Today in my Beverly Hills Office I saw a 30 year old woman who wanted a fresher look. Many men and women will tell you that they just are starting to look older, but it is difficult to pinpoint the area(s). Well, good news. Skilled plastic surgeons can tell you, and turn a general request into very specific treatments. For one, I always evaluate the skin. With age, pigment changes begin. That is, the skin gets irregularities in color. Sometimes a mild bleaching agent will improve this. These agents are generally much less expensive than lasers. Next, is the skin texture. With age, large pores and fine wrinkles develop. This is where something like Retin-A and Botox help. Lasers may work also, but often these two products alone do wonders and can save patients hundreds of dollars and multiple trips to the office. The next thing I look at is shadows generated by descent of tissue and volume loss from the bottom of the face up. Areas that make someone look old in the lower third of the face are the shadows below the corner of the mouth, the area just in front of the early jowl, and the upper and lower lips which lose its curl and volume. These areas are easily filled in the office with Juvederm or Restylane. The upper lip also elongates with age to hide the upper teeth with parting of the mouth at rest. This looks old. An easy fix to this is a lip lift which can be done in the office. Lip augmentation is often necessary to restore young lips.  Poutiness can be restored to the lips by injected simply the middle third of the lip – extending injections toward the corner of the mouth impart a trout-pout fake look. We’ve all seen it. Middle third of the face aging is marked by deepening of the laugh lines, also called nasolabial folds. An easy quick way to soften the middle third of the face is Juvederm or Restylane injections into this region. Moving upward, the areas below the eyes tend to follow out with age giving a tired appearance to the face. Juvederm or Restylane into this region freshens the face, and tends to look very, very natural. Lastly, with age, is the generation of an upside down heart-shaped face- bottom heavy, if you will. Thus, I like to inject high on the cheek bone just a pinch to build out the arch of the cheek bone. It is subtle, but significant, and imparts a mild shadow below the cheek bone that looks very attractive.  Ultimately, at some point, the amount of Juvederm needed to optimize correction of shadows and add volume become unrealistically expensive and impractical.  This is where fat grafting has a role.  Fat can be taken from an unwanted area such as the hips and flanks, and injected into the deepest shadows of the face such as the temples, the orbital hollows, under the eyes, lips, jaw line, and cheek bone.  I often inject up to 50 cc in a face, which is the equivalent of over 60 Juvederm syringes.  The results of fat grafting are dramatic and very natural looking.  It is one of my favorite operations.  For a recent fat grafting before and after, click on this fat grafting link.

In my Beverly Hills, Glendora, and even now in the Dubai offices, I do quite a bit lip augmentation with Juvederm. I would state that half of the patients I am seeing now never had lip augmentations. As such, this blog is devoted to the lip augmentation newbies.

Some of the most common questions are how long will it last and will it hurt?  I’ll address those questions in a bit.  Let me entice you first.   I like to use Juvederm Ultra or Juvederm Ultra Plus. These are both hyaluronic acid fillers similar to Restylane. The Ultra Plus has lidocaine in the syringe. Thus there may be added comfort to using this product, but it costs a bit more. Generally, Juvederm in the lips last approximately six months. However,  some people note that the fullness is retained longer. I am not sure if this is related to prolonged Juvederm life or just a remodeling of the tissues from the injection.

“Is this going to hurt?”.   Well, a little. There are ways to alleviate the discomfort of these injections. Some of them include nerve blocks similar to the one that you get from a dentist. These are done prior to injecting the lips which are much more sensitive than the cheek and the mandible where the nerve blocks are performed. Two is topical cream. This could be applied to the lips. This probably has a minimal relief with topical application of lidocaine cream. Some people use ice to numb the lips. I often use a combination of all of these. Very rarely I have a patient who wants nothing at all and just wants the injection. This is rather courageous and is very atypical.

