Mommy Makeover Manual

Choosing Your Surgeon

Beyond the decision to undergo surgery in the first place, choosing your surgeon is possibly the most important decision when it comes to a Mommy Makeover. There are a large number of surgeons who are performing Mommy Makeovers. However, not all of them are necessarily the same. As such, it is a field that requires careful navigation. Below are some crucial points to evaluate before choosing your Mommy Makeover surgeon.

Is your surgeon a “cosmetic surgeon” or a “plastic surgeon”?

While these two terms are often thought to be the same, they are not. Due to marketing, this field can be very confusing. People use the terms cosmetic, aesthetic and plastic interchangeably while they are absolutely not. It is crucial to understand the distinction between these terms in order to make an informed decision about your surgeon. Unfortunately, just because a patient's friend had a successful outcome, it does not mean that surgeon will reproduce those same results. One or two successful results does not guarantee high quality work in a reproducible fashion.

The term aesthetic surgeon has no real meaning. Aesthetic surgery is not a discipline, it is an adjective. Aesthetic, referring to the world of beauty, is a term that does not distinguish a surgeon's qualification by any means. It simply means the surgeries they perform are in the realm of beauty. Therefore, if your prospective surgeon is marketed as an aesthetic surgeon, you must dig deeper as to his or her training and qualifications.

The term cosmetic surgeon is not an officially recognized specialty by the American Board of Medical Specialties. Essentially, it is an unregulated field, despite the fact that it looks very similar to the field of plastic surgery. If a physician is called a “cosmetic surgeon,” this does not mean he has undergone extensive training in plastic surgery. It is possible that he has completed a short fellowship under another cosmetic surgeon, or he may have simply done a series of weekend courses. In either case, he can legally call himself a cosmetic surgeon, and in neither case is he actually a board-certified plastic surgeon. Dr. Rahban has treated countless patients who received a botched surgery, all because the surgeon was not properly trained in plastic surgery. For this reason, it is of critical importance that your surgeon is board certified in plastic surgery.

When a surgeon is marketed as a “board-certified cosmetic surgeon,” patients often become confused. The truth is, there is no such thing as a board certified cosmetic surgeon, because the field of “cosmetic surgery” is not recognized by the American Board of Medical Specialties. The term “board-certified cosmetic surgeon” is an illusion created to give the impression that someone is a board-certified plastic surgeon. So how is this possible?

For the sake of illustration, let's take a physician who is trained in an entirely separate field. Perhaps he's an OB/GYN, ENT, orthopedic surgeon or even general surgeon. He completed his original training in this field and became board certified. At a later date, he decides he wants to perform aesthetic surgery. He gets some kind of training, hopefully, and calls himself a cosmetic surgeon. Therefore, if your surgeon is a “cosmetic surgeon,” you must ask him what field he is originally trained in.

As a side note, there is an organization called the American Board of Cosmetic Surgery. However, this organization is unrecognized by the American Board of Medical Specialties. If a surgeon is a “board-certified cosmetic surgeon,” this shouldn't hold very much weight.

Patients often ask how this is possible. Isn't anyone regulating this? Unfortunately, there is no larger authority overseeing these surgeons and preventing them from doing things they are poorly trained to do. In the US, once you are trained in surgery, you can do anything you want in the privacy of a surgery center. There is no larger, regulatory board that oversees all surgeons to make sure they deliver only procedures they are qualified to deliver. Because of this, it is incumbent on each patient to do her homework and decipher the true qualifications of her surgeon. This includes checking their training, reading their reviews and looking for malpractice suits.

Patients should not be deceived by official looking letters following a cosmetic surgeon's name in advertising. In many cases, these titles are self-regulated and self-created. In the world of cosmetic surgery, such things often have nothing to do with plastic surgery. These titles are created by the cosmetic surgery community at large and are not regulated by the ABMS, which is the most well-respected organization since the conception of medicine.

Once you've determined if your surgeon is a plastic surgeon, the next level of distinction is discovering board certification.

Is your surgeon board-certified by the American Board of Plastic Surgery?

