— Janet d M., Coto de Caza, CA

A: Mid-facelifts are relatively new, but we have been doing them for 10–15 years. Both types of facelift procedures are designed to turn back the hands of time, but each addresses different aspects of the aging process. A standard facelift is still the ideal procedure to tighten a loose neck and to help with jowls.

You are correct in saying that the mid-facelifts are relatively new procedures, but they address an age-old problem: drooping and hollowing of the cheek areas below the lower eyelids, which creates a so-called “tear trough” deformity. These mid-facelifts can be done as an isolated procedure to freshen a face in the late 30s or 40s that is showing the earliest signs of aging, or combined with a traditional facelift in an older person, or as an isolated procedure in an older patient who has had a traditional facelift but the mid-face was not addressed.

One of the beauties of a mid-facelift is that it can be done through short incisions that are hidden behind the hair line and through a tiny stab wound in the fold between the cheek and the upper lip, just large enough to let us insert a few very long needles, which heals without a visible scar. The mid-facelift will not alter your jowls or neck laxity, so if these are an issue, a traditional face and neck lift will also have to be performed to achieve optimal rejuvenation.

Facial rejuvenation is at the top of the list of the most common aesthetic surgical procedures performed here at Orange County Plastic Surgery. Most people feel physically and mentally vigorous and energetic long after their appearance has begun to deteriorate due to aging. A face, neck, brow or mid-facelift procedure is designed to provide you with a rejuvenated appearance. The degree of improvement achieved depends on the severity of the initial deformity, the age of the patient, tissue elasticity and the recommended procedure.

Here are a few patients that show the benefits of the mid-face and traditional facelifts:

(Actual patient of Dr. Bunkis) 47-year-old female before and after mid-face thread-lift with lower-lid blepharoplasty, without the need for a traditional face or neck lift.

(Actual patient of Dr. Bunkis) Similarly aged, 47-year-old female with neck laxity and jowls, but not much in the way of mid-face laxity, before and after an endoscopic brow lift and facelift. No need for a mid-face here. Conversely, a mid-facelift would not have addressed the things that bothered her most: jowls and neck laxity.

(Actual patient of Dr. Bunkis) 54-year-old female a year after a traditional facelift done elsewhere, neck still quite tight, but complaining of mid-face and lower eyelid laxity. To address her concerns, a mid-face thread lift was performed by Dr. Bunkis to lift the drooping cheek tissues next to the nasolabial fold, thus removing the oblique trough that forms across the cheek as people age, and giving her a nice and youthful cheek. This procedure also elevates the junction between the eyelid and cheek, allowing us to shorten the eyelid, adding to a more youthful look. The “after” photos, six years later at age 62, show that the improvement has been well maintained.

It is important to seek a surgeon who is well-versed in all of the options, so that a customized plan can be developed for your concerns.

Please feel free to call Dr. Bunkis at Orange County Plastic Surgery (949-888-9700) for a complimentary consultation so that we can lay out all your options for you.

It would be difficult for me to tell you specifics without seeing you in person, but I can give you some generalities about such procedures, which we call upper and lower eyelid blepharoplasties.

What is Blepharoplasty?

A blepharoplasty procedure is designed to remove excess skin or bagginess around the eyes to give the eyes a more youthful appearance.  As people age some develop lower eye lid “bags” or “dark circles” and excess upper lid skin which drapes down over the lashes.  These signs of aging can be reversed by a plastic surgeon by removing excess skin or repositioning the lower lid fat.  Wrinkles around the eyes which are etched into the skin cannot be removed by a blepharoplasty procedure alone, without the addition of a skin wrinkle treatment such as a laser resurfacing or a chemical peel.  Likewise, a brow lift is frequently recommended to complete the rejuvenation of the eye area.  Frequently such rejuvenation procedures are combined with tightening of the neck skin or elevation of the brows to give the face a more youthful harmony.

Your goal as a patient is to make sure that all of your questions are answered and that you fully understand the procedure and it’s consequences before you decide to go ahead with such surgery.  Your surgeon should explain the procedure to you, give you detailed hand outs about the procedure, show you photographic examples of his/her work, and preferably either show you a staff member who has had the procedure or have a patient who has had a similar procedure contact you so you can get a patient’s insight into having the procedure done.  Do some research online.  Visit your surgeon as many times as necessary to have all your questions answered.

Understand the alternatives as well.  For example, if a patient has a low eyebrow, just removing excess upper eyelid skin will not change the distance from the eyelashes to the eyebrows and a brow lift may be recommended to give a more open eye look.  Sometimes a laser resurfacing will be desired to remove excess wrinkles.

You should visit your surgeon as many times as you wish to have all of your concerns addressed.  At your final preoperative visit, your final questions will be answered and you will confirm that you have understood the procedure to be performed and that you accept the risks by signing the informed consent forms.

The operation is performed using local anesthetics with intravenous sedation, or under a light general anesthetic, to make you comfortable throughout the procedure. The anesthesiologist will administer the medications and monitor you to ensure your safety and comfort.