Then next common question is,  “How much Juvederm do I need?”. Well, that depends on what kind of augmentation you desire. As a rule, the smaller the lips, the less volume is needed to make them noticeably larger. Very large lips need larger amounts of products to make a noticeable difference. A common request is patients asking to simply fill their upper lips in order to either save money or because they do not see the benefit of adding volume to the lower lip. This is a big no-no. I have never injected just an upper lip. The consequence of simply injecting the upper lip and ignoring the lower lip is creating a very fake looking lip augmentation. It is important to know that the bottom lip should be 1.5 times the size of the upper lip. But it is not just the volume; it is the shape and curvature of the vermillion border. This is the area between the skin and the lip. When you inject a lip along the border like we do with Juvederm, we curl it. To curl an upper lip and not a lower lip makes the lips look obviously augmented. In addition, there are certain aesthetic units of the lip which should be injected and certain areas of the lip that should not be injected. Violation of these aesthetic lip units (like the midline of the lower lip) can create an unnatural appearance. In addition, the injection should not extend beyond the middle third of the upper lip. As the injection moves towards the corners of the mouth, a trout pout develop. This is another big no-no. I generally explain all of this to the patient before we conduct a lip augmentation.

2012 is here. This blog is devoted to prediction regarding upcoming trends for the New Year in Beverly Hills plastic surgery. Indeed, even the econonic crunch has made its impact in Los Angeles.  Virtually every honest Beverly Hills plastic surgeon (yes, there are plenty) will tell you that their volume is down from 2007.    In 2012, for one, I think we will start seeing an improving economy.  Perhaps banks will be less stringent upon loaning money, and people will have more money to spend on plastic surgery procedures such as breast augmentation, tummy tuck, face lift, rhinoplasty, and fat grafting, etc.

Beverly Hills plastic surgeon Dr. Tim Neavin looks forward to a great year, predicting that the growing trend of injectables will continue, and banks will get looser in lending money, etc. There was a time when clients would take a home equity loan out to finance their new body. Now, getting second loans have been very, very tough. Carecredit is a rather helpful company that provides financing to plastic surgery patients at a reasonable rate.

The lousy economy from 2008-2011 has been an important lesson for Beverly Hills plastic surgery.   Patients have moved towards using a lot of the injectables such as Botox, Restylane, Radiesse,  and Juvederm. We have learned that these products not only work well, but when you use them regularly on patients, it is rather easy to maintain beauty.  And products like these alone can make men and women happy.    After all, beauty IS maintenance.   Injectables like Botox every four months and Juvederm every 6 months is something that many men and women just accept, now.   And so it is likely that this of more injectables and less surgery for the face will continue because patients have found out how magnificent these products actually work in rejuvenating the face. And when used properly, the results of Juvederm and fat grafting are incredibly natural looking.

As far as our office is concerned, we will be structuring new financing programs for patients for breast augmentation, tummy tucks, face lift, rhinoplasy, and various plastic surgery procedures. Please inquire with the office for details; however, they have been formulated so that the pricing is very fair and competitive.

Another Beverly Hills plastic surgery trend I think you will see in 2012 is the gaining interest in plastic surgery and Botox and Juvederm for male patients. Most common procedures for male patients in my practice include Botox, Juvederm, rhinoplasty, liposuction, and facial fat grafting.  These trends will continue, I’m certain. Anyway, those are the Beverly Hills plastic surgery predictions in 2012. We look forward to seeing you in the office!  Happy New Year!

You may be aware of the Beverly Hills breast augmentation that saved a woman in a dentist’s office from a bullet.   She was shot in the chest, and the silicone breast implant took the blow.   If you forgot this story, you can find it here.  But here’s another tale of the breast implant bizarre:

Breast implants come in many shapes and sizes. Breast implants can be big, small, high profile, and moderate profile just to name a few examples. Breast implants may also be made of silicone or saline. The risks and benefits of breast augmentation and breast implants are well known. The upside to breast augmentation is that a plastic surgeon can turn your droopy or flat breasts into a perky C cup (or A or B, to each their own). The downside of breast augmentation is mainly the cost of surgery, and the infrequent risk of complications. Thankfully, life threatening complications from breast augmentation are exceptionally, exceptionally rare. However, there is an apparent advantage to large silicone breast implants that you may have not known about.  And I’m betting you never tried to rationalize dropping several thousand dollars for this one.  Ready?   Did you know that they can save your life?  Well, I wouldn’t sell this benefit by any stretch of the imagination, but it makes for good news.  On  7, 2012, a Russian newspaper Pravda reported that a  woman from Moscow was stabbed with a knife by her  husband, but her life was spared when the knife struck her silicone breast implant, absorbing most of the impact!  Ironically, the woman’s husband asked his wife to enlarge her breasts five years ago.   Just as interesting, the implant didn’t even leak, and the implant (and breast) retained its normal shape.  While I’m not sure that the moral of the story is that big silicone breast implants save lives, or if a Beverly Hills breast augmentation (or a Moscow, St. Petersburg, or any city breast augmentation)  can save your life, or perhaps there is no moral of this most bizarre breast tale.