To become a plastic surgeon in the US, a surgeon must complete either an entire general surgery residency followed by a plastic surgery fellowship, or directly complete an entire plastic surgery residency, after which time he or she is a plastic surgeon. On average, this takes between 6 and 8 years. Once they have completed their training and are in practice, they have the opportunity to sit for their board certification. This is an additional examination, which further scrutinizes their capabilities and is one more measure by which you can determine your surgeon's qualification.

If your surgeon is board-certified, it doesn't 100% assure you that your surgeon is excellent, but it is the single best measure that your surgeon is well trained. You must still do your diligence in investigating your surgeon based on his patient reviews, as even board-certified surgeons can be bad surgeons. In today's world, there is a sufficient number of board certified plastic surgeons who are well qualified and are good surgeons, causing no reason for a patient to compromise the quality of her surgeon.

While you can certainly ask your surgeon directly, you can also visit the American Board of Plastic Surgery website to verify his or her membership.

From the American Board of Plastic Surgery website:

“The mission of The American Board of Plastic Surgery, Inc. is to promote safe, ethical, efficacious plastic surgery to the public by maintaining high standards for the education, examination, certification, and maintenance of certification of plastic surgeons as specialists and subspecialists.”

As such, all physicians who have earned board-certification in this prestigious board are subject to continuous scrutinization. They have demonstrated a stable record of outstanding results and satisfied patients.

Does your surgeon spend enough time with you?

If your consultation feels rushed or lacking in care or succor, it may indicate the level of care present in the operating room. While plastic surgery is elective, it is still a major surgery, and surgeons should show the care and bedside manner that's warranted. When it comes to your surgeon, you want someone who is going to be there for you from beginning to end, and even long after surgery is over. Your surgeon is your partner in the plastic surgery journey, and you should feel 100% comfortable and trusting.

Your consultation should be done by your plastic surgeon and not by his staff, such as his patient coordinator. Many times patients are offered free consultations, but you must understand that generally means you'll get a hurried or inadequate consult. As a point of reference, Dr. Rahban on average spends up to an hour with each patient, reviewing not only what the patient came in for, but also explaining all the nuances such as the risks and alternatives to what that patient has requested. There is no way to accelerate the dissemination of knowledge when it is so complicated and crucial.

Examine your surgeon's before and after photos

At the end of the day, plastic surgery is all about a good cosmetic result. Unlike other medical specialties, plastic surgeons cannot hide their results. Therefore, patients should be able to obtain a decent idea of the surgeon's overall skill prior to selecting him.

When looking at a surgeon's before and after photos, here are some pointers:

• If your surgeon only has a few photos, be wary. Any well qualified surgeon with extensive experience should have multiple photos of each procedure in his gallery.
• Be wary of surgeons who have a poor quality of photos. This is often a reflection of how they approach all aspects of their care.
• Beware of flash photography, as this can disguise contour irregularities that may exist in patients who have undergone liposuction or other body contouring procedures.
• Do not become enamored by any single result. Many patients will come in holding onto one photo of a breast as if it's a sofa they're ordering from IKEA. You need to see many good results in order to feel con dent that your surgeon and you have the same aesthetic goals. If a surgeon only has one result that you like in his entire gallery, it is unlikely that he will be able to reproduce that result again.
• Surgeons are like designers. They generally have a style and an aesthetic. And it is crucial that you find a surgeon whose overall body of work you like.
• Unfortunately we do live in a world of Photoshop, and there are surgeons who are unscrupulous. If you see no scars on any patient, this should be considered suspect.

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Mommy Makeover Scars - The Healing Journey

Prior to a Mommy Makeover, many patients' reluctance to undergo surgery is rooted in a fear of having unsightly scars. For many, the concern is exchanging one physical deformity for another and hence not feeling like it will actually regain their self confidence. With any surgery, scars are an inevitability. However, with a skilled and fastidious surgeon, the visibility of scars can be minimized almost completely.

In most cases, wound healing is very predictable--the healing process is very similar from one patient to the next. There are mild variations, but most patients stick to the same basic timeline. This healing journey is covered below.

