Plastic Surgery, Women's Health PDR Family Guide

s there anyone who's completely thrilled with what nature—and genes—have given them? Don't we all have a secret little wish list of body parts that could stand improvement? Today, it seems as though all you have to do is imagine a little tuck here, maybe a nice boost there, and plastic surgery makes it so.

Of course, it's not really that simple, but there has been a lot of progress in the past two decades: Procedures that were once exclusively the privilege of the rich and the famous are now being done for the rest of us. The surgery is safe and available, and can make a tremendous difference in the way you see yourself and how you face the world. You have to remember, though, that plastic surgery is a clinical procedure, not a panacea. It must be approached with realistic expectations. If you look for improvement rather than a miracle, you'll avoid a lot of disappointment. Here's a look at what's available, what it can do, and what's really involved.

Facialplasty: The Classic Facelift

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Gravity and longevity are a formidable combination, leaving their mark on the skin and on all that lies beneath it. The skin shrinks here and sags there, thins out, and becomes increasingly susceptible to the damage caused by exposure to the sun.

Sad to say, our faces begin to rearrange much earlier than most of us would like to admit. “Crow's feet,” those short straight lines radiating from the outer edge of the eyes, can appear any time after the age of 30. Skin in the upper eyelids loosens as well. Creases in the forehead, between the eyebrows, and around the nose and mouth suddenly seem more noticeable when a woman reaches her 40s. By the age of 50, the neck starts to wrinkle, the jawline seems to blur, and the tip of the nose may look a bit droopy. Although signs of age appear at different times in different women, facial wrinkling and sagging become hard to ignore by the sixth decade of life.

A facelift (facialplasty) can turn the clock back a few years. Such procedures have been done since the early 1900s, but the modern era of facelifting dates from the 1970s when plastic surgeons began using techniques that correct the age­related changes that occur deep beneath the skin.

While a properly performed facelift will make a woman look younger, the procedure won't work miracles. Surgery can't transform you into a “different” woman, or save a marriage. One of the toughest jobs facing a plastic surgeon is deciding who will truly benefit from the surgery and who is likely to be disappointed.

Planning and Preparing for Surgery

Careful questioning during the first appointment helps doctors identify women who expect the impossible. If you have trouble describing exactly what you want to change or seem distraught about a relatively minor “deformity,” you are not a good candidate for a facelift, and probably won't receive one.

If the doctor thinks plastic surgery would be good for you, he or she will ask about your medical history, any allergies, previous surgery, reactions to medication, and personal habits such as smoking.

Anything that may interfere with natural blood clotting mechanisms such as high blood pressure and medicines containing aspirin, poses the danger of excess bleeding and must be avoided. Smoking causes skin sloughing, in which areas of skin literally slide off the face, leading to additional scars. Surgery may therefore be delayed for several weeks until your blood pressure has dropped to normal levels, for example. Aspirin and smoking are banned for at least two weeks before surgery.

Preparations for surgery include a comprehensive physical examination. The doctor also checks every part of the face for creases, wrinkles, lines, puffiness, and sagging. The doctor will assess your skin's thickness, elasticity, and mobility; check the jaw and neck for fatty deposits; examine the thickness of the hair and note the location of the hairline; and document any previous surgical incisions and scars. An assistant will then take a series of photographs which the surgeon will use to plan the operation and explain the procedure to you. The photographs will also remind you later of how you looked before surgery. Such photo sessions are standard before just about any kind of plastic surgery.

The doctor will explain the surgical plan feature by feature. Some trouble spots can be improved but not eliminated. Forehead lines, crow's feet, and creases around the nose and mouth can be softened, for example, but not removed altogether. Fine wrinkles can, however, be treated with a chemical face peel after the area has healed.

Facelifts involve close work around the mouth and hairline, where bacteria hide in large numbers. To minimize contamination, you will be asked to remove all makeup the night before surgery and to scrub your face and wash your hair and scalp with a medicated soap.

The Operation

Your hair will be combed away from your face. Antibiotic ointment may be combed into your hair to flatten it and prevent infection. You'll take antibiotic medication and perhaps a sedative as well.

The surgeon will place marks on your face as a surgical “blueprint” just before you receive general anesthesia.

The relatively small facialplasty incisions, next to each ear, give the surgeon full access to the face, from cheeks to chin. The forehead, eyes, and nose are done with separate incisions. Electrocautery is used to singe the blood vessels and minimize bleeding. The skin is pulled tight, redraped, and tacked down in two spots above and behind the ear. The surgeon trims the extra skin and closes the incision. The procedure is then repeated on the other side of the face.