Aging faces are not just wrinkled. In fact, that’s just a small part of the genesis of physically aging. If we took a 60 year old man or woman, and evaluated their photo, we would certainly see wrinkles.  Perhaps lots of them!   But what if we erased all the wrinkles on the face with the computer? I assure you that wrinkle-free person will still look in their fifties or sixties  Why is that, you ask? Volume loss, and shadows. Think of the fullness of a babies face. Or, look at your own photos when you were a teenager. The face is plump and full.  It is, well, fat.  As we age, we lose fat in our face. Shadows develop. Folds appear. And we look old. So old. Tugging skin back with lifts efface some folds and make one look younger, but often we need to FILL depleted areas.  Tugged faces without fat look just tugged!  Hollowed out areas need to be filled. With what? Juvederm, Restylane, Radiesse. Or, your own, unwanted fat. This is called ‘fat grafting‘, and its results are often dramatic!  Fat grafting is a great way to fill out hollowed areas of an aging face.  Fat grafting works not quite as well in small folds – for folds I prefer Juvederm, Restylane, or Radiesse.  But fat grafting can do wonders for sunken areas under the eyes or enhancing cheek bones.  So, fixing wrinkles, folds, and lines really isn’t a secret.  It just takes a proper evaluation of the problem, and the right person to put the correct product in the right place! For more about fat grafting see this blog devoted to the art of Beverly Hills fat grafting and fat transfer.

When small women want a breast augmentation greater than 450 cc, I do tell them that there are increased problems associated with larger breast implants. Increased complications that can arise from very large implants include bottoming out and perhaps even capsular contracture.  Some capsular contractures require breast revision surgery.  Larger women with more breast tissue can generally support larger implants.  That is, their native breast tissues are likely to be thicker.

However,  thinner women may experience a loss of breast tissue resulting from excessive pressure from an over sized implant (atrophy).  Atrophy is a thinning of the breast structures.  The result may  cause the breast to hang (bottoming out).  Also, it is important to realize that  even though the breast enlargement may “look good” for months after the surgery, the problems with really big breast implants may not develop for years.

Thus,  I usually have patients come to the office on more than one occasion to not only try the sizes of implants on and they go over with the plan again from surgery to postop care. Particularly, if they desire very large breast implants.  Perhaps one of the most important things in breast surgery is the postoperative care and patients are encouraged to be active and massaging their breasts and wearing the appropriate kind of bras to make sure that the implants fall and develop into the beautiful breasts that they want.

Breast augmentation incisions

Beverly Hills breast augmentation, breast enlargement, breast implants, breast augmentation incisions blog: 

Regarding breast augmentation incisions, they can vary from many locations such as the armpit also called axillary approach, inframammary (which is in the breast crease), periareolar, or some people refer to this as around the nipple (although technically it is around the margin of the slightly darker areola), and transumbilical or belly button, referred to as TUBA (transumbilical breast augmentation). Please refer to this page regarding the benefits and disadvantages of all these incisions.

Regarding incision length, many women wanted to know how large is the incision going to be. The most important determining factor in incision length with breast augmentation  is the breast implant size and content. Saline breast implants come deflated or empty. Thus, they can be placed in a smaller incision.