The Healing Journey

During the first one to three weeks, provided your surgeon closes you well, your incision will be very thin and narrow. This is known as the inflammatory phase. The edges have been brought together in a precise fashion, and it usually looks very secure. At this stage, however, the incision has not even begun to heal, and if enough force were applied along the wound edges, the wound would separate.

Between three weeks and six months after surgery, the body moves into the proliferation phase. This is the time you will have scar tissue formation and new blood vessel regrowth. This is your body welding itself closed. It is normally during this period of time that the incisions become redder, thicker and firmer. Patients often also note some itching during this period of time.

Finally, between six months to two years, your incisions will transition into the remodeling phase. During this time, your incisions should gradually become flatter and lighter, and in the best of scenarios, become very difficult to see. This is due to your collagen or scar tissue rearranging itself in a more organized fashion, hence the name remodeling.

How to Achieve the Ideal Scar

Now that we've described the natural progression of wound healing, let's discuss the difference between a desirable scar and a poor scar. People are often misled to think that plastic surgery means no scars. That is not the case. All surgery, including plastic surgery, will leave you with scars. The goal of good plastic surgery is to leave you with scars that fade over time and are very difficult to see.

While many patients are led to believe that bad scars or unsightly scars are a result of their own biology, this is usually not the case. All too often, Dr. Rahban sees patients who come to him for revisional work with unsightly scars who have been labeled as poor healers or keloid formers. Over years of doing scar revisions, it became apparent to him that, when these patients did not form these scars again, the issue was not their biology but their poorly done surgery. Certainly in some cases a patient will make thicker scars than other patients, but they represent the vast minority of patients.

So what are the factors that lead to a desirable scar? There are many things that your plastic surgeon should do in order to optimize your wound healing. These things include:

1. Treating your skin or tissue delicately while performing surgery. Remember that whatever is cut has to eventually be closed. If, during surgery, your tissue is either damaged from mishandling or cauterization, the wound edges will become inflamed and heal poorly.
2. Removal of excess tissue either during breast lifts or tummy tucks will lead to too much tension between the edges of the incision. Your body's response will be to create more scar tissue to hold things together. Because of this, it's crucial that your surgeon remove the correct amount of tissue as well as place multiple, deep stitches to offset the tension on the skin edge.

3. Low grade or overt infections of the wound will lead to increased inflammation and later thickened scars. It is imperative that your wounds be properly irrigated during surgery, and you have appropriate post-operative wound management.

4. Minimizing strenuous activity for the first six weeks reduces unnecessary tension on your scars. Remember, as the body begins the proliferation phase, it is responding to the tension on your wound edges to determine how much scar tissue it needs to create. The more tension the body feels along the skin edges, the more cement, or scar tissue, it will form to weld your scar together. Early strenuous activity tells the body to create a greater, thicker scar as it's undergoing more tension.

5. Accuracy of closure of the final skin layer of an incision. While the deeper tissues have to be realigned accurately, the final layer of skin is the most crucial in the prevention of scar formation. Many times surgeons close the skin in a rush, with the skin edges not perfectly aligned, leaving the body to correct the gap. The body only has one form of healing, and that is through scar formation. Therefore, the more accurate the skin closure is, the less burden is placed on your body, and the less scar tissue is formed. When Dr. Rahban closes the final skin layer, he does so in two additional layers, whereas many doctors only close with one layer.

Dr. Rahban's Compulsive Closure

As mentioned above, one of the most crucial elements for a desirable scar outcome is how the wound is brought together. Once a tissue is incised, many layers have to be separated from the skin all the way down to the muscle layer. When a wound is closed, it is imperative that the same layers that were initially opened are brought back together. While that may seem obvious, many surgeons either omit layers or close them incompletely, therefore leading to less than ideal outcome.

Dr. Rahban's closure technique includes the use of multiple, deep, under-the-skin, absorbable sutures to close the fat and muscle layers, followed by multiple absorbable sutures to close the dermis, hence creating a tension-free skin layer. The final layer is re-alignment of the skin itself. Because there are so many absorbable sutures placed deep, Dr. Rahban can use permanent sutures to close the skin, as he will be removing them within a week. He uses these permanent sutures to fine-tune the edges, leading to minimized scar formation.

