This is a very good question, Judith. I’m glad you asked because it’s one that we hear every week at our practice!

I’ll start with some brief background. The first silicone breast implants were inserted in the mid 1960s. By the mid-1970s, when I began doing surgery, breast implant procedures had become mainstream. During these early years, I don’t recall much discussion with manufacturers, other physicians, or even patients regarding the longevity of such implants. The assumption was that they would last forever and never need to be replaced! But boy, were we all naïve at that time!

Knowing what we know now, hip joints, knee joints, heart valves and pacemakers all wear out and eventually need to be replaced.

The reason that most patients who have received a hip, knee, heart valve or pacemaker don’t require a replacement, is that such implants are frequently placed in older patients who don’t live long enough for the implant to wear out or malfunction. But anyone in their 20s who receives an artificial knee, hip, heart valve or pacemaker surely knows that someday these implants will have to be replaced.

Now we know that all breast implants will rupture eventually if the patient lives long enough. This raises two important questions that need to be addressed:

1) Does a ruptured implant cause a patient any harm?

2) What is the expected duration of a breast implant and when should it be replaced?

Breast Implant Safety Studies

In the early 1990s, breast implants came under scrutiny after numerous reports outlined that older breast implants were frequently found to be ruptured by mammography or during secondary surgical procedures. At the same time, a few reports surfaced questioning whether the presence of silicone led to an increased incidence of autoimmune diseases such as lupus and arthritis.

Gel implants were removed from the market by the FDA until further studies could be conducted. 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 breast 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.

Approval of Silicone Gel Implants

In November of 2006, silicone gel implants were approved by the FDA for breast augmentation in the United States. These are now the most common type of implant used in our practice.

Judith, you mentioned that you were seeing a gynecologist, which is a good thing! Whether or not a person has breast implants, it is highly recommended that each female examine herself monthly for breast lumps and undergo mammography as suggested by your personal physician.

All women, whether or not they are contemplating breast surgery, are encouraged to obtain a baseline mammogram at age 35 (or even sooner if recommended by your gynecologist due to family history of breast cancer) and a yearly mammogram or MRI past the age of 40. In conjunction with your mammogram and gynecological examination, PAP smears should also be performed.

In addition, we strongly believe that any patient who has had any type of implant inserted should see a surgeon of that same specialty as the one who inserted the implant. Do this on an annual basis! For example, if you’ve had a knee implant, please see an orthopedic surgeon every year. Likewise, if a woman has had a breast implant procedure, she should see a plastic surgeon annually.

Why See Your Surgeon Every Year?

Annual visits are recommended for a few reasons. First of all, even though family practitioners or gynecologists may know more than a lay person about knees, heart valves, pacemakers or breast implants, they do not have the in-depth knowledge possessed by a surgeon of inserting specialty. As plastic surgeons, we learn about breast implants every year from our own experience, by attending scientific meetings and from reading plastic surgery journals. Such specialized knowledge is paramount for a thorough, annual breast exam.

Secondly, we occasionally learn in a medical meeting or through an FDA notification of a problem with a product or medication. If we have been seeing a patient who had breast implants inserted many years ago on an annual basis, there is a high likelihood that a letter, email or phone call will get us in touch with the affected patient. On the other hand, if someone has not seen us for many years, there is a high probability that the person has moved, married or divorced and can no longer be reached at the last known address.

Similarly, many patients who had implants inserted many years ago can no longer remember the name of the surgeon who inserted them, which year it was, or what type of implant was used.

At Orange County Plastic Surgery, we see many patients who had implants inserted elsewhere. We are happy to examine any patient on an annual basis as a complimentary service.

How Long Will Breast Implants Last?

This question is a little more difficult to answer. I will start by telling you what happens when an implant gets inserted and why an implant eventually ruptures.

It is normal for a body to make a thin layer of scar tissue around every foreign device that is inserted, be it a chin implant, a knee joint, a breast implant or a pacemaker. If you were to look inside the pocket around a breast implant, you’d see a thin layer of scar tissue, the so-called “capsule.” From the inside, it appears smooth, soft, whitish and looks like the inside of a plastic bag. An implant is basically a loose, floppy bag that has folds in it. Normal movement inside the pocket can cause the shell to fail anywhere along a fold.