For an upper lid blepahroplasty, the incisions are placed in the normal skin folds of the upper lids.  For lower lid procedures, the incisions are placed just beneath the eyelashes or, if fat has to be addressed but there is no skin excess, a hidden incision can be used just inside the lower eyelid.  Excess skin is removed and the bulges caused by hereditary fat pockets are corrected by repositioning the fat or removing the excess.  The incisions are closed with very fine sutures that will be removed approximately five days later.  Within weeks, the incision will be very difficult to see.  The approximate operating time for upper and lower eyelid blepharoplasties is two hours.

After Blepharoplasty Surgery

There is very little pain associated with a blepharoplasty and most patients do not require pain medication.  What will limit your activities in the immediate post operative period is the presence of significant bruising and swelling.   Our post operative instructions ask the patient to avoid much in the way of physical activity for the first two days, to sit and rest with your head elevated, and to apply ice packs to your eyes continuously except when getting up to eat or go to the bathroom.  Ice does not help after the first 48 hours and the patient is free to do whatever they are comfortable doing.  For example, most patients can walk as many miles as they wish, but in the first week, running would be uncomfortable.  By the end of the first or second week, all bruising should be gone and the patient should have resumed normal activity.

As the years go, the skin will continue to thin and wrinkle but the fatty excesses that were removed do not grow back.  We expect your eyes to look better than they would have without the procedure for the rest of your life.

If you have any specific questions about cosmetic procedures, your best bet would be to see a qualified plastic surgeon to review your options. Please feel free to contact our office at 949-888-9700 to set up an appointment with Dr. Bunkis; you may also check out our web site to learn more about our practice and eyelid surgery in particular.  Here are a few before and after photos to give you an example of what can be achieved with such surgery.

(Actual patient of Dr. Bunkis)  51 year old female before and two years after a lower eyelid blepharoplasty.

(Actual patient of Dr. Bunkis)  71 year old before and after an upper eyelid blepaharoplasty.

—Leslie R., San Juan Capistrano, CA

Liposuction is currently one of the most commonly performed surgical procedures in the United States by plastic surgeons, second only to breast augmentation. You certainly are not alone if you have concerns with unwanted fatty deposits! The beauty of this purely elective procedure is that it allows the surgeon to remove bothersome, disproportionate, localized fat deposits through relatively inconspicuous incisions.

Liposuction Explained

The liposuction procedure has been designed to vacuum away localized, stable fatty deposits—ideally those which cannot be controlled by diet and exercise. Liposuction should not be considered as an alternative method of weight control or a treatment for generalized obesity; nor will suction lipectomy help loose skin (unless combined with a traditional resection). Only the fat within the layer between the skin and the first layer of muscles is accessible to liposuction—fat within your abdominal cavity, for example, can just be decreased by consuming less calories or by burning more calories!

Plastic Surgeons usually performed liposuction in an outpatient surgical facility under a deep sedative or a light general anesthetic, supplemented by local anesthesia, although an occasional, a small area may be suctioned strictly under a local anesthetic alone. It should be noted that liposuction these days is frequently performed by non-surgeons, like dermatologists, family practitioners and even dentists.

Since such practitioners are not surgeons and cannot get surgical privileges in hospitals or surgery centers, they will generally attempt to do such procedures in an office with just a local anesthetic (it is illegal in California to administer a general anesthetic in an office setting). This is technically feasible, but not as comfortable for the patient, or as safe, because such offices do not have to live up to the same quality and sterility standards as surgical facilities do.

If you are considering seeing a particular doctor, you can always check the American Board of Plastic Surgery web site to see if the doctor you are interested in is a Board Certified in Plastic Surgery. Go ahead and give it a try—you’ll be amazed at how many doctors who represent themselves as plastic surgeons are indeed not plastic surgeons!

The liposuction procedure is done via small incisions in convenient skin folds and should not leave visible scars. Through these incisions, a metal cannula which is connected via rubber tubing to a vacuum machine, is inserted and passed back and forth in the fatty layer, removing the excess.    During the early days of liposuction, larger cannuals which could leave surface irregularities were employed and blood loss could be significant.   Now cannulas are of a much smaller diameter and fat removal is more precise.

Liposuction Research Results

In 1986, Dr. Bunkis and associates published the results of their research with liposuction associated blood loss (Quantitative analysis of blood and fat in suction lipectomy aspirates. Plastic and Reconstructive Surgery 78:765) and recommended instilling local anesthetics containing epinephrine into the surgical fields to reduce blood loss. As a result, most surgeons doing liposuction today infiltrate large amounts of saline solution containing local anesthetics into the surgical sites prior to suctioning. Infiltrating this wetting solution is generally know as the tumescent techique and has resulted in less blood loss and reduced bruising, thus expediting recovery after liposuction.