Since the wound is not relying on these outermost stitches for integrity, he is able to remove these stitches after seven days without any separation. He uses permanent sutures because they are less inflammatory than absorbable sutures and lead to less scar formation. This is a time consuming process, both to place the sutures and to remove them in the office. The reason many surgeons do not do this step is because it requires lots of time in the office to remove these sutures.

Additionally, Dr. Rahban firmly believes that the surgeon himself should be the only one closing the patient. While this may seem obvious, it is far from the case in today's world of aesthetic surgery. More often, the scrub technician or an assistant surgeon, unbeknownst to the patient, will assist during closure. This is done in order to accelerate the time of surgery, hence increasing profit for the surgeon. Dr. Rahban will only do as much surgery as he can himself close.

What Actually Works

So much emphasis today is placed on wound management once a bad scar is formed. As you have read above, Dr. Rahban's philosophy regarding scars is focused on prevention rather than treatment after the fact. However, many patients feel strongly or have been sold on the idea that there are special creams, potions or lasers that can make their scars better. Dr. Rahban is very academic about the way he practices medicine. He is a big believer of science and evidence-based medicine. As such, the overwhelming majority of scar management treatments today have no evidence that they work. There are only several things that do actually work, and these are as follows:

1. Massaging scars. This is the cheapest and probably the most effective method of wound management. As we mentioned above, during the proliferation phase, the body is placing collagen and scar tissue in a disorganized fashion. By massaging, you are telling the scar to reorganized into a more narrow arrangement. This leads to a more desirable scar.
2. Avoiding sun exposure for nine to twelve months is crucial, as the scar is very vulnerable and reactive during this period of time. Unnecessary sun exposure will lead to formation of pigment and darkening of your scar.
3. High grade medicinal silicone, either in the form of sheets or creams. Historically, doctors used silicone sheets in the area of burn care. Patients who are burned often make the worst scars, and a lot of the science in wound care comes from those patients. The science is a little bit unclear as to why silicone works, but we know that it definitely helps with scar management. As silicone sheets are difficult to wear, we've now advanced to liquid silicone which can be applied on the wound. It is crucial to understand that liquid silicone is merely a small adjunct to wound management and can definitely not take the place of good surgical closure.
4. Steroid or kenalog injections. Be very careful when it comes to injecting scars with steroids. While many surgeons and dermatologists routinely do this when a scar begins to thicken, it is extremely risky. Steroids are intended to change the biology of the wound healing process, reducing the amount of scar formation. However, this process is incredibly inaccurate. In addition to thinning out undesirable scar formation, steroid injections are notorious for causing damage to surrounding healthy tissue. This is most commonly seen by thinning out or atrophy of adjacent tissue like skin and fat. Dr. Rahban has had many patients present to him after their surgeon or dermatologist injected them with several rounds of steroids, only to be much worse than they were prior to the injections. Dr. Rahban seldom injects steroids in scars for this reason.

Scar Myths

Lasers. Daily, Dr. Rahban hears patients coming in for revisions, asking if lasers can improve their scars. Despite marketing and mass media, the effect of lasers on unsightly scars is limited or none. They may help slightly with wounds that have color issues, as lasers are designed for pigmentation issues. They will not, however, help with thick or wide scars, as that is not what they are designed to do.

Mederma. Mederma is a very well-known scar cream being sold with thousands of claims. There is no real science that has proven that Mederma has significant clinical benefit. Understand that all scar creams will show you before and after photos with scars that appeared unsightly and became thin. Remember that if nothing had been done, those scars would most probably have improved without the treatment over time. Therefore, the claims that the ointment produced that effect is unsubstantiated. In order for a cream to be proven to work, they need to compare it with controls, which very few manufacturers are willing to do.