THE SURGICAL REMEDY FOR SAGGING SKIN

A facelift can't produce perfection, but it can reduce the bags, wrinkles, and creases that come with advancing age. Tucked under the hairline and behind the ears, the basic incisions are almost unnoticeable. Separate invisible incisions alleviate baggy eyes. Be prepared, though, for a long convalescence: it can take up to 3 months for swelling and bruising to totally disappear.

After the Operation

After the procedure, an elastic net dressing that leaves only a small part of the face and eyes exposed will cushion the skin flaps and absorb drainage from the wounds. This dramatic mummy­like dressing helps remind you to let your face rest.

Dietary restrictions are necessary after facial surgery to limit the nausea and vomiting induced by anesthesia. Furthermore, chewing can cause bleeding. You'll start out on clear liquids and quickly progress to a full liquid diet. Soft foods are added the day after surgery. If all goes well, you can return to your usual menu the day after that.

Movement is discouraged for 24 hours. Don't talk on the phone and walk as little as possible. Keep your head still and slightly elevated at a 30­degree angle. After 24 hours, you can resume light activity. Most surgeons keep their facialplasty patients in the hospital for at least one night.

You'll wash your hair on the third day after surgery and at least every other day after that, to keep the incisions clean. The stitches will be removed on days 5 through 10 after surgery.

You can expect swelling, black­and­blue marks, and numbness for many weeks after a facelift. Most women are confident enough to venture out of the house after a few weeks although all swelling and bruising may not disappear for 3 months. Sun block is strongly recommended for the first 6 months.

Several complications can follow facialplasty:

Hematomas. The most common problem you may encounter is the formation of a hematoma, the pooling of blood under the skin. If too much blood collects—a situation that occurs only 10 percent of the time—the surgeon pierces the skin and drains it. Most “major” hematomas appear within the first 10 to 12 hours after surgery. Another 10 to 15 percent of patients develop smaller hematomas, many of which aren't noticed until the swelling goes down.

Skin sloughing. This happens most often in the skin around the ear, where the skin is especially thin and is also geographically farthest from the circulation system that supplies blood to facial structures. Superficial skin sloughs (in the top layer of the skin) may leave little or no scarring. In the 1 to 3 percent of facialplasty patients who develop deeper, full­thickness skin sloughs, however, some amount of scarring is inevitable. The risk of skin sloughing is up to 12 times greater in cigarette smokers than in nonsmokers.

Numbness. Your face may feel numb for 2 to 6 weeks after surgery. The reason is that lifting the skin disrupts the sensory nerves that provide feeling to it. Disturbing a facial nerve branch can interfere with your ability to move parts of your face. Full movement usually returns within a few weeks to a year after the injury, but can sometimes take even longer.

Scars. Facelift scars tend to fade away, becoming virtually invisible. The scars can become more evident if the blood supply to the skin flaps was compromised during surgery or the skin was pulled too tight, causing tension on the incision.

Hair loss. About 1 to 3 percent of people who have had facialplasty lose some hair, usually around the temples, where the incision interrupted the blood supply.

Dark Spots. Patches of darker skin may appear when facial swelling prevents the diagnosis of small hematomas. In most cases, the skin gradually lightens back to normal, although the process can take 6 to 8 months. In rare cases, the darker spots become permanent.

Related Operations

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Many women have other procedures performed along with facialplasty. Tightening the muscles in the neck and cheeks lifts and contours the cheeks, redefines the jawline, and eliminates “turkey neck.” Some patients request cheek implants; others have fat removed from their cheeks. Silicone chin implants are another common request; a small implant can dramatically improve a formerly chinless profile. Chemical peels remove the fine spiderweb of wrinkles that a facelift can't touch. Dermabrasion smoothes deep pitting or scarring.

Chemical Peel

A chemical peel erases the wrinkles that remain after a facelift. The procedure is also used to treat discolored spots on the skin. Because the line between peeled and unpeeled skin blends more evenly in lighter skin, results tend to be best in women with fair complexions.

Chemical peeling can be performed on wrinkles in some areas, such as those around the mouth, at the same time as facelift surgery. A lower eyelid peel, on the other hand, is never done at the same time as eyelid surgery. To prevent heavy scarring extensive peeling is postponed until after the facelift heals.