After the implants have been in place a long time—say, over 15 years—the body may begin to deposit calcium in this scar tissue around the implant. These calcium deposits grow in size and begin protruding into the pocket housing the implant, just like stalactites and stalagmites grow into an underground cave. Once this occurs, very frequently with implants that have been in place for 20 or more years, the roughened calcium deposits cause the implant shell to rupture.

We strongly recommend replacing all implants that have been in place for 20 years.

A More Natural Look and Feel

Another, purely aesthetic reason that old implants should be replaced is that we rarely see a breast more than 20 years after implantation that still looks great or feels normal. As the pocket contracts and begins to calcify, the breast frequently becomes firm, sometimes uncomfortable, and often looks distorted. This is another reason to replace old breast implants.

While insurance companies, rightfully so, do not cover the cost of implant insertions for cosmetic reasons, most (PPOs, not HMOs) will cover at least a portion of the expenses involved in removing old, contracted, ruptured implants. I have helped countless women with breast revision surgery over the last 30 years and would be happy to see you for a complimentary consultation to answer any of your questions.

One reason breast implant surgery is so popular is because there is a high patient satisfaction from such procedures.

The important thing to take away from this discussion is that implants are safe and rarely lead to problems if inserted properly and replaced before the 20-year mark.

Let me show you an example of an implant I removed this week from a patient who had some firmness, but otherwise felt fine, some 35 years after the implants were inserted.

(Actual patient of Dr. Bunkis) When performing an uplift at the same sitting while replacing an implant (long incisions are necessary for the uplift, which also makes it easier to remove the capsule), it is desirable to remove the old implant in one piece, like a softball, surrounded by an intact layer of scar tissue. This prevents any loose silicone from spilling into the surgical site. Spilled silicone can be removed from a surgical site—just like oil can be removed from a beach or honey can be cleaned from a kitchen floor. But the trick is to not spill it, thereby avoiding the difficult and messy cleanup. After removing the implant and scar tissue in one piece, a new implant can be inserted and the wounds closed before opening the scar pocket to see what’s inside. The patient should have a nice soft breast for the next 20 years.

(Actual patient of Dr. Bunkis) In this case, as we began opening the scar pocket, you can see that the implant had ruptured and free gel was present in the pocket! Good thing we were able to get these out of the body in one piece!

(Actual patient of Dr. Bunkis) Finally, after opening the pocket and removing the broken implant and free gel, I turned the scar pocket inside out, in the same way you would turn a sock inside out to show what was inside the pocket and rubbing against the implant. Note the heavy sheets of jagged, sharp calcium deposits along the upper half of this opened pocket. The bottom contains smooth, soft scar tissue and looks like any healthy lining inside a relatively new capsule. It is these sharp calcium deposits which rupture most old implants.

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 at www.orangecountyplasticssurgery.com to see further examples of similar patients.

Thank you for asking, this is an important question. Assuming you are a candidate for both eyelid (blepharoplasty) and neck rejuvenation procedures, you would first need to decide if you would indeed like to have both improved. That can only happen after you’ve had a thorough consultation with a qualified plastic surgeon.

Should you then decide that you’d like both your eyes and neck done, my advice would be to do them together at the same sitting for a couple of reasons:

Recovery Time

The first reason is time spent recovering. If you do just the eyes, you’ll be uncomfortable and bruised for up to two weeks. Likewise, when you have your neck done. If you combine these procedures, the total recovery time will still be about two weeks (instead of losing two weeks twice).

Less Cost, More Uniform Improvement

Aside from time considerations, you will save money by going into a surgery center only once versus twice. Probably the best reason of all to do it in one sitting is that you will be able to enjoy a uniform improvement over your entire face as soon as you have healed. This would be akin to enjoying a house that has been totally cleaned, rather than only half done.

The best way to describe this further is through photographs. Take a look at the accompanying pictures below of a 52-year-old female who chose to have her eyes, face, neck, and brows lifted, and to have a small chin implant inserted—all in a single procedure that took less than four hours!

52-year-old female patient of Dr. Bunkis before and after a brow lift, upper and lower lid blepharoplasty, facelift and chin augmentation.

Side view of the same 52-year-old female patient before and after a brow lift, upper and lower lid blepharoplasty, facelift and chin augmentation.

One of the best ways to envision how you would look following such procedures is through the use of computer imaging.  If you would like to set up a complimentary computer imaging session, please feel free to contact Orange County Plastic Surgery at 949-888-9700.