All other lotions and potions. Just like Mederma, there is no actual proof that ointments or creams are effective in minimizing scars. For this reason, we cannot stress enough that you vet your surgeon to ensure his closing technique is exquisite. Closure of your incision is the number one factor in scar prevention.

All in all, Dr. Rahban believes strongly that the only two elements that are relevant in your wound healing are:

1. Your surgeon and his skill
2. Your biology

As your biology is not within your control, and as Dr. Rahban mentioned, most people's biology is favorable, then the only thing you can chose is your surgeon. All too often, patients forego the skill of their surgeon in hopes that some special scar management treatment will help them get the results they want. In reality, ninety-nine percent of their outcome is determined by their surgeon's closure technique.

Don't be fooled by surgeons who tell you that they have a post-surgery scar management protocol. That is all marketing. All too often, patients are misled to think that their doctor has some special scar management technique that allows him to get great results, when in reality there are very few things, other than his own technique, that have been PROVEN TO WORK. This technique is to get a leg up on another doctor, giving the impression that he has a treatment that no one else has. It doesn't exist except to close the deal.

What to Ask Your Doctor

At Beauty After Baby, our purpose is to give mothers the power of knowledge. When you visit a prospective surgeon, it's important to be armed with plenty of questions. Below are questions as they relate to individual procedures. To learn more about each procedure, please visit beautyafterbaby.com.

General Questions

Do you close my incision or does someone else?

In closing an incision, Dr. Rahban carefully sutures each underlying layer from the inside out, maximizing support. It is crucial that your surgeon personally closes all incisions, as there are some plastic surgeons who allow a surgical tech or surgical assistant to close.

Do you use layered closure? Tell me about your closing technique.

Closure of incisions can be as simple as staples and/or glue, and as complex as a multiple-layered technique. Dr. Rahban feels strongly that closing the skin with multiple layers in a fastidious fashion is the single most important step in having scars that will be minimal and that will ultimately fade over time.

An enormous number of deep sutures which are absorbable are placed in order to reduce tension on the skin. The less tension on the skin, the less thick the scar will be. Additionally, there are multiple, permanent sutures placed within the skin that will be removed at two weeks in order to align the skin edges, giving the most optimal outcome.

Do you offer a second consultation prior to my procedure?

Every patient goes through a thorough pre-operative process. This begins with a pre-op visit two weeks prior to surgery. This is similar to a second consult. During this time, you will go over the details of your surgery with Dr. Rahban, and you will get a second opportunity to ask questions and go over your procedure, thus ensuring a complete understanding.

How many follow-up appointments do we have?

After a Mommy Makeover, Dr. Rahban schedules a total of five follow-up appointments. Most plastic surgeons schedule two follow-ups, during which time you may not even see the doctor. During every follow-up appointment, Dr. Rahban sees his patients personally. He generally sees you at one week, two weeks, six weeks, three months and one year.

Breast

Breast Augmentation

Do you perform dual-plane breast augmentation? Am I a candidate?

With the dual-plane approach, the implant is under the muscle, yet the muscle is released or moved out of the way so the implant can settle into the bottom half of the breast, filling it in a more natural way. This technique tends to be Dr. Rahban's preferred approach.

How do you help me determine size? Do you use sizers during surgery?

One of the most common causes for unhappiness after breast augmentation is inappropriate size. Many patients are disappointed as they did not receive the size they are requesting. This is because there is no ideal way pre-operatively to determine cup size. Most doctors utilize bras filled with implants, rice or peas to determine size. This is obviously very inaccurate, as the ultimate goal is not based on CCs or a cup size, but rather the aesthetic outcome.

Dr. Rahban uses a unique technique, whereby he has you select photos of breasts that you feel are slightly too small, slightly too large, and ideal. He then places these photos in the operating room during your surgery and uses multiple sizers during surgery, sitting you up and down until you look like the photos you have selected. This requires time and energy by your surgeon but leads to a much higher satisfaction rate, as there is no certainty to the exact size before. Dr. Rahban uses a measurement system measuring your breasts exactly and only using implants that fit your measurements.

Do you sit me up during surgery so you can see how the implants naturally sit?