The peeling procedure is simple. A small amount of a chemical solution, usually phenol, is applied to the face with a cotton­tipped swab. The skin is gently stretched to allow the fluid inside the wrinkles. The solution is applied all the way to the hairline so that no line will be visible between treated and untreated skin.

When the solution dries, the skin will have a white, frosted appearance. The face should not be washed for 24 to 48 hours. After about 10 days, the “crust” falls off to reveal the smooth, pink skin. Normal color returns to the skin within 6 to 12 weeks.

Irregular heartbeat is the most common complication associated with phenol peels. This problem can be avoided by applying the solution to small areas of the face one at a time over the course of an hour.

Chemical peels always create some redness, which generally lasts no more than 6 weeks. Some people, especially those with darker skin, notice that their skin is lighter or that they develop a blotchy sunburn. Scarring is uncommon but will occur if aggressive peeling is done in combination with an extensive facelift or if the peel is done on the neck.

Dermabrasion

When skin irregularities cannot be treated by facelift or chemical peeling, they can be “sanded off.” The procedure is most effective in repairing the pits that result from deep scarring, such as from severe acne.

Dermabrasion wears down the raised areas of skin around the depression so that the difference in elevation is less noticeable. The results are permanent; once the skin has been thinned, it never regains its former thickness.

The procedure can be performed under either local or general anesthesia. There is a small amount of bleeding as the skin is scraped. Ointment is sometimes applied afterward. The deeper the abrasion, the longer it takes to heal.

Women with fair skin tend to have the best results. Those with darker skin may notice a change in skin color as they heal. The procedure causes a certain amount of redness, which can persist for several months. Because the skin is more sensitive after dermabrasion, direct sunlight should be avoided for several months.

Forehead and Brow Lift

A facelift tightens only the lower part of the face. It will not correct age­related “defects” above the cheeks. At the initial evaluation, the plastic surgeon may recommend separate procedures on the eyelids or forehead to correct such problems. These operations can be performed separately or in combination with the facelift.

A forehead and brow lift is generally recommended to counteract sagging and to reduce creases and wrinkles across the forehead and between the eyebrows. This procedure also corrects baggy upper eyelids. A forehead and brow lift can help eliminate eyelid fullness that cannot be corrected by eyelid surgery alone.

An aging forehead dramatically affects the appearance of the rest of the face. The forehead muscle is stimulated by nerves that can cause wrinkles. With time, the wrinkles gain prominence and the brow sags. As the skin pushes downward, the eyelids become puffier, and the skin on the nose may even slide down the bridge so that the tip appears to droop.

Repeated muscle contractions in the forehead create lines and creases. The scowling facial expression that results eventually pulls the forehead further downward. The contractions also pull the nasal skin upward, causing wrinkles and creases around the nose.

The operation is tailored to individual needs. The surgeon checks the position of the upper eyelids and eyebrows and gently pushes the forehead up towards the hairline. If the surplus eyelid skin “disappears,” a forehead and brow lift alone will work well. If too much skin remains, eyelid surgery (blepharoplasty) will also be necessary.

In most cases, the incision for a forehead lift is made a couple of inches behind the hairline. It's not necessary to shave the hair. If facialplasty is also being done, the two procedures are performed simultaneously and the respective incisions are joined.

Before you receive anesthesia, the surgeon will mark the incision line and the forehead and brow creases. The doctor then injects anesthetic solution into the incision line, across the top of the eyes and down to the top of the nose. This solution causes the blood vessels to constrict, thus limiting the amount of blood that can escape from the incision. A plastic lens may be placed on each eye to protect them during the operation.

A sagging forehead is corrected by stretching the skin up toward the hairline. Forehead lines are eased by removing some of the muscle that causes the creases. The skin is then brought back up over the forehead and held in place with surgical staples. The extra skin is trimmed and the wound is closed. The incision is covered with gauze. The same type of elastic dressing is used as after a facelift.

Pressure and mild discomfort are the most common complaints after a forehead and brow lift. Hematomas are rare. Since your eyes may not close completely for the first day, you'll be given special ointment to keep the corneas from drying out. Swelling and bruising around the eyes are often greater on the second or third day.

If you've not had any other surgery, the dressing can be removed after the first day. If you've also had a facelift, the forehead dressing will be left in place for an extra day. Daily hair washing is allowed starting on the second or third day after the forehead and brow lift.