A large variety of liposuction machines are now on the market and each manufacturer will tout his as the best one available (just as Chevy, Ford or Chrysler will tell you that their cars are superior to the competition, but is one brand really that superior to another?). We have a variety of machines available at the Laguna Hills and Tracy Surgery Centers where I perform liposuction, but it is generally accepted in the scientific literature that results are based more on surgical technique and the size of cannulas (the smaller the cannula, the less bruising and blood loss) than on brand or type of machine. The various Laser, Vaser, Water Jet, Power Assist, Laser and Ultrasound machines all produce comparable results, the main advantage over the older generation of machines being the decrease in bruising and the decrease in surgeon fatigue!

The only layer of fat which we can access with liposuction cannulas is the one between the skin and the underlying muscle (the amount you can pinch above the muscle). Despite loud claims to the contrary, none of the liposuction procedures significantly tighten loose skin!  This is one good reason to have a surgeon who also does traditional excisional procedures evaluate you before you consider going ahead with a body contouring procedure.  Such a qualified surgeon can offer both a liposuction alone option versus a combination of liposuction and skin removal to a patient, based on each patient’s needs and desires. Thus, patient expectations are more likely to be met!

The bruising that results from liposuction usually subsides within three to four weeks, but the final swelling will not dissipate before three to four months have passed by (longer for ankles and calves).

Liposuction Limits

The absolute maximum amount of fat that can be removed safely in the ideal young and healthy candidate is limited to 5 liters of aspirate. Because of a few overzealous surgeons who have caused patient deaths in the past, this 5 liter limit is now encoded as law in the State of California.

Not every patient is a candidate to have 5 liters of fat aspirated at any given procedures—the patient’s age, general health and body size may limit the amount of fat which can be removed safely at any one operative sitting to a number fat below the legislated 5 liter limit. Suctioning of larger amounts will increase health risks and could necessitate a transfusion. Performing a second operative procedure three to four months after the first procedure will be recommended as a safer approach if removing more than a total of five liters of excess fat is anticipated.

If you have any specific questions about liposuction or body contouring procedures, your best bet would be to see a qualified plastic surgeon to review your options. Please feel free to contact our office at 949-888-9700 to set up an appointment with Bunkis.

Also check out our web site for further information about our office or procedures we offer.  Here are a few examples to give you an idea of the possibilities that liposuction offers:

(Actual patient of Dr. Bunkis) 46-year-old female, before and three years after aspiration of excess fat from abdominal wall and flanks.

(Actual patient of Dr. Bunkis) 42-year-old female before and after neck liposuction and upper eyelid blepaharoplasty.

(Actual patient of Dr. Bunkis) 34-year-old male before and after abdominal wall, flank and chest liposuction (5,000 cc).

Twenty five years ago, it was rare to have a patient walk into a plastic surgeon’s office after substantial weight loss. But these days, we routinely see patients at Orange County Plastic Surgery who have lost in excess of 100 pounds. About three quarters of the massive weight loss patients we see did so with the assistance of bariatric surgery. Such procedures have been designed to either decrease the size of the stomach pouch or some variety of “bypass,” which shunts food down the intestines quicker without absorbing as many calories. Since you fall into the post-massive-weight-loss category, you are first to be congratulated for losing so much weight!  You have done your general health a massive favor!

Unfortunately, most skin does not go back to its pre-stretched condition. The part that is most obvious to most patients is the skin excess in the abdominal area, but removing this alone rarely gives a patient a satisfying result as they will next focus on the loose skin of the back, thighs, breasts, arms or face. To get a total correction, one that requires two or more procedures, most post-weight-loss patients desire to have the excess remaining skin from backs, thighs and arms removed, their breasts uplifted (with or without an implant) or reduced, and lax facial skin tightened.

You are not alone in the struggle to loose weight. There is an obesity epidemic in the United States: 11–15 million Americans are morbidly obese, a 200% increase in the last 20 years. According to a report from the Centers for Disease Control and Prevention, obesity became the leading cause of mortality in the United States in 2005, with a death toll of 500,000 per year, surpassing the death toll from tobacco use. As a result, the popularity of bariatric weight reduction operations like gastric banding and gastric bypass surgery is soaring (approximately 200,000 cases per year). The health benefits to such patients are measurable but many are horrified by the amount of loose skin they see over their legs and thighs, abdominal and back, breast, arm and facial areas. Such patients frequently end up at Orange County Plastic Surgery to seek the expertise of Dr. Bunkis and his staff.

Here is an overview of what to expect if you decide to go ahead with a resection of your excess skin.

Preoperative Preparation

Bariatric surgery is just the beginning of an ongoing journey toward weight loss through lifestyle changes. Patients have to learn how to eat differently, exercise more, and keep adjusting their wardrobe as they shed pounds. Most go through this journey with the assistance of a support group consisting of many individuals including the bariatric surgical team, dieticians, personal trainers, others who have lost weight and some include plastic and reconstructive surgeons.

Once weight loss has stabilized, most patients wait a year or so before considering another round of surgical procedures to correct the global skin laxity that almost invariably is associated with significant weight loss. Associations such as the American Society of Bariatric Plastic Surgeons’ can help patients find a qualified surgeon to help them on this long road to recovery.