The Evolution of Cosmetic Surgery

Boosted by baby boomers doing all they can to maintain their youth, cosmetic surgery is growing in popularity at a rapid pace. Statistics report that over the past five years, cosmetic surgery procedures have grown by almost 300%.

Desired concepts of beauty are constantly changing, due in part to new technology and expert techniques. According to plastic surgeon, Juris Bunkis, M.D., F.A.C.S. of Orange County Plastic Surgery in Rancho Santa Margarita and Dublin, California, the tight, pulled “wind tunnel” look was the signature of a 1970s-era facelift. There was also the scooped nose with a pinched nasal tip, and unnaturally round, hard breasts after breast augmentation surgery.

Such obvious signs of surgery are no longer desirable by most people, and increasingly shunned by patients who wish to turn back the clock in a more natural way, without such tell-tale signs of surgery.

“Facial surgery is not about looking 30 at age 75! No amount of skin and muscle tightening can achieve such an unrealistic goal,” stated Dr. Bunkis. “It’s about looking the best you can, at any age.”

Other factors play a role in relaying a patient’s age such as the quality of the skin, sparkling eyes and the sound of a voice. The goal of facial rejuvenation today is to create as youthful a result as possible while maintaining a balanced and natural, un-operated look.

New Approaches To Facial Surgery

Dr. Bunkis explained that the newer approaches to facial surgery are primarily aimed at the mid facial region. The relatively new midface lift specifically addresses the central facial hollowness that naturally occurs as many people age. By suspending tissue back to its original place, the aging face can then be sculpted tension free to recreate the soft and graceful curves of youth.

“It is absolutely necessary to achieve this balance to arrive at a pleasing surgical result, explained Dr. Bunkis. “My techniques have changed over the last twenty years, and the concept of a pleasing result continues to evolve.”

Compared to the mid 1970’s, when Dr. Bunkis began doing surgery, techniques today utilize shorter and less visible facelift incisions and a greater emphasis has been placed on midface lifts and other techniques which elevate the fallen tissues in a more natural way. Today’s techniques do not raise the sideburn, distort the hairline behind the ears, or leave patients with a horizontal, pulled back look that was so common in years past.

Understanding the Aging Process

A key factor in plastic surgery advances has been a better understanding by plastic surgeons of the nature of the aging process, and the development of techniques that address aging skin tissue. Nevertheless, technical advances still cannot guarantee a perfect result. Patients must start by choosing the right surgeon—one who not only understands their concerns, but one who also has the ability to focus on what the surgery will achieve, as well as the artistic talent to achieve the desired result. With his years of experience and artistic touch, Dr Bunkis brings to his patients a knowledge and expertise in aesthetic surgery that makes him a leader in his field.

Dr. Bunkis’ main objective is to achieve a natural look for each patient, and to allow each patient to look as good as they can for their given age. He evaluates each patient’s concerns, decides how best he can help them, and offers a solution to their problems. This frequently requires a discussion of areas or procedures that the patient may not have previously considered.

“For example, if someone comes in with a complaint about a droopy neck, but does not mention their severely sun damaged skin, I feel it my duty to discuss laser skin resurfacing for completeness sake”, said Dr. Bunkis. He believes that a layperson may not realize that tightening droopy muscles and skin will not affect the skin’s quality. Such a person may wake up after a face lift with a gorgeous jaw line and face contours, but be disappointed because the skin is still blotchy and sun damaged. Not approaching the face as a whole may create an unnatural result and deprive the patient of full benefit of the doctor’s talents.

The ideal facial rejuvenation procedure leaves the patient with a jaw line that matches the rest of the face including eyes, forehead and skin texture. This process, Dr. Bunkis explains, begins with a through consultation.

Facial Rejuvenation Consultation

So what are the consultations like and what suggestions may be made? This depends on each patient’s concerns, desires, and present condition. Dr. Bunkis begins each facial consultation with an explanation of the aging process and discusses generalized skin care, as well as general anti-aging treatments, which may be applicable.

Normal facial aging is a two-prong process. The first prong is genetically determined, such as the formation of the jowls, drooping of the neck or brows, bagginess of the eyes, the degree of chin prominence, or the size of the nose. These features are not under the patient’s control and cannot be changed without surgery. The second prong of the aging process includes skin texture and the general health of our skin, as well as the amount of fat in our necks, and the impact of sun exposure, obesity, smoking and excessive use of alcohol. This latter group is obviously under a patient’s control. Dr. Bunkis attempts to help each patient develop a healthier lifestyle and, along with his aesthetician, discuss sun protection and long-term skin care options.