At this point, he will refer to the photos you have given him, and will insert the size of implant he believes will accomplish the goal. He will then sit you up while you are asleep and look at the photos and compare to determine if the size is correct. If need be, he will repeat this procedure with various sizers until he feels confident that your size is consistent with what you selected, and that both breasts are symmetrical in size.

Do you have a full consignment of all sizes of implants in your surgery center or do you bring specific implants?

Dr. Rahban has the entire range of breast implants on consignment in his operating room, so he does not need to guess preoperatively which implants to bring during surgery. Dr. Rahban does not try to determine the exact size of your implants before surgery, as he is aware there are nuances that occur during surgery. He uses sizers to determine what is best for you and is not limited by the implants that he brought to surgery by speculation.

Do you use a Keller Funnel?

When inserting silicone implants, the implant is large and the opening is small, requiring force to insert the implant into the pocket. This jeopardizes the integrity of the implant, and often causes damage to the skin around the incision. Dr. Rahban uses a product called the Keller Funnel™ which is a device that facilitates the insertion of the silicone implant into the pocket with great ease. This is a one-time-use device and he absorbs the cost himself, as he feels this is paramount in achieving a good result.

Breast Lift

Do you mark my breasts prior to surgery or do you wait until I am lying down?

The most crucial step in a breast lift is marking the breasts prior to surgery. The markings will determine how well the surgery is performed in terms of symmetry and overall shape. Some physicians do the markings during the surgery. However, Dr. Rahban finds this to be incredibly inaccurate, as patients are lying down and their breasts are not sitting naturally.

How do you make sure your markings are accurate before proceeding with surgery?

Next, prior to making any incision, Dr. Rahban likes to confirm that the markings done preoperatively are accurate. Therefore, with the patient asleep, he will temporarily staple his markings into place and sit the patient up, looking at each breast for its own shape as well as symmetry between the two.

Breast Reduction

Do you use the superomedial pedicle technique or do you use a different pedicle?

The most common way that breast reductions are done in America is with an inferior pedicle technique. The term “pedicle” refers to the blood supply. In this technique, the upper breast tissue is removed, leaving behind the heavy lower tissue. This often leads to bottoming out and deficiency of the upper breast area post-operatively. Dr. Rahban does not like this technique for this reason, and therefore uses a different technique called the superomedial pedicle technique. This technique preserves the upper breast tissue while removing the lower, heavy breast tissue, leading to a better looking breast that lasts longer.

Can this be done using my insurance? If so, what is the minimum breast tissue you need to remove? Will my breasts will appear attractive?

Cautionary note: Make sure that your breasts are not over-reduced in an effort to meet insurance guidelines. Many insurance companies have strict volume reduction requirements in order for you to qualify. Some doctors may remove too much breast tissue in an effort to meet these requirements, leaving patients with breasts that lack fullness.

Is the size that I'm asking for still going to have a round and attractive appearance? Or will it look boxy and flat?

Often, patients will tell their surgeon that they would like to be a small C, and to their dismay, when the swelling settles and 6 months have gone by, their breasts look wide and flat, not small and round like an attractive breast. This is the result of over-reduction.

In many cases, breast reductions are considered solely from a size perspective and aren't approached with the same aesthetic consideration as other cosmetic procedures. Doctors may feel that a patient with smaller breasts will be happy irrespective of the shape, as the primary goal is reduction in volume. However, without proper markings, patients may find their breasts are boxy or misshapen after breast reduction surgery.

Can you maintain my scar within my crease?

Some surgeons are not compulsive with their markings preoperatively and rely on adjusting markings during surgery. Often this requires them to extend the incision into the armpit or the cleavage, hence making scars that are visible and destroying the result. It is crucial that your surgeon spends ample time marking you preoperatively and adhering to those markings.

Do you sit me up during surgery to ensure the proper size and symmetry and how many times?

In the operating room, patients' arms should be safely secured on arm boards, allowing them to be safely sat up during surgery. One of the main methods to ensure accuracy and attractive outcomes is sitting the patient up multiple times throughout the surgery. While this may take extra time for a physician, this critical step allows for him to see the progression of his breast reduction and create symmetry.