Although hematomas are rare with this surgery, the potential consequences in terms of hair loss can be worrisome. A patient complaining of pain will be watched very closely. Patients generally don't lose much hair unless the skin was pulled too tight when the incision was sutured. Patients with thin, fine hair are more likely to notice some hair loss, particularly where the staples were placed. When hair loss occurs during routine brushing and combing, the problem is likely to continue for as long as 3 to 6 weeks.

Muscle paralysis is rare and usually when it does occur, temporary. If you can move your forehead at all, you will eventually regain normal movement. Full recovery, however, can take as much as 10 to 12 months. You may also feel itching and numbness for 6 weeks or up to 6 months.

Eye Tuck

The first signs of aging generally appear around the eyes. When a woman reaches 30, the forehead begins its downward descent, taking the eyebrows along with it. The downward pressure bunches up the sagging skin and gives the upper eyelid a hooded appearance. These effects intensify with age. Blepharoplasty, which tightens the eyelids, is usually more effective after a forehead and brow lift has reduced the amount of skin around the eyes.

During your evaluation, the surgeon will explain that incisions within the eyelid usually heal without noticeable scars. The surgical technique will be tailored according to your goals, the amount of muscle relaxation and sagging in each eyelid, and whether you are also getting a forehead and a brow lift. The plastic surgeon may check with an ophthalmologist about your vision and the possibility of glaucoma.

Many surgeons perform blepharoplasty with local anesthesia and a sedative. This surgery requires close work, with a very bright light shining into your eyes. The doctor may cover your eyes with ointment to protect against dryness and possible injury if an eye is scraped by gauze. Ointment is reapplied after surgery.

The surgical technique is basically the same as for facelifts and forehead lifts. The skin is freed from underlying tissue, pulled tight, trimmed, and sutured. The surgeon may also remove fat deposits to eliminate bags under the eyes. Note: If the plastic surgeon overcorrects the eyelid problem, the skin may be too tight, leaving a perpetually surprised look.

After the operation, cold compresses for the first 24 hours reduce swelling and help ward off feelings of claustrophobia from having your eyes bandaged. The eyelids will not close completely at first. This situation gradually corrects itself as swelling subsides and the eyes regain their muscle tone. If the problem persists, there are several exercises and techniques that can help return the eyes to normal. Examples include tightly closing your eyes to strengthen the eyelids and taping them shut when asleep.

Makeup is banned for 2 weeks after blepharoplasty. After that time, women are cautioned to remove their makeup as gently as possible.

Rhinoplasty: Refashioning the Nose

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What is sometimes disparagingly called a “nose job” can do much more than create a smaller, cuter nose. In addition to improving appearance, it gives an opportunity to correct any breathing problems you may have.

The nose is a complex structure consisting of an outer layer that slides over the semi­rigid inner layer of cartilage and lining. The two layers work together in a delicate balance. Any manipulation of either can upset the equilibrium and lead to serious physical and aesthetic problems. An aggressive attempt to reduce the size of the nose can compromise its underlying structure. The cartilage could collapse and obstruct the airway.

Surgeons prevent this type of problem by rearranging, rather than reducing, the underlying skeletal structure, reshaping the nasal contour while preserving nasal function. The trouble is that many prospective patients don't understand that rhinoplasty is always a compromise.

Explaining what can and cannot be accomplished is a considerable challenge for the surgeon. One important point to remember is that the nose is not perfectly symmetrical; the two sides develop independently.

Removing a hump or bump on the bridge of the nose may reveal a natural curve that must then be camouflaged by another procedure. Trimming a bulbous tip may throw off the proportions of the rest of the nose; what looks good in profile may be unattractive when seen from the front.

DECEPTIVE ANATOMY OF THE NOSE

Underlying the smooth exterior of the nose is a hodgepodge of bone, cartilage, fatty tissue, and mucous membrane. It's no wonder, then, that rhinoplasty is a highly individual operation, and that a second operation is occasionally needed to make adjustments for the first. You can count on a protracted recovery period, too: anywhere from 3 months to a year.

Planning and Preparing

At your first appointment, the surgeon will take photos from all angles and ask you to explain what you consider good and bad about your nose. The nature of your complaints will influence the surgery, too. There is a big difference between “my nose is too large” and “I can't breathe.”