Different Facelift Approaches

Dr. Bunkis gave examples of different approaches that might be offered to patients of various ages with various degrees of aging: “For a patient in her thirties with a slight neck fullness, a lipo-sculpting procedure may be all that is required to give her a youthful jaw line, as the skin will usually have sufficient elasticity to snap into place. This same approach would not be appropriate for a patient in her forties, as skin and muscle laxity would be expected to persist if the issue is not addressed.

“For such a patient, however, a traditional facelift may not be required yet. Quite possibly an excellent result could be expected by combining the liposuction with a short incision under the chin to tighten the neck muscles. Or we may add to this a midface lift, which can be achieved with a small stab wound in the fold between the cheek and the upper lid and a short incision behind the sideburn—avoiding incisions around the ears. In an older patient, not only would a full facelift be indicated, but also brow lifts, lip enhancements, or skin resurfacing may be added to achieve the optimal result.”

Setting Expectations

Whatever approach is suggested, Dr. Bunkis explains the expected outcome to each patient thoroughly. “I can do this by placing the patient in front of a mirror and lifting their skin, or by using computer imaging. During the consultation, I always relay my philosophy and give each patient a realistic idea of what they can expect to achieve with surgery. This is an art form and the patient deserves to know my vision before we embark on the surgical voyage,” concludes Dr. Bunkis.

Dr. Bunkis practices in South Orange County and in the San Francisco East Bay. A Board Certified Plastic Surgeon specializing in cosmetic surgery of the face and body, Dr. Bunkis has years of unsurpassed surgical expertise. Below are examples of actual patients of Dr. Bunkis that illustrate the various options for facial rejuvenation.

A 35-year-old anesthesiologist patient with a full neck, before and after neck liposculpture, chin implant and rhinoplasty. This same neck contour and sagging could not be corrected as effectively with an isolated liposuction procedure in someone a decade or two older because of the loss of skin elasticity and muscle laxity.

A 48-year-old, weathered female patient who looked significantly older than her stated age, before and two years after (at age 50) following a full-face CO2 laser resurfacing, endoscopic brow lift, facelift, upper and lower eyelid procedures. The neck was liposuctioned as a part of the facelift, but a neck liposuction alone would only have left her with a thinner but saggier neck and not addressed the unusual laxity and sun damage she had.

Dr. Bunkis can be reached by calling (949) 888-9700 or you can write to him at bunkis@ocps.com.

Q: “I would very much like to enhance my breasts before the bikini season is over! A few doctors I’ve seen have recommended an uplift along with implants, but I was not happy with the pictures of the scars that they showed me. What should I do?” — Sara P., Coto de Caza, CA

A:  Breast enhancement surgery is as elective as it comes and each procedure should be designed to meet the patient’s expectations. The first question you should answer is: what are your expectations?

Many options must be considered when planning breast enhancement. But the planning has to take into consideration each patient’s anatomy and expectations! Breast enhancement can be accomplished via a breast reduction or a breast augmentation (with or without an uplift) or with an isolated uplift. It all depends on the desires of the patient.

An enlarged breast almost always has some drooping of the nipple, and the nipple is raised in most breast reduction procedures. Breast reduction is a separate subject. This article will focus on breast enlargement, with or without an uplift, and isolated breast uplifts without the use of an implant.

Breast Augmentation vs. Uplift

A breast augmentation by itself rarely leaves visible scars. The tiny incisions can be placed in the fold under the breast, around the areolus or in the armpit area.

Breast uplifts, on the other hand, can never be done without leaving a scar that will be visible forever. The surgeon must make sure that the degree of improvement warrants the resultant scaring. If an uplift is attempted for a very minor degree of breast ptosis (drooping), it is unlikely that the patient will be thrilled with the trade off. On the other hand, if the nipples are hanging halfway down to the navel, the minor scaring visible with uplifts will not be much concern to the patient. The trick is to make the right decision for the patient who falls in the grey zone in between these two extremes.