Breast Revision

What is my exact diagnosis? How will you fix it?

With a vast amount of experience with breast surgery, Dr. Rahban has seen all types of breast complications. The key with breast revision is correct diagnosis. Your surgeon must know what the problem is in order to give patients the correct options. As the breast tissue is no longer 100% normal, it is unforgiving and therefore an error in diagnosis will lead to a very poor outcome and make further revision even more difficult.

Will my breast revision require the use of extracellular matrix? Have you used it before? How many times?

Extracellular matrix (ECM) is tissue from other sources, removed of all its cellular components, leaving behind a matrix or scaffolding of tissue. Your surgeon needs to be familiar with not only the various ECM products, but also how to use the material effectively. Unfortunately, this material is still quite expensive, and therefore should only be used when truly necessary.

If I have capsular contracture, will you perform a complete or partial capsulectomy?

The correction of capsular contracture requires either a capsulectomy or capsulorrhaphy. Dr. Rahban's preferred approach is a complete capsulectomy. This involves removal of the entirety of the scar tissue, hence creating a brand new pocket without any of the old scar tissue.

How do you perform my scar revision?

Unfortunately, unsightly scars are a very common problem following breast surgery. All too often, patients are told that the cause for their unsightly scars is their poor healing, when in reality it was due to poor closure. In this instance, your surgeon would need to excise all of your scars and re-suture them using a multi-layered closing technique.

If I'm reducing my implant size, do I need a lift? Which kind?

Correction of large implants may involve not only exchanging to a smaller implant, but may necessitate some type of lift procedure. When an implant is downsized significantly, the breast is left with excess tissue that, if not addressed with some type of lift, would lead to sagging.

Have you used the neo pocket procedure for correction of symmastia, double bubble or lateral displacement? How many times?

In order to correct symmastia, double bubble or lateral displacement, there is a new and advanced technique called a neo pocket procedure, whereby your surgeon will create a new implant pocket above the old capsule that is smaller to accommodate the actual size of the implant.

Inverted Nipple Correction

What technique do you use for inverted nipple correction?

Because inverted nipples are usually caused by some kind of tethering, the corrective surgery usually involves releasing the fibers that keep the nipples inverted. This begins with an incision at the base of the nipple to access the ducts or fibrous tissue that is holding the nipple down. From there, tissue is rearranged in order to allow for improved nipple projection. Finally, the incision is closed with precise sutures that create minimal scarring.

What do you do to maintain the erect position during the healing process?

Special care is then taken to maintain the nipple in the erect position during the healing process. Dr. Rahban uses a special technique to keep them projected. This is crucial, as the nipple has a tendency to retract during the early healing phase.

Nipple and Areola Reduction

Which technique do you use for reducing my nipples?

Most commonly, Dr. Rahban addresses enlarged nipples by using a telescoping technique, in which he removes redundant tissue at the base of the nipple, allowing him to set back the nipple into the areola. With this approach, the nipple retains sensation and breast milk production. If a nipple is too large, he uses another technique called the transection technique whereby the nipple is reduced from the top down. With this technique, sensation and breastfeeding may be altered.

What's your technique for reducing the areola?

In reducing the areola, Dr. Rahban makes an incision around the areola in the size that he would like. He then makes a second incision around the residual pigment that is larger than the desired areola. He then removes the intervening pigment and subsequently closes the outer incision using a pursestring technique with a permanent suture. This allows the overall size to be significantly smaller and permanent. If a permanent suture is not used, your areola will stretch out again.

Body

Tummy Tuck

Will the length of my incision fully address all excess skin and avoid a dog ear?

A tummy tuck is not about the length of the incision, but rather the contour of the abdomen. A shorter scar with poor contours is not better than a slightly longer scar with smooth and beautiful contours. If the scar is too short, residual tissue will be left on the outer side of your abdomen, creating a lump, also known as a dog ear.

Do I have enough extra skin on my flanks that I require an extended tummy tuck, or is a standard tummy tuck sufficient?