The surgeon will use a model of the nose to describe what will be reduced, what may need to be enlarged (augmented), and what should be left alone. If you already consider your nose too large, you may be surprised to hear the surgeon suggest augmentation. But adding a little bit here or there can make another part of the nose look smaller without interfering with the airway.

It is important to understand the finer points of rhinoplasty and to agree with your surgeon on the approach to be used. You'll also need to accept the surgeon's priorities of safety, function, and appearance, in that order, and be willing to live with the potential consequences and complications.

Sometimes a second operation is required to modify the results of the first one or to make additional changes after the nose has healed. Also, some “defects” must be corrected in stages in order to keep a passage open for air.

Rhinoplasty encompasses several procedures. As a result, it's hard to generalize. The surgeon can't always predict the complete anatomy of a nose or visualize its volume and texture until it has been opened for surgery. A standard procedure to correct a specific problem may have to be modified once surgery begins.

After the Operation

You'll wake up after rhinoplasty to find your nose packed with bandages layered around plastic tubes called suction catheters, placed to keep the nasal airway open. Many people find that they can breathe much more easily than before, catheters and all. Depending on the type of surgery and the amount of bleeding, the packing will remain in place for 24 hours to a week.

Bleeding is fairly common with certain procedures and can be frightening. The more upset you get, the more likely you are to bleed. Often, simply remaining calm will dramatically reduce the blood flow. Infection is rare. The nasal packs are sometimes covered with antibiotic ointment, especially when packing must remain in place for several days or more.

Healing can take as long as a year. The nose continues to contract for several weeks after surgery. The outer layer of skin feels hard and remains stiff for up to 3 months and maybe for as long as a year. The tip of the nose will probably rotate slightly. Swelling seen from the front disappears slowly, and the nose will look bigger than it really is until the swelling has subsided.

Sometimes subsequent surgical “rehabilitation” is necessary to fine­tune nasal function or appearance. If so, the follow­up procedure will be scheduled after healing is complete, usually in 6 months to 1 year.

A person who has realistic goals is likely to be very happy with her “new” nose. A patient who expects the impossible, however, is sure to be disappointed.

Breast Augmentation

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Society's preoccupation with large breasts has caused unhappiness in quite a few women with small ones. Breast augmentation to make up for nature's “shortcomings” can give a major boost to a woman's self­esteem. Having bigger breasts won't guarantee happiness or solve emotional or psychological problems. But, when performed for the right reasons, breast augmentation can greatly improve a woman's outlook on life.

Breast augmentation surgery first gained popularity when the silicone gel prosthesis was developed in 1963. Over the years, a variety of implants became available. Today, however, for a variety of legal and regulatory reasons, only the saline­filled silicone implant is in general use. Fortunately, this implant does a relatively good job. Besides the fact that saline (salt­water solution) is considered by many to be safer than silicone gel, breasts augmented with saline­filled implants are less likely to get firm or hard. The trade­off is that saline implants are not quite as soft as those filled with silicone gel and, if they develop a leak, will quickly go flat and need to be replaced.

The controversy over silicone gel implants remains unresolved. There is no conclusive scientific evidence that this type of implant poses a significant health hazard. Nevertheless, there have been accusations that it does and there are still unanswered questions. The best guess among the experts is that when all the information comes in, silicone gel implants will be shown to be either entirely safe (if anything can truly be said to be entirely safe) or to pose a risk to only a very tiny minority of women who develop unusual reactions to them. For now, however, the best advice is to use saline­filled implants.

Planning and Preparing

The evaluation for breast augmentation begins with a complete medical and personal history. The doctor will ask whether you have ever had breast disease, cysts, or breast pain or tenderness. Information about your life-style and recreational activities will help the surgeon design breasts that look natural when you engage in your usual activities.

The next step is a thorough examination of your “old” breasts. The doctor will see whether both breasts look the same (symmetry) and evaluate the elasticity of your skin to determine whether it will be able to stretch enough to accommodate an implant. Any congenital deformities and pronounced scars are noted. The doctor will look at the angle formed by the breast against the chest to determine the possible effects of heavier, implanted breasts and whether you will be able to support them.

If a breast mass or any other abnormality is found during the physical examination of the breasts, or if the medical history reveals any worrisome or questionable condition, the doctor will order further tests.

The psychological evaluation is just as important as the physical findings. Some women have unrealistic expectations and think that new breasts will solve all their problems. Any reputable doctor who suspects that a woman expects too much from the operation or is emotionally unstable will postpone surgery and recommend counseling.

