The article explores something called “Awake cosmetic surgery,” a technique that is marketed under the guises of lower cost and lower anesthesia risk. However, the risks and the costs may be higher than patients realize.

To obtain a clear understanding of the issue, we asked Dr. Hess to directly address the story.

Are surgical procedures like breast augmentation and liposuction being performed under local anesthesia in Fairfax or the Washington D.C. area?

I am very aware of these sort of shenanigans going on in the Fairfax, Va. area.  I know this because I have seen patients that have undergone “local liposuction” and had to stop because of the pain.  These patients have terrible contour deformities that require delicate, very localized liposuction performed under general anesthesia so that the patient is comfortable and the areas for correction are easily identified and corrected.

In addition, these doctors are NOT plastic surgeons. They may be dermatologists, OB/GYN, internists etc.  I have seen patients with over a dozen scars on just the abdomen from liposuction from these untrained doctors.  I use only three well-camouflaged incision sites.

Lidocaine toxicity is one of the biggest problems pointed out by the article.  Maximum lidocaine blood levels are not reached until 8 hours after the injection, so if a breast augmentation is performed and the maximum amount of lidocaine is exceeded the patient could very well go home and die later from this toxicity. Many if not most of these untrained doctors don’t understand the pharmacokinetics of the medications they are using. Plastic surgeons, on the other hand, are well trained in this area.

We are witnessing tremendous technological advancement in the “office-based” surgery arena.  But unfortunately, the majority of these devices are designed for the non-plastic surgery trained doctor/dentist/chiropractor etc. to “cash in” on the cosmetic surgery market.

Unfortunately, we likely won’t see regulation against this foolishness until more patients are seriously injured.

I think local procedures (procedures under a local anesthetic) should be limited to things like nevus removal or minor scar revision. Procedures that are simple, short and carry very, very little risk of a poor outcome.

Christopher L. Hess, M.D., F.A.C.S.

The NBC Today Show recently featured Sculptra aesthetic on their “Today’s Health” segment. Along with a treatment demonstration and some patient testimonials, Dr. Roshini Raj of the NYU school of medicine appears on the show to explain the details regarding Sculptra treatment. She covers the advantages and disadvantages of Sculptra and of course, compares the filler to Botox.

Sculptra was recently FDA approved for cosmetic use. While the wrinkle filler has been used off-label in cosmetic applications for a long time, the recent FDA clearance has spawned a renewed interest of the drug in the cosmetic surgery industry and in the media.

The people who go through with liposuction aren’t necessarily overweight – many are actually in decent shape!  The problem is, a shift occurs at a certain age and it doesn’t seem to matter if you run, use the elliptical, pump iron, or practice Yoga and Pilates, unrelenting dimples, bumps and bulging areas still show. They don’t go away! Those saddlebags sometimes  just don’t respond to exercise or diet at all.

Fortunately, good plastic surgeons are now well-versed in many forms of liposuction.  There are many fancy platforms out there that may or may not be as effective as advertised.  Tumescent Lipo is still considered the gold standard and many doctors still believe it is by far the gentlest, safest and least traumatic.

If you are interested in learning more about how to slim down those problem areas with liposuction, contact Hess Plastic Surgery.

Questions like the ones above were asked by researchers during the Beauty for Life survey, a collaborative effort by the American Society for Aesthetic Plastic Surgery and the American Society of Plastic Surgeons.  ASAPS President Renato Saltz says the survey was intended to help surgeons “understand what patients are most concerned about at different stages of their lives.”

Participants were grouped according to age so researchers could determine how members of each generation approach physical appearance of the self and physical appearance of ones partner or potential partner.

Respondents in their 20s, 30s, and 40s reported that a “fit, well proportioned body” was what they found most appealing in another person.  When it came to their own physical characteristics, the same group was apparently more concerned about their own faces.  The abdomen and hips were said to be areas of significant concern (especially in the 30s), but across the board, patients said they were most conscious of their facial appearance.