Once you have decided upon a surgeon, you should visit your surgeon as many times as it takes to have all your questions answered.  Most people require a head-to-toe type of reconstruction but it is necessary to break the number of procedures into manageable portions that can be done safely with any given procedure lasting six hours or less—longer procedures are associated with an increased incidence of complications such as blood clots in the calves and infections. Most patients begin with addressing the abdominal area with a belt lipectomy (a resection of abdominal and back skin). At the same sitting, many will also do their arms or breasts, and then return after they have healed for a tightening of the thighs and perhaps a face lift.

At your final preoperative visit each time, you will confirm that you understand the procedures to be performed, and that you accept the risks of the procedures you have chosen. You will be given prescriptions for surgical soap that will be used before surgery, as well as for pain pills and antibiotics. Laboratory test results will be reviewed—many bariatric patients are a little anemic and iron tablets may be recommended. Patients will be asked to stop smoking a month prior to surgery in an effort to maximize your body’s ability to heal following the surgery – and hopefully the patients will use this opportunity to quit smoking permanently.

Patients are asked to scrub the surgical sites with a special soap for ten minutes the evening prior to surgery and a final time the morning of surgery before leaving home. This step, along with taking antibiotics after surgery, will lower the possibility of an infection occurring after surgery.

All patients should avoid all anti-inflammatory drugs (Ibuprofen/Advil), all aspirin products, and excessive quantities of Vitamin E for two weeks before surgery, as these substances inhibit the clotting mechanism and increase the chance of unnecessary operative bleeding.

Surgical Procedure

The operations are all performed in an outpatient facility under a light general anesthetic, either at the Laguna Surgery Center in Southern California or at the Tracy Surgery Center in Northern California. A well-trained, board-certified anesthesiologist will ensure your safety during the procedure.

Depending on the part of the body to be worked on during the current procedure, incisions will be made as discussed with you preoperatively, and the excess skin and fat will be trimmed.  Sometimes it becomes necessary to suction some of the excess fat that can not be resected, but there is a limit to how much fat can be removed without jeopardizing the viability of the overlying skin flaps. Silicone rubber drains are frequently inserted prior to suturing the wound closed to prevent excess fluid from collecting under the skin. This drainage usually subsides in a week to ten days but may take up to a month or even longer to stop. In addition, small catheters which infuse local anesthesia into the surgical field to decrease post operative discomfort may be inserted—these are removed 2–4 days after surgery.

Postoperative Recovery

Most patients will spend the first night or two with a registered nurse, usually at a hotel near the surgery center. Thereafter, the patients will be comfortable enough to go home with an adult family member or friend. We have two basic rules after almost any surgery we perform. First of all, even if you do not have discomfort, take it easy and rest the first two or three days after any procedure. Take a walk frequently to avoid the possibility of potentially deadly, blood clots forming in your calf veins, but don’t take on any other tasks.

After the third day, patients are all over the map in comfort levels. Each patient should listen to their body and do what is comfortable, avoid anything that is not!  All patients can walk around but no one will be able to run in the first week. Those who wish to run or do a sit up or lift a weight should do so whenever they are comfortable.

Generally, it takes six to eight weeks before most patients can resume all their prior vigorous activities. Swelling in the surgical sites takes up to six months to go down and the scars could take a year and a half to finally mature and fade. If a patient keeps their weight down, these procedures will never have to be repeated.

I could not begin to tell you what your best option would be without evaluating you in person. Please call us at (949) 888-9700 and ask the staff to arrange a complimentary consultation for you and I will be happy to give you my best opinion as to your options. But to leave off, here is a “before” weight-loss patient, and a final follow-up photo taken after I completed her reconstruction in multiple stages.

(Actual patient of Dr. Bunkis)
Before weight loss through a diet and exercise program and after reconstruction by Dr. Bunkis.

Patient’s maximum weight was 260 but she did not have any photos at that weight (“I was camera shy”).  Photo on the left is patient at 235 pounds, on the right currently at 130 pounds!

A:  A tummy tuck tightens abdominal tissue that results from weight loss, including after a pregnancy. See photos.

Q:  What are the benefits of a tummy tuck?

A:  It is particularly effective in removing stretch marks from the lower abdomen, but it must be understood that not all stretch marks can be eliminated, and that some laxity, particularly noticeable when flexing the hips, will persist.

Frequently, particularly after childbirth or weight loss, patients present with a weakness of the abdominal wall muscles. In such cases, the defect between the anterior muscles is repaired (“fascial repair”) before trimming the excess skin and fat.  See photos of some of Dr. Bunkis’s actual patients tummy tuck results.

Q:  Who is an ideal candidate for a tummy tuck?

A:  The type of skin, degree of elasticity and age of the patient all influence the overall result that is obtained. The operation should not be undertaken if the patient intends pregnancies in the near future. Should a patient become pregnant after an abdominoplasty, a normal pregnancy will ensue but the abdominal wall will again get stretched.  While it is not necessary for the patient to reach a certain weight before surgery may be performed, it is desirable that the patient’s weight be stable for at least six months prior to surgery and that the patient be at a weight he/she feels can be maintained after the procedure.