The surgeon can't promise you a specific bra cup size or measurement. A lot depends on your weight. An extremely small­breasted woman with tight skin may be able to handle only a slight increase in breast size, followed by additional surgery after the skin has had time to stretch. A heavy woman, on the other hand, might notice only a slight change in her breasts even after receiving large implants.

THREE ROUTES FOR IMPLANT SURGERY

Although breast implants always wind up in roughly the same position, the best route inward can vary. Here are the pros (and cons) of each major approach. Inframammary:—in the fold underneath the breast. This site permits a large incision, which provides better access to the breast and makes it easier for the surgeon to avoid blood vessels and ducts while creating the pocket. The scar is concealed by the natural fold of the breast. Periphery of the areola: around the edges of the areola, the area of darker skin that surrounds the nipple. The scar is naturally camouflaged by the areola. If the areola is small however, the incision may not be large enough to receive the implant. Transaxillary: under the arm. The scar is hidden beneath the arm. Drawbacks: The surgeon must cut through more tissue to reach the center of the breast, and may have more difficulty controlling bleeding.

It's important to agree with your surgeon about your goals for mammoplasty. While the doctor will certainly consider your wishes, final decisions regarding the size and volume of the implant must often be made in the operating room. Many surgeons favor a course of moderation to make sure the newly enlarged breasts don't overwhelm the woman's body.

As you discuss the operation the doctor will tell you about types of incisions and anesthesia, where and how the surgery will be performed, potential postoperative problems, and follow­up procedures. Photographs of both breasts are taken from the front and from each side. You will be instructed to avoid taking aspirin for 2 weeks before surgery and not to smoke for 1 week before and 1 week after surgery. Aspirin­induced bleeding could cause serious problems. Smoking leads to coughing, which places a strain on the chest. Smoking also causes blood vessels to constrict, which can result in high blood pressure and increased bleeding.

The Operation

During the operation, the surgeon will first create a pocket within the breast, then insert a prosthetic implant into it. The surgery can be performed in a hospital or in an outpatient clinic. General anesthesia is preferred, although local anesthesia can be used. The surgeon chooses an insertion site (see box nearby).

Many prefer the below­the­breast route, which provides good access, leaves a very thin scar, and usually makes a second incision unnecessary.

After forming the pocket, the surgeon decides what size the implant should be. Using a selection of sterile “sizer” implants, the surgeon literally begins trying them on for size. The temporary implants selected are placed in both breast pockets and gently manipulated to make sure the breasts appear natural. The two breasts are then compared from all angles to make sure they match. The next step is to raise the patient into a more vertical position. Overhead lights are aimed at the nipples from either side, and the surgical team moves to the foot of the table for yet another visual inspection. The woman is returned to the reclining position and the temporary sizers are replaced with permanent implants.

After the Operation

Dressings are removed after 24 hours, at which point you may bathe or shower as usual. Wearing a brassiere is optional. The ban on smoking continues for a full week after surgery. Vigorous physical exercise is inadvisable for 3 weeks. You may be asked to move the implant upwards and sideways once or twice a day. Sutures are removed 7 to 10 days after the operation.

Improved surgical techniques have greatly reduced the problems that were formerly common after breast augmentation surgery. Infection and hematomas are now rare. There may be some discomfort, numbness, and thickened scarring. The skin may be highly sensitive when touched or lack normal sensation.

Some complications occur as part of the normal healing process. For example, the skin and tissue may constrict or tighten around the prosthesis, causing the implant to feel firmer than expected. This most often happens 6 to 12 months after surgery and represents the body's natural response to a foreign substance. If necessary, the situation can be corrected surgically.

Breast Reduction

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Heavy, sagging breasts often lead to neck and back pain and soreness where the brassiere straps cut into the shoulders. Rashes or sores can develop under very large breasts due to their constant contact with the chest wall. This chronic problem is aggravated by perspiration in hot, humid weather.

Tremendous breasts can cause no end of embarrassment or simply get in the way. An out­of­proportion chest makes exercise difficult and causes many women to feel that they are not taken seriously in their professional lives.

Reduction mammoplasty, which solves these problems, is not some 1990s fitness fad. This surgery is believed to date as far back as the mid­1600s. It is typically performed on young women in their late teens to early 20s, after the breasts have stopped growing. The psychological benefits of resembling one's peers during the emotionally traumatic teenage years, however, make surgery a wise choice for many young girls, even if more surgery is needed for additional growth later.