Reasons given for maintaining an attractive physical appearance included the following:

1. Boost self confidence
2. Make friends
3. Attract partners
4. Increase job prospects

In all age groups, cosmetic procedures ranked fairly high, alongside diet, exercise, and skin care.  Through the link listed below you can easily view the results (in a pdf file) of the Beauty for Life survey.

• http://www.surgery.org/private/download/BFLUserSurvey.pdf

Previously I wrote on how I thought the moms in their 30′s, 40′s and 50′s were the ones now considered “the ones to watch” or the “hot” moms.  It didn’t dawn on me until today, as I walked around Las Vegas,  why that might be true.  These are the women that in the 1980′s, were fixated on their weight and appearance.  Skinny jeans were trendy then too but so was being skinny.  On the flip side, the incidence of eating disorders and girls/women with unhealthy figures was significant.

Today, as a country we have an ever-increasing incidence of over weight children and obesity.  At the same time those skinny jeans are back in.  See the correlation?  More fat in the waist area + skinny jeans = the muffin top.   Now I’m not saying that all of these women are over weight.  On the contrary,  many are probably more healthy than their moms were in the 80′s.  After all men do like curves believe it or not.  But what I am saying is that just because a fashion is in doesn’t mean it’s right for every woman.  So you can change fashions or…

What else did you think I was going to say.  As a plastic surgeon I would be remiss if I didn’t suggest to all of those women who want to wear the latest fashions that body contouring through liposuction and possibly a tummy tuck is an excellent way to achieve this.  Let’s just leave it at that.  I’ve been married long enough to know when to stop.

Our preoperative package includes an extensive list of all medications, herbs, vitamins and anything else that has been shown to increase bruising.  The patients must read the list and initial our copy so that they understand the importance of it.  All medications etc. are stopped 7 days prior to surgery.  In addition I make sure there are no blood pressure issues.  High blood pressure definitely increases the risk of severe bleeding and bruising.  And while this is all well and good it’s really the surgeon who has the most control over the bruising.

Liposuction involves infiltrating the fat with tumescent solution.  This solution is lactated ringers with epinephrine and sometimes Lidocaine anesthetic.  The solution is infiltrated in a 1:1 ration of tumescent:fat removed.  This provides for the least amount of bleeding.    But the key is the epinephrine which allows the small blood vessels to constrict leading to less bleeding and bruising.  When the tumescent is infiltrated it takes approximately 7-10 minutes for full vasoconstrition.  Once this occurs the fat can be removed with very little blood in it and thus little bruising.  The problem is most surgeons don’t want to wait because the patient is paying for the room time and idling standing waiting for the skin to turn white increases cost.  So they start suctioning immediately and the result is bad bruising.

The final issue is compression.  The compression garments I use are always tight but in addition I add Topifoam(Byron Medical) with allows more compression with even distribution of pressure.  Topifoam decreases bruising and swelling after surgery and is left in place for 48 hours.

So bruising should not be severe.  Have a thorough discussion with your surgeon and voice your concerns about bruising before surgery.  If you would like to discuss liposuction or any cosmetic concern click here or call my office at 703.752.6608 for your complementary consultation.

What we do know is that it is much more common in post pubertal females and less common in males.  However, males with deficiencies in male hormones and thus a relative increase in female hormones (we all have both) also show a higher propensity for it.  So it appears that female hormones are partly to blame.  However, other hormones including insulin, adrenaline, noradrenaline, thyroid hormone and prolactin are all believed to participate in the development of cellulite.  Other causes include:  obesity, excessive amounts of fat, carbohydrates, salt, too little fiber, smoking, lack of exercise, standing or sitting in the same position for too long,  distribution of subcutaneous fat, predisposition to circulatory insufficiency and underwear design.  Anatomically the most logical explanation is that the connective tissue surrounding fat is less flexible the cellulite areas and thus when the fat cells enlarge the skin has less rigidity and thus expands more than the connective tissue.