Q:  How is a tummy tuck performed?

A:  The operation will be performed in an outpatient facility under very deep sedation or light general anesthesia, supplemented by local anesthetics. An incision is made across the lower end of the abdomen, and the skin and fat of the abdominal wall are elevated to the rib margins.  The navel remains attached to the abdominal wall, but is released from the surrounding skin and fat through a diamond shaped incision around the navel.  The abdominal muscles are tightened by suturing them together in the midline.  These internal sutures are permanent but all of the remaining sutures used for the skin closure are absorbable.  The excess skin and fat from the lower abdomen are trimmed. On occasion, it may be appropriate to suction some of the excess fat that can not be resected, but there is a limit to how much can be removed without jeopardizing the viability of the skin flaps. A new opening is created in the skin of the abdominal wall to reinsert the navel.  Drains and pain pump catheters are inserted prior to suturing the wound closed. The pain pump catheters are connected to a reservoir that contains local anesthetic solution that will automatically infuse into the surgical site for the first three days or so to minimize your discomfort. The pain pump catheters are optional (strongly recommended) but all patients will have drainage tubes inserted. The drains remove excess blood and serous fluid and will be removed after the drainage has decreased to less than 25-30 cc (about an ounce) of fluid per day. This usually takes about a week to ten days, but can take up to a month.

Q:  Are there risks and complications in a tummy tuck procedure?

A:  There are risks with EVERY procedure, every car ride, every time you eat, or go to a ball game. The trick is to keep the risks manageable and to do everything right to minimize the possibility of untoward events.

Serious complications after an abdominoplasty are relatively uncommon. However, there will be a long scar (usually, but not always, within the bathing suit line) extending from hip to hip. The scar may remain itchy, painful, thick, or otherwise unsightly. It is unusual, but possible, for areas of fat to liquefy and drain through the incision for many months, or to cause a tender mass to develop beneath the skin, which may require excision at a later date. As with any abdominal procedure, it is also possible for a suture to become infected and to erode through the skin years later.

One of the most common problems after an abdominoplasty is a persistent collection of serous fluid under your skin after the drains have been removed. Should this occur, this fluid will be aspirated with a needle during your post-operative visits. Such drainage always stops eventually (but may persist for more than a month) and usually does not affect the final results. If wound problems develop, it may take several weeks or even months for healing to take place, and the patient will be required to wear dressings over the open wound.  Because of the extensive skin and fat undermining, areas of skin may die and slough, or even require surgical debridement or a skin graft.  Rarely, phlebitis may develop in leg veins and even more rarely, blood clots could travel to the lungs, potentially leading to a fatal complication.

Perfect symmetry does not exist before or after abdominoplasty surgery. Scars will never be identical from side to side and the umbilicus will not be exactly midline.

Secondary procedures may occasionally be desirable to revise scars, to excise more skin, or to thin the abdominal layer above the scar (usually with liposuction). The patient will be responsible for all costs associated with secondary surgical procedures.

It is not possible to list every conceivable complication. As with any operation, there could be potential complications, which could even be fatal. The foregoing is not intended to frighten or upset you but to enable you to make your decision with an understanding of some of the involved risks.

Q:  How much does a tummy tuck cost?

A:  If a significant spreading of the anterior muscles or a hernia is present, your insurance company may, rarely, reimburse you for a portion of the Surgery Center bill and of the professional fees. In some instances, it may be possible to verify the amount covered by your insurance carrier in advance; the office staff can assist you in making this determination, but cannot guarantee a level of payment. The office staff will provide you with the necessary information to submit to your insurance carrier. All fees are due prior to the surgical procedure and, if any portion of your procedure will be covered by your carrier, you will be reimbursed directly by your insurance company.  Insurance carriers sometimes (rarely) pay for the muscle repair portion as this may be considered corrective surgery; they will not pay for the skin tightening or other purely cosmetic portions of the procedure. If desired, the office staff can also help you arrange financing for your procedure.

In compliance with suggestions adopted by the American Society of Plastic Surgeons, it is customary for the patient to pay all fees for cosmetic surgery prior to the desired operation. This ensures that the patient is sincere in his or her motivation and can afford the surgery, thus creating a better patient/physician relationship. A non-refundable deposit will be required to secure your desired surgery date when booking your procedure. The remainder of the fees must be paid prior to the surgery, usually at the time of the preoperative visit, but never later than one week before surgery. Additional fees are also required for laboratory tests, surgical facility fees and the anesthesiologist. If additional surgical procedures become necessary, additional facility, laboratory, anesthesia, and professional fees will be incurred. The surgical facility and anesthesiologist fees quoted will be based on our best faith estimate; the final fee may vary as these fees are based on surgical time, and it is not always possible to predict exactly how long a procedure will take to complete. It is important that you understand that the patient is responsible for all costs associated with all secondary surgical procedures or for the treatment of any complications that may arise as a result of this elective surgery.

Q:  How long do the results of a tummy tuck last?