Some women in their 60s and 70s enthusiastically choose reduction mammoplasty to resolve a lifelong problem. There are physical benefits for older women as well. As a woman ages, it can become increasingly difficult for the skeletal system to support heavy breasts.

Planning and Preparing

Before reduction mammoplasty, a screening mammogram x­ray is done so that the surgeon can rule out the possibility of encountering a mass or lump during the operation. Another mammogram will be taken a few months after surgery to serve as a basis for comparison with future x­rays.

Reduction mammoplasty entails removing large amounts of breast tissue, which is full of blood vessels and capillaries. Because a considerable amount of blood may be lost during surgery, women who plan to have this operation are advised to donate 2 units of blood beforehand. If a transfusion is necessary, for safety's sake it can then be done with their own blood.

The Operation

In the operating room, you'll sit on the side of the operating table as the surgeon quickly marks your breasts to indicate what parts will be removed.The procedure itself will vary according to the methods chosen to remove the skin and tissue and the planned location and appearance of the scar. Tissue is removed on either side of a vertical strip containing the areola and nipple. This strip of skin and tissue, which runs the entire length of the breast, from top to bottom, is called a pedicle. The pedicle protects the nerves and blood supply to the nipple and areola.

The surgeon weighs the amount of tissue removed from each breast to keep the reduction equal. The final size and symmetry, of course, will depend more on what remains than on what was removed.

Once enough tissue has been removed, the surgeon makes a cosmetic tuck at the top of the pedicle, moving the nipple and areola into their new position, and begins to close the skin around the breasts. If one breast appears to be larger or fuller than the other, the surgeon may decide to remove additional tissue and improve the match.

The marking that takes place before surgery begins is one of the most critical aspects of the procedure. If the surgeon moves the nipple and areola too high, they will seem to sit unnaturally on top of the breast instead of at the tip. The surgeon must also anticipate the “dropout” effect that will occur as the breast slowly settles into place. As gravity and time move the tissue within the breast, the breast volume can shift, leaving the nipple and areola out of place. This condition can be corrected by additional cosmetic surgery, but only with difficulty.

After the Operation

The nipple and areola area also causes concern after surgery, as the surgeon waits to make sure this important tissue has survived the procedure. The surgeon checks the color of the nipple and areola on each breast soon after surgery to make sure the blood supply is still in good shape. If the surgeon has any reason to suspect a problem during surgery, a fluorescein dye may be injected to trace the movement of blood through the breast.

You can probably leave the hospital within 2 days of this surgery. You'll be told to wear a brassiere 24 hours a day for the next 2 weeks.

Nipple Grafting

This procedure involves removing most of the breast, reshaping the remaining tissue, and grafting the nipple and areola back onto the new breast. The nipple and areola are removed quickly and placed on a moist saline sponge. The surgeon then removes much of the breast tissue, creates a pocket within the breast, and inserts the remaining breast tissue. The skin is gathered around the new breast, which takes shape as the surgeon begins to suture the skin. The nipple and areola are then sutured in place. The major concern during surgery is the possibility of amputating too much breast tissue and thus having too little left over to create the new breast.

One advantage of this free nipple grafting technique is that it enables the surgeon to fashion an attractive breast from scratch. It's especially useful when the woman has very large breasts. Because this type of surgery can be performed quickly, anesthesia is brief and blood loss is minimal.

Another advantage of the procedure for very large­breasted women is that it can be extremely difficult to protect the pedicle when there is extensive tissue removal. Reshaping a greatly reduced breast around a pedicle can also lead to a disappointing result in terms of the new breast's shape and form.

However, nipple grafting also has disadvantages: The nipple and areola are likely to look unnatural and may not even survive. Their color may fade, which is a particular problem for women with darker skin. The nipple will lose all sensation and fail to become erect when stimulated. Breastfeeding is no longer an option once the milk ducts have been greatly rearranged if not removed entirely.

This procedure is considered preferable to reduction when the nipple and areola must be moved up by more than 6 inches. It is also a good choice for elderly women who don't consider nipple sensation a top priority. While surgeons tend to avoid using this procedure in younger women, those with particularly massive breasts commonly have relatively little nipple sensation before surgery anyway.

Breast Lift

One of the more pleasant aftereffects of breast reduction surgery is that the remodeled breasts are higher and tighter. Mastopexy is the name of the procedure that lifts the recently reduced breast into its new position. Mastopexy can be used to counteract the effects of time and gravity even when no surgery is done to alter breast size.