In many cases, pregnancy can cause a buildup of loose, excessive skin that extends beyond the abdomen. When loose skin can be seen on the flanks in addition to the tummy, an extended tummy tuck is the correct procedure to eliminate excess skin and tighten the underlying musculature.

Do I have rectus diastasis? Is it severe enough that I need a standard tummy tuck or is a mini tummy tuck sufficient?

As the belly expands during pregnancy, it does not only affect the outer skin—it also stretches the underlying abdominal muscles, known as the abdominal fascia, hence creating rectus diastasis. When this occurs, the muscles tend to bulge outward, creating a pooch and unflattering appearance. That being said, during a mini tummy tuck, the muscle separation is often not addressed or addressed incorrectly, making the abdominal contour worse.

What percentage of my stretch marks can I anticipate will be removed with my tummy tuck?

When it comes to the stomach, stretch marks are an extremely common problem. There is no treatment that has been proven to reduce stretch marks, beyond surgical removal of the offending skin. If your stretch marks fall within the area being excised, they will be removed.

What will you do with my mons during my tummy tuck?

During your tummy tuck, Dr. Rahban will rejuvenate the pubic area and the mons. Plastic surgeons will often ignore the pubic region, leaving it sagging and puffy. They only rejuvenate the abdomen and reattach it to a puffy mons. With every single tummy tuck, Dr. Rahban rejuvenates the mons or pubic region. He removes excess fat from underneath the mons and removes excess skin. He then lifts up the mons and re-secures it to the abdomen, creating a younger looking pubic area.

Liposuction

Do you believe my skin will be smooth and tight after liposuction?

Liposuction candidates should have good skin elasticity, which will allow it to conform to the new, slimmer contours. If this is not the case, liposuction will produce some improvement, but at the same time will make you look worse, as the fat underneath the skin is what's holding the skin tight. Quite often after having even one child, a woman's skin has lost enough elasticity to make her a relatively poor candidate for liposuction. Remember, the goal is not slimmer, but tighter.

How many access points do you use for my liposuction? How do you close the cannula sites?

The key to liposuction is using multiple access points--from which the cannula will remove fat--rather than one. While at first patients are concerned about the number of incisions, it's more important that the target area get addressed from multiple areas so the contour is smooth. When closed well, incisions should heal with a minimal scar. Make sure that your surgeon closes your cannula sites in a multiple layered closure just like your tummy tuck, in order to prevent unsightly scars.

Do you use a basket cannula to equalize the fat?

After Dr. Rahban is done removing the fat, he goes back with a special cannula called a basket cannula that equalizes the remaining fat. Because fat is solid or semisolid, it is removed in globules rather than a flowing stream. The remaining fat doesn't naturally fill in the removed globules. By breaking up the remaining fat with the basket cannula, Dr. Rahban helps it to settle in a natural, even contour.

What do you do during liposuction to preserve my superficial layer of fat?

In order to accomplish smooth contours, you need to leave behind an upper layer of fat that's been untouched. The fat is generally divided into superficial and deep layers. The fat in the deep layer is the fat that should be removed, leaving behind the superficial layer untouched as a buffer so your skin looks smooth.

If you perform liposuction of my love handles, what position am I in when you do it?

If a patient is undergoing a tummy tuck, surgeons may say their waist won't look good without liposuction. Dr. Rahban feels this is often simply an upsell and is not actually needed. If liposuction of the flanks is to be performed, he believes it must be done with the same cosmetic forethought as the tummy tuck itself.

Many doctors will perform liposuction of the flanks as an afterthought, with the patient lying on her back. This is not ideal. The correct way to perform liposuction of the flanks is to start patients on their stomach, perform the liposuction, then turn them onto their back for the tummy tuck.

Labiaplasty

What steps do you take to ensure that my labia are not over-reduced?

The labia will be marked prior to any infiltration of local anesthetic. The markings are the most crucial element. Since the labial tissue is stretchable, the biggest error with labiaplasty is over-resection. Surgeons may pull too hard on the labia when marking, therefore thinking there is more tissue than there actually is.

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