A:  This is impossible to state. Factors affecting the length of the improvement include physical conditioning afterwards, type of skin, and alterations in weight. In general, it is not necessary to repeat this procedure to maintain the optimal result. It should be noted that this procedure removes the skin and fatty excess that a patient has at the time of the abdominoplasty but does not prevent a patient from gaining weight and stretching the abdominal wall again in the future. Should a patient wish to repeat the operation, regardless of the length of time since the initial operation, the degree of laxity or fatty excess remaining, each patient will be responsible for the cost of a subsequent procedure.

If you have any specific questions about cosmetic procedures, your best bet would be to see a qualified plastic surgeon to review your options. Please feel free to contact our office at 949-888-9700 to set up an appointment with Dr. Bunkis. You may also check out our web site to see examples of patients similar to your age and size to see what’s realistic for you in our photo galleries.

A:  Fashion may be fickle but women have been coveting fuller breasts for years.   If you are considering a breast augmentation, or any surgical procedure, you have to understand that there are risks, as there are with any activity in life, but the trick is to keep the risks manageable.   I’ll give you a little history of breast augmentation and review some of the refinements that have taken place to make this operation safe in the vast majority of instances.

Prior to 1960, many attempts at breast enlargement with large globs of patient’s fat, various sponges and liquid silicone injections caused many disasters and few, if any, natural feeling or looking breasts.   The modern era of breast implantation began in the early 1960’s with the introduction of silicone gel implants.  Silicone is a chemical element that occurs in combination as the most abundant element next to oxygen in the earth’s crust and is used for many things in the medical and electronics fields.   The original implants frequently ruptured.   Another problem with early implantation attempts was the development of capsular contractures – an unnatural firmness of the breasts.   Every type of implant inserted into the human body develops a thin layer of scar tissue around the implant, and even the softest, most natural feeling breasts have this layer of scar tissue surrounding the implants.

With a breast implant, the idea is to create a large pocket under the breast tissue and to put an implant in the space which is significantly smaller than the confines of the space, allowing the implant to move and the breast to feel natural.   Two factors can cause the breast to feel unnaturally firm:  first of all, if too large an implant has been chosen for any given patient and the implant does not have room to move around, the breast does not have a chance to feel normal and will feel hard; and secondly, if an appropriate pocket was originally created for a given implant but the scar tissue contracts, shrinks down, the implant again will not have room to move and the breast will feel hard as well.    Saline implants were introduced to counter these problems but were found to be less satisfactory because the saline filled bags just did not feel as good as a silicone implant in the average patient, and the contracture problems occurred anyway, thus proving that it was not the presence of silicone per say that caused the contracture.    In the early days of breast augmentation, some saline implants had steroids placed within the implants in an attempt to control the scar tissue build up (and it did) but in some cases, the steroid caused tissue thinning and erosion of the implants through the skin, leading to removal of the implant – thus, that practice was abaondoned.   Early implant patients also had a significant infection rate but by the 1980’s, most of these problems were solved, all patients given antibiotics for example, and very few patients today experience an infection.

Refinements in implant materials and surgical techniques lead to improving results throughout the 1980’s, and continued popularity of such implants.  In the early 1990’s, a Connie Chung television show raised doubt regarding safety of breast implants, bringing to light that many patients were now walking around with ruptured breast implants and questioning whether breast implant patients had a higher likelihood of developing autoimmune diseases such as arthritis or lupus.  Much publicity ensued and the safety of implants was reviewed by the FDA as well as other regulatory health agencies world wide.   Most issued rulings that the safety of silicone breast implants had to be studied further and such implants were removed from the market.  Hundreds of scientific studies were carried out, some retrospective, looking at the history of previously performed cases.   Others were prospective, studying patients after new implants were inserted in carefully monitored situations.  These prospective studies were set up by the major implant manufacturers in the United States, under the auspices of the FDA, and all data was presented to the FDA.  I was chosen to be one of the investigators in these studies and was able to have access to silicone implants during the years that they were not available to non-investigators.   After carefully studying all the data from these studies and other studies worldwide, the FDA concluded that silicone implants do not increase the incidence of any other diseases.

We now know that all implants, whether gel or saline filled, will rupture eventually but the important thing to know is that with current implants and early detection, there is little likelihood of harm to the patient following a rupture of either saline or gel filled implants.  In November of 2006, silicone gel implants were reapproved by the FDA for breast augmentation in the United States and this created a flurry of interest in breast augmentation with gel implants.    More and more women opt for breast augmentation each year.   212,500 breast augmentations were performed in the year 2000 but the number had increased to 291,350 by 2005, a 37% increase, and in spite or our current weak economy, this number just continues to grow!

Today’s implants have two major changes compared to implants used prior to 1990. The gel that was used in the 1960’s through the 1980’s was a thick, gooey liquid.  The gel in implants today is “cohesive”, the consistency of a marshmallow – when cut in half, these implants stay in one piece and do not “leak”.    Secondly, today’s implants contain thicker and more durable shells.    And finally, surgical techniques, antibiotics and anesthetic agents have improved greatly since the early days of breast implantation, making the procedure a very safe one with low surgical risks.   Incisions now are much shorter and more hidden, a variety of different approaches, including entry through the arm pit or nipple area, have been developed and placement of the implants above or beneath the pectoralis major muscle has been perfected.