You are correct in thinking that the traditional uplift procedures do leave visible (when naked) inverted “T” scars. But newer techniques today allow a surgeon to obtain similar results with minimal incisions, sometimes limited to a circle around the areolus. Incision patterns chosen by the surgeon will be dictated by the surgeon’s experience, the patient’s anatomy and each patient’s expectations. Basically, the droopier a patient is to begin with, the more skin will be resected and the more scaring can be expected.

When a Breast Uplift Is Recommend

A key anatomical factor in deciding whether or not an uplift is recommended is based on the position of the nipple in relation to the inframammary fold (the fold that runs under the breast). With the patient standing, if the nipple sits above the level of the inframammary fold, a breast uplift is not indicated. If the nipple is an inch or more below the fold, an uplift will be necessary to achieve normal breast shape.

The difficult decisions come when the nipple is within an inch or so of the fold, the so-called grey area. In these situations, the patient (note that I said “patient”, not surgeon) will have to decide if a breast uplift is desirable. In such borderline cases, we help the patient make an informed decision by showing examples of various breast configurations, with or without uplifts, and showing each patient examples of expected scars. Each patient then has to decide whether the improvement in breast shape is desirable enough to warrant the scars associated with a breast uplift.

Breast Lift vs Lift Plus Implant

To help a patient decide between a lift alone versus a lift plus a breast implant, I explain that an implant makes the breast volume increase but does not significantly change breast shape. Conversely, a bra will lift a droopy breast in a manner similar to a breast uplift but, by itself, does not change breast volume. So if a patient is happy with their volume and only wants to be uplifted, an uplift by itself should be recommended. Whereas, if a patient puts on her bra and still feels that a fuller breast would be desirable, she would be better off having an uplift with implants.

Here are a few examples of enhancements to illustrate the difference:

(Actual patient of Dr. Bunkis) A 25-year-old desirous of breast enlargement before and after implant placement. Note that her nipples are well above the fold, so an uplift is not indicted.

(Actual patient of Dr. Bunkis) A 25-year-old mother of two with droopy breasts, nipples just below the level of her inframammary folds, before and after uplift with implant. She was happy with the shape of her breasts in a bra but not with the size. She was a candidate for an uplift with incisions just around each areolus and insertion of implants.

(Actual patient of Dr. Bunkis) A 35-year-old mother of two before and after a breast uplift with a short scar technique. She was happy with her breast shape and size while wearing a bra. Implants were not indicated in this case.

As you can see, the topic of breast enhancement is a complicated one.

Any decision regarding which technique will be most desirable can only be made after a thorough consultation and a discussion of the options and patient expectations.

More information is available at: www.ocps.com

or: www.ocbreastenhancement.com

What’s most important is to find a surgeon who is well-versed in all of these techniques, and to choose the procedure that will give you the results you expect with the least possible amount of scarring.

Please feel free to call Dr. Bunkis at Orange County Plastic Surgery (949) 888-9700 to discuss your options.

— 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!

“I am interested in a breast reduction but my research has shown me a lot of examples with very noticeable scars. Do all breast reductions end up with bad scars?” — Kelly P., Coto de Caza, CA

You are correct in thinking that the traditional breast reduction and other cosmetic breast procedures frequently leave rather noticeable scars, especially if compared to the rarely visible scars after procedures such as a face lift or eyelid surgery. These scars run around the areolus, vertically down to the fold and horizontally along the fold (i.e. the inverted “T” incision”). But newer techniques today, most of them pioneered in Europe and South America, allow a surgeon to obtain similar results with minimal incisions (as short as a single incision, one quarter of an inch long, if the procedure can be done using liposuction techniques).

Incision patterns chosen by the surgeon will be dictated by the surgeon’s experience, the patient’s anatomy and each patient’s expectations. It is possible today to significantly reduce many breasts with minimal incisions, occasionally utilizing liposuction alone. The decision regarding which technique will be employed can only be made after a thorough consultation and a discussion regarding patient expectations.

The liposuction procedure can reduce breast volume but will not result in a significant skin tightening or elevation of the nipple. If a significant reduction also requires elevation of the nipple, the newer techniques which result in incisions either just around the areolus or including a vertical component may suffice. And occasionally, with very large breasts or a desire for an elevated nipple, the surgeon may still recommend the inverted “T” incision if a significant skin excess is present. Various options can be seen in our gallery, and some are below.

