeve of mine, as I explain here.
My approach is first to understand the problem to be dealt with and then recommend the best way to get there. Sometimes there is a straightforward way, but other times something more involved is needed. Either way, it is a process and a conversation that is important to have to end up with the best result.
If you would like to talk one-on-one about the best plastic surgery procedure for you, please request a consultation online or call (865) 450-9253 to get in touch with my Knoxville, TN, office.
All the best,
David B. Reath, MD
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