Some patients today still choose a saline implant but most of these do not feel as natural as the average breast containing a silicone gel implant.   Breast implant surgery is obviously very elective and prospective patients should not be in a hurry to make a decision before they have truly been educated regarding the various aspects of breast implantation surgery.    The proper thing to do at this time is to go over all the indications, alternatives and risks and provide each patient with the pros and cons of all available implants types and to let them participate in the implant choice.   But once my patients have had a full consultation, including an opportunity to see or feel both types of implants, most today choose a gel implant for themselves.

If you have any specific questions about cosmetic procedures, your best bet would be to see a qualified plastic surgeon to review your options. Pease feel free to contact our office at 949-888-9700 to set up an appointment with Dr. Bunkis; you may also check out our web site to see examples of patients similar to your age and size to see what’s realistic for you in our breast enhancement photo gallery.    I must say that breast enhancement patients are some of the happiest patients after their procedures!   Here are some examples of ways that patients express their thanks to us!

Card Dr. Bunkis received from a happy young lady!

Examples of cakes given to Dr. Bunkis by grateful patients!

A:   All surgery leaves some kind of scar but the newer midface lifts do not leave visible scars.  Such procedures are done either through tiny stab wounds in the nasolabial fold (the fold between the upper lip and cheek) or through incisions inside the mouth, as well as a tiny scar behind the sideburn area.  While the incisions are “minor”, the procedure itself is not “minor” and is done in an operating room, just as a standard face lift would be.

Through these incisions, the flesh is freed from the bone and suspended upward with heavy sutures.  But first let’s discuss what these procedures are good for.  As people age, they develop a depression from the lower lid, downward obliquely across the cheek, the so called “tear trough”.  The midface technique is designed to eliminate or minimize this tear trough, and to restore a youthful roundness to the cheeks.  As healing occurs, these “midface” structures heal to the bone at a slightly higher level, thus improving the appearance of the cheeks and the lower eyelid region.  This is an appropriate procedure for a younger patient without neck laxity or jowls, who is noticing the earlier signs of aging such as a flattening of the midface area and development of tear troughs.  It is also a great procedure for an older patient who has already had a traditional facelift, without a midface lift – yes, some surgeons still do a traditional lift without addressing the midface area!

In our practice, with the exception of some patients with a very round face to begin with, we include a midface lift with almost every traditional face lift to give the patient total rejuvenations.  The midface procedure by itself does not address neck laxity or significant jowls, and a more extensive procedure with a traditional lift will be recommended if this area is a concern.  The modern midface lifts are frequently combined with eyelid surgery, neck liposuction, a full facelift or other aesthetic procedures.  Your best bet would be to visit with a qualified plastic surgeon for an evaluation and to outline your various options.   But I can give you some idea of various possibilities with the following examples:

(Actual patient of Dr. Bunkis)  40 year old female, before and after a mid-face thread lift, lower lid blepharoplasty and secondary rhinoplasty.   Notice the rejuvenated appearance of the cheeks, below the eyelids, as a result of the midface lift.   She was an ideal candidate for a midface lift without a traditional face lift as, at her early age, she did not have any jowls or neck laxity.

(Actual patient of Dr. Bunkis)  54 year old female a year after a traditional face lift done elsewhere, neck still quite tight, but complaining of midface and lower eyelid laxity.  To address her concerns, a midface thread lift was performed by Dr. Bunkis to lift the drooping cheek tissues next to the nasolabial fold, thus removing the oblique trough that forms across the cheek as people age, and giving her a nice and youthful cheek.  This procedure also elevates the junction between the eyelid and cheek, allowing us to shorten the eyelid, adding to a more youthful look.  The after photos, six years later at age 62, show that the improvement has been well maintained.

(Actual patient of Dr. Bunkis)  54 year old before and after a traditional facelift along with a midface lift and tear trough microfat grafting to address the flattening and sagging of the midface area, along with upper and lower eyelid blepaharoplasties.

I have operated on patients in their late 30’s who were good candidates for a facelift, but those instances have been few and far between, and usually with extenuating circumstances such as severely stretched skin from obesity and subsequent weight loss. You are correct in feeling that younger patients with early signs of aging usually are not candidates for a full face lift. Such patients can frequently be helped quite considerably with one of the newer minimal incision techniques including neck liposculpting, tightening the neck muscles through small incisions just beneath the chin and perhaps the ear, endoscopic forehead lifts, or some of the modern midface lifts that are performed through hidden incision inside the mouth and behind the hairline.

Perhaps a series of one of the nonablative laser treatments or intense pulse light (“IPL”) treatments will remove surface blemishes and tighten the skin sufficiently to buy you some time. A lot of the decision making depends on your expectations as well and the degree of laxity you have. But to tell you the truth, as I stated earlier, I could not begin to tell you what your best option would be without evaluating you in person. Please call us at (949) 888-9700 and ask the staff to arrange a complimentary consultation for you and I will be happy to give you my best opinion as to your options. I see patients at the Waves Beyond Skin Care Spa in San Clemente on a regular basis and could see you there if it’s more convenient for you. But first, I will show you examples of three younger patients who received minor procedures that bought them some time before they were ready for a full facelift.