Aging is not kind to the breasts. The skin stretches, the volume of the breast thins out, and the breast loses its firmness and begins to sag. Pregnancy, weight loss, breastfeeding, and menopause all speed the natural aging process. The stretch marks that may linger after pregnancy make the breasts look flabbier than they really are. Rapid weight loss can have the same effect.

Mastopexy is performed with local anesthesia in an outpatient facility. Nipple placement is the most crucial part of the operation. After selecting the new nipple site, the surgeon marks the areola, which stretches with time like the rest of the breast. If this circle of tissue isn't trimmed, it will appear to cover a disproportionate amount of the newly tightened breast.

Even mastopexy can't eliminate the constant pull of gravity. Some additional sagging is expected about 6 months after surgery. The surgeon plans for the inevitable by making the lift a little tight.

If the breasts start sagging right away or if the sagging is excessive, the surgeon can do a minor revision in the office. Women who had serious sagging before surgery undergo a remodeling procedure similar to breast reduction. Other women have breast augmentation in conjunction with mastopexy.

After surgery, you'll wear a brassiere 24 hours a day for 6 weeks. The brassiere acts as a bandage while providing support. The breasts may look strange at first—somewhat flat, with the nipples pointing downward—but this situation generally corrects itself within a few months.

Although some scarring is inevitable, most of it can be hidden in the natural breast fold. Some women notice a loss of cleavage. Despite the disadvantages, mastopexy provides good­looking breasts that are tighter, firmer and back to a higher point on the chest.

Body Contour Surgery

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Body contour surgery (torsoplasty) is basically an aesthetic tune­up for the entire body. The surgical team develops a plan to lift and reshape any desired combination of the breasts, abdomen, buttocks, thighs, flanks, and upper arms.

Surgery can be performed all at once or in stages. The decision depends on many factors, including age, weight, overall health, and the amount of tissue that must be removed.

A full torso overhaul takes 5 to 6 hours. Cumulative blood loss is a concern. Women scheduled for three or more procedures as well as liposuction donate at least 2 units of their own blood before surgery. This assures an infection­free supply in case transfusion is necessary.

For women over age 50, surgery is usually done in two stages, with at least a 3 months between operations.

Liposuction, which involves removing fat deposits through a medical “vacuum cleaner,” is an even more accessible form of full­body surgery. It can be done more quickly than more traditional types of surgery and is less invasive.

The various procedures used in body contouring follow the same basic protocol: The surgeon makes an incision, dissects the skin away from muscle and tissues, removes whatever needs to be removed, places the skin snugly back into position, trims any excess skin, and closes the incision.

Abdominal surgery (abdominoplasty, or “tummy tuck”) restores elasticity, tightens the skin over the abdomen, and eliminates stretch marks. Flank surgery corrects flab below the waist and above the buttocks. Surgery on the buttocks makes them smaller, lifts them, removes dimples caused by years of gaining and losing weight, and improves their shape. Similarly, surgery on the thighs and upper arms tightens wobbly skin and removes excess volume with liposuction, which can create an even, pleasing contour. These operations can be performed in any combination. Work on the breasts and abdomen is by far the most popular.

Intravenous antibiotics usually are given during surgery and for up to 5 days afterward. A vacuum drain is placed in the stomach after abdominoplasty to remove fluids. The drain remains in place for most of the hospital stay, which is 3 days or longer.

After breast reduction, abdominoplasty or flank surgery, an elastic girdle and brassiere must be worn for 4 weeks. After liposuction alone, the girdle is worn for 10 days.

Once discharged, you'll stay home for the rest of the week. You may venture out during the second week until you begin to feel tired. Most women can resume their regular schedules, including driving, by the third week. They can swim and enjoy other outdoor activities 4 weeks after surgery and do moderate exercise after 8 weeks. Sunbathing is strongly discouraged for 4 months. The abdomen can develop a severe burn if exposed to direct sunlight before this time.

Making Your Decision

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As you can see, plastic surgery is not something to undertake lightly. A facelift will disrupt your life for weeks or even months as you progress to full recovery. Work on your nose could take as long as a year to heal completely. In spite of it all, however, more and more women have decided that the prospect of many years of better looks and greater self­confidence outweighs the temporary pain and inconvenience they know to expect.

Is it right for you? Only you—and your doctor—can ultimately decide.