Silicone breast implants already come prefilled with silicone. Hence, placing silicone breast  implants require a larger incision. The length of the incision for silicone breast  implants depends on the size of the implant. Naturally, bigger silicone breast implants require longer incisions. It is not uncommon for a larger silicone breast implant, that is, a silicone breast implant greater than 450 cc could be 4.5 cm in length. Larger silicone breast implants may even require larger incisions.  In fact, a determining factor to incision location is the size of the incision that needs to be placed. Periareolar incisions can typically be as great as half of the circumference of the areola. Thus larger silicone breast implants are difficult to place through the periareolar incision, particularly if the woman has very small areola. Sometimes, silicone breast implants that are forced through smaller periareolar incisions cause scar hypertrophy making the incision once it heals more noticeable.   Trading a smaller, more noticeable scar for a larger one that is almost unnoticable  is generally not a good idea.  Never be sold on promises from someone who boasts they can give you the “smallest incision”.  That may not be in your best interest. 

Regarding saline breast implants, regardless of the size of the implant because they can be inflated, these could generally be placed with incisions as small as 2.5 to 3 cm. The main trade-off, of course, is more realistic (natural) look and feel of saline versus silicone. For more information about this, please refer to this article.

In my Beverly Hills office I saw a man who had gynecomastia, also referred to as man breasts, or as colleague and good friend Dr. Billi Gordon would call them, ‘MWTs” (you can ask him about the meaning of his acronym).  Gynecomastia  is the abnormal development of large mammary glands in men resulting in enlarged breasts.  It is most often seen in male adolescence, and in the elderly.  When it occurs in adolescent boys, for the large majority  the condition the breast development shrinks or disappears within a couple of years.  For young and older men, the causes may be related to several known factors, or no known factors at all!

Although the exact causes of common gynecomastia remain uknown,  it has generally been attributed to an imbalance of sex hormones.  However, for most cases, a definitive cause of the gynecomastia  is not determined for individual cases.  This is often referred to as idiopathic gynecomastia.   Up to to 10%  of gynecomastia cases are due to drugs such as Spironolactone (Aldactone), Digoxin and Furosemide.  Other well known causes of gynecomastia include steroid abuse, obesity, marijuana use (maybe), tumors, genetic disorders, liver disease, and aging.  If obesity is the culprit for the gynecomastia, sometimes weght loss alone can correct it.  If medications are thought to be the cause of the enalrged male breasts, then changes in medication can sometimes resolve the condition.  However, for any people, the only good remedy is plastic surgery.

With both liposuction and excisional surgery, the results can be immediate and fantastic with very little post operative pain and downtime.  And importantly, the results can be permanent.  For more information about gynecomastia, the following is a useful site: http://www.medicinenet.com/gynecomastia/article.htm

Beautiful breasts

One of the most frequent questions I get asked in my Beverly Hills and Glendora office about breast augmentation is down time from surgery.  The best way to answer this I’ve found is to walk the patient through the process.  Generally, breast enlargement surgery takes about an hour and a half.   Women are asleep with general anesthesia and will go home the same day of surgery with specific wraps around the upper pole of the breast. I generally see patients the next day in the office and then again the following week. During the second visit, women are instructed to massage their breasts.  Massaging can accomplish two things.  One,  it can reduce the rate of capsular contracture which is a hardening of the tissue around the implant, and two, it can perhaps encourage the breast implants to drop. They are also instructed on how to wrap their breasts to encourage implants to facilitate this dropping.  When do breast implants drop?  It really depends.  See this blog that addresses this question.

Regarding exercising, I generally ask women to not do anything vigorous for at least two weeks after breast augmentation surgery. The reason for this is that you do not want their heart rate or blood pressure going up and the postoperative setting, because this can cause a bleeding episode inside the breasts. With a submuscular breast implant placement where part of the muscle is surgically  detached from sternum, it is critically important to make sure patients understand to take it easy with their arms. I generally ask patients to not lift anything heavier than a gallon of milk for the first few weeks. They are instructed to not go to the gym for at least four to six weeks.  However, women can return to the normal job within one week of surgery as long as they are not doing any strenuous activity.

In addition, I instruct patients after breast augmentation that I do not want their arms above the level of their shoulders for the first two weeks. Thus, I ask them to wear button-down shirts to make it easy to remove their clothes without violating this rule. Overall, recovery for breast augmentation

is also very uneventful and easy with no major inconveniences.  It’s a fantastic operation for women who either want a breast enlargement.