So what works to reduce the appearance of cellulite?  There are numerous touted therapies:   iontophoresis, ultrasound, thermotherapy, pressotherapy, lymphatic drainage, electrolipolosis, lasers, liposuction, and medications both topical and oral too numerous to list.  Liposuction seems like it should work, right?  Remove the fat and the lumps and bumps go away.  The problem is that the cannulas that remove the fat also penetrate the connective tissue which results in scarring and thus scar contracture.  Thus there’s less fat but the connective tissue septa have shortened.  So liposuction usually will not make the cellulite worse but it also usually doesn’t help.

There’s are general rules in medicine: 1.   if there are multiple causes for something no one knows the answer 2. if there are multiple therapies none of them work.  So I’d love to say come see me and I’ll take get rid of that cellulite but I can’t.  But feel free to click here or call 703.752.6608 for a complementary consultation.

Similar to brain cells, fat cells achieve their maximum number early in childhood.  After this number is reached we will no longer add to the number of fat cells unless we gain approximately 100lbs over ideal body weight.  Instead as we gain weight the fat cells get larger.

When liposuction is performed fat cells are removed from the site never to be replaced (unless the patient gains significant weight).  So when the patient gains weight following liposuction there are less cells at the surgical site that will enlarge.  So for example if you normally gain weight in your abdomen and I perform liposuction on the abdomen, if you gain weight you will still gain it in the abdomen but since there are less cells the contour will still be smaller than the surrounding areas.  And no other areas won’t preferentially get larger.  People tend to gain weight in specific areas according to their genetics.

But really the question is moot because after obtaining that great surgical result most patient either continue to lose weight or maintain their post surgical weight.  To see some liposuction results click here then contact Dr. Hess for a complementary consultation in Fairfax, Virginia.

After the tumescent has had time to work, the fat is removed mostly from the deeper layer with small 2.0-4.0mm cannulas.  Removing the fat via different directions and keeping deep to the skin reduces the amount of contour irregularity that can occur after the procedure.

Recently we have seen the introduction of laser-assisted liposuction such as Smart Lipo, Cool Lipo and LipoLite.  These systems use laser energy delivered through a 1.0-2.0mm cannula to heat the fat cells causing their rupture. The fat must then be removed via standard liposuction cannulas.  The claim of companies that make these products is that the procedure can be done in the office under local anesthesia and there is skin tightening due to the interaction of the laser with the underside of the skin.

To date there are no published scientific studies that have demonstrated the effectiveness of these devices to both remove fat and tighten skin.  I have seen patients in consultation that have undergone this procedure and are quite unhappy.  Patients complain that there wasn’t any skin tightening and there is considerably more contour irregularity.  This is likely because the fat is removed more from the superficial layer than the deeper layer.

In these tough economic times patients are looking to improve their appearance at the best cost/benefit ratio and with the least down time.  Unfortunately, products that are marketed in response to this may not be the most appropriate in all situations.  While I do think that these technologies will find a use, such as removal of small amounts of fat under the chin, I don’t think they are necessarily appropriate for larger areas.

It has always been my philosophy that it’s good for patients to see several surgeons and get different opinions before proceeding with any procedure.  Ask lots of questions and be sure that the procedure you have decided on is right for you.  I feel very strongly that new technologies are necessary to advance our medical field.  However, only after thorough scientific evaluation can we determine the usefulness of each.

Liposuction offers the benefit of removing excess fat from localized areas of the body where dieting does not. However, liposuction should not be used as an alternative to dieting and proper exercise.

Today there are many forms of liposuction techniques and procedures and a patient needs to thoroughly research their options before deciding on what would be best for them.

If you live in Fairfax or Northern Virginia and have been considering liposuction, please contact Hess Plastic Surgery today. Dr. Hess would be pleased to talk with you about your goals and desires for a slimmer more youthful appearance. Dr. Hess is board certified by the America Society of Plastic Surgeons and can help you decide if liposuction would be right for you.