But the most important part is to find a surgeon who is well-versed in all of these techniques, and to choose the procedure which will give you the result you expect with the least amount of scarring possible. Please feel free to call Dr. Bunkis at Orange County Plastic Surgery (949-888-9700) to discuss your options.

(Actual patient of Dr. Bunkis)
39 year old Hispanic female, before and seven months after a short scar breast reduction (before the scars have finished maturing).

First of all, for those of you who missed it, last week a whole bunch of kind-hearted people helped a 71-year-old Mexican artist get rid of a large skin cancer which had eaten away the center of his face!  The surgery was performed at the Laguna Hills Surgery Center and all services for his surgery were donated by Orange County Plastic Surgery, the Surgery Center, its staff, Dr. Kevin Becker the anesthesiologist and surgery center medical director, and the pathologist, Dr. Allan Rushovich.

With Dr. Rushovich’s help, we were able to determine the extent of the tumor and to remove all of it. This entailed removing what was left of his nose and about half of his right cheek. I was able to close the central defect with a flap from his forehead, rotating it 180 degrees to cover the area that had been occupied by his nose. The flap is 100 % viable and he is making a remarkable recovery.

There were a few days when he was down but as the swelling is starting to go down, Manuel realizes that he will eventually look much better than he did before his cancer was removed. When a flap is rotated 180 degrees like this, a pucker is created at the point where the skin is turned on itself. In this case, the pucker is located just below the right eyebrow medially. This temporary pucker is necessary because it contains the blood supply to the flap and cannot be transected until the flap gains new blood supply from the area in which it was placed. In a month or two he will return to have this pucker resected and he should be ready for more photographs.

This is what Manuel looked like prior to going in for his surgery. The pink are on his right cheek was also tumor and had to be resected.

Thank you to all of you who helped and for the many of you who sent us encouraging words!

Summer is around the corner and we should all be cautious to minimize sun damage to our skin. Excessive exposure to the suns UV rays is the cause of skin cancers.  It has been shown conclusively that skin cancers occur more frequently in areas that enjoy more sunny weather (definitely more common in California, Texas and Florida than in Washington state or Minnesota). It occurs more commonly in fair-skinned people and definitely more common in people who have spent more time in the sun!  But that does not mean that we should avoid the beautiful outdoors we have here in California! Just do whatever you can to protect your skin from exposure.

Sun block should be applied to all exposed skin and a hat should be worn whenever possible to keep excessive rays of sunshine off our face. Get a good sun block that you like. Look at the SPF factor. In general, the higher the SPF factor, the longer the sun block will protect your skin.  A 15 SPF may have to be reapplied every hour to be effective, while a 45 SPF will protect you for four hours. And if you hate the white look, it is possible to get a very effective spray tan before you go outside – and then put sun block over it!  The best place to do this in Orange County is one of the five Unique Tan Bronzing Boutiques. If you have a choice, plan your outdoor activities in the early morning or later in the afternoon instead of mid day when the sun’s rays are most intense.

Manuel had a basal cell carcinoma, by far the most common type of skin cancer.  A basal cell carcinoma will continue to grow and grow, eating the flesh locally but cells from this cancer do not metastasize – if not treated, this tumor can create local havoc but cells do not break away and travel to the brain, lungs, liver or lymph nodes, and they can with the other two skin cancers.  Manuel got into the trouble he did because his cancer was not treated adequately – he had it for 27 years!

In this country, it is possible to see a case like this in some more remote area, but it is very rare because these cancers do not grow quickly and most people would have enough sense to get it treated. The other two types of skin cancers, squamous cell carcinomas and melanomas carry a more serious threat as they can spread to other parts of the body.  Squamous cell carcinomas usually occur in older folks who have been in the sun a lot (for example, older fishermen, golfers or tennis players) but melanoma’s can strike the young as well as the old, and can be very deadly if not caught early.  Melanomas frequently arise from moles. If you have a lot of moles over your body, you should see a dermatologist at least once a year for a total body skin check. Dr. Daniel Di Cesare of Orange Coast Dermatology is an excellent dermatologist and we would recommend him highly. He works our of our Orange County Plastic Surgery office and can be reached at 949-888-8500.

So look beautiful this summer, but be wise. Use sun block, wear a hat and sunglasses, and do see a good dermatologist once a year if you have a lot of moles or if you have had a cancerous or precancerous skin lesion in the past.