42 year old female with early signs of cheek hollowing and deepening of nasolabial folds (the fold between the lips and cheeks), before and after injections with Sculptra Aesthetic®, a long lasting filler.   By the time this filler wears off and her neck droops more, she will be ready for a full face lift.

Actual patient of Dr. Bunkis – 35 year old female with some upper eyelid hooding, a minor neck adiposity, and early facial laxity, before and after a one hour procedure in which I did her upper eyelids and liposuctioned her neck and jaw line.

Actual patient of Dr. Bunkis – 44 year old female with more than average sun damage, before and after a full-face phenol peel.

A:  Alejandra, first of all, you are to be congratulated for having lost so much weight and for making exercise an important part of your life. Studies have shown that such weight loss after surgical procedures dramatically improves the health of the patients who have lost the weight. I am sure that you have worked very hard to achieve this remarkable result so far. But you are not alone in noticing that the skin does not go back to its pre-stretched appearance after weight loss.

Over the years, I have seen many patients who have lost large quantities of weight like you have. Twenty five years ago, however, it was rare to have a patient come in for skin reduction surgery after such significant weight loss – I would see one or two such patients each year. But now such patients come in to see us weekly! With the advent of laproscopic surgery, lap band surgery and more sophisticated bypass and stapling techniques, the efficacy, safety and popularity of such procedures has sky rocketed. This year over 220,000 such “bariatric” surgical procedures will be performed in the United States, and the popularity of such procedures just keeps on growing.

The areas which we can address with plastic surgery are the ones you mentioned – the inner arms, abdomen and back of the trunk, hips, thighs and buttocks, as well as the breasts and faces. Removing such skin excesses is serious surgery and may require multiple sessions to achieve an optimal result. Long scars result but the improvement in contour and tightness leaves most patients very satisfied with their final results. Unfortunately, although the bariatric surgery itself might be a covered benefit, almost universally the skin reduction procedures are not covered by insurance companies.

The best way for me to illustrate what we can accomplish is with photographs. If you still have any questions about these procedures, your best bet would be to see a board certified plastic surgeon to review your options but be sure to check out the doctors’ track record with such large scale recontouring as such procedures are relatively new and not performed frequently by all surgeons. Ideally, your surgeon should have extensive experience with such procedures, be a board certified plastic surgeon and belong to the American Society of Bariatric Plastic Surgeons.

Please see the photos of some of Dr. Bunkis’ actual patients below:

]]> http://www.ocps.com/blog/q-a/ive-lost-a-lot-of-weight-now-what/feed/ 0 http://www.ocps.com/blog/q-a/hand-aging-and-rejuvenation-options/ http://www.ocps.com/blog/q-a/hand-aging-and-rejuvenation-options/#comments Mon, 22 Feb 2010 19:09:34 +0000 Dr. Bunkis http://www.ocps.com/blog/?p=985 Q:   I am 46 yrs old and have been a sun worshiper until recently. Now, I take care of my skin really well and I manage to keep my face looking healthy. The only area that really shows my age are my hands. I have very skinny hands that show my veins and some brown spots as well. Is there anything I can do to improve the appearance of my hands?
- Linda D.
Newport Beach, CA

A:   Hand rejuvenation is becoming a very interesting topic that draws attention nationwide. The hand is an important tool that we use to interact with the society but it has long been ignored by aesthetic surgeons. This trend has now changed and we can offer our patients some options.

There are two main problems that we can address with regards to aging of the hands:

1.  Thinning of the skin with increased visibility of the veins: The best way to improve this situation is by Microfat injections. With this technique, the plastic surgeon harvests your own fat, which is handled very gently to maintain the viability of the fat cells, and transfers it beneath the skin of the hands. The fat globules add volume into thin hand, camouflage the veins and restore the hand volume to a younger looking texture and feel. The most frequent question regarding this technique is “How long will the improvement last?”

Fat grafting has been done for many years. Early attempts at fat grafting did produce only temporary improvement. However, present Microfat injections differ from the older technique because it uses finer instruments and deals with the fat in a very gentle way to preserve the viable cells and separate them from dead cells and oil, thus improving graft take. In order for the fat grafts to survive, the individual small clumps of fat must have a blood vessel that attaches to a vessel in the recipient site – if this happens, the fat will continue to live forever, but if adequate blood supply is not available, the grafts will atrophy and disappear within a few months.

2.  Brown spots (hyperpigmentation).  IPL or chemical peel can lighten these spots. Multiple sessions are usually required to accomplish this goal. It is also necessary to protect the hands with sun blocks whenever you are outdoors; otherwise the damage will just continue occurring.

Actual patient of Dr. Bunkis
60 year old female, before and a year after a single treatment with microfat grafting.