FAQ

Plastic Surgery FAQs

LIPOSUCTION

1If I remove fat from one problem area will other areas of my body become problem areas?
After puberty we do not make new fat cells. Some of the cells are programmed to survive regardless of diet and exercise. These areas are different for everyone. Once fat cells are removed with liposuction they are gone forever. However, the cells that remain can grow and shrink if stressed. The average weight cycle in a year of 10lbs (up in the holidays down in the summer) will not have a visual change to the body. If someone was to gain a significant amount of weight such as 40lbs they would notice less weight gain in the areas of liposuction compared to the other areas of the body.
2What is the difference between traditional liposuction and what you do?
Traditional liposuction is performed under general anesthetia, typically in a hospital. Dr. Neinstein makes people comfortable with oral medication sometimes a bit of IV medication and just like at the dentist where they numb your teeth we numb the areas of liposuction by putting numbing fluid under the skin into the fat. Laser and other energy devices are used to help melt the fat and tighten the skin allowing tiny instruments to be used with minimal trauma to the tissues making the procedure, the recovery, and the results smoother.
3Tell me about downtime
By using tiny instruments and being careful to only touch fat, we can reduce the inflammation that causes pain and swelling. Most patients will take pain medication for one day but will feel sore (like you just did 1000 sit ups) for two weeks or so. Almost all of our patients will have surgery on Thursday or Friday. They will typically rest on the day of surgery, get back to half speed the next day and by the third day resume all activities with some soreness but no need for medications. Patients told us, they are too busy for downtime and don’t want to use vacation days for recovery. Our goal is surgery Thursday or Friday and back to Work/Life on Monday. If people want many areas we just break it up into two sessions.
4Does it matter what kind of Doctor and where procedure is done?
You want and need to have your procedure done by a Board- Certified Plastic Surgeon. You will not find Plastic Surgeons performing Heart Transplants or Colonoscopies because we were never trained to do so. So, you should wonder why a Gastroenterologist or a Primary Care Doctor or a Dermatologist is performing a procedure they were never trained in? The procedure must be done in an accredited facility. This means the facility meets the safety standards as required by the state.
5How Do I get my Partner, Spouse, Family, Friends on Board?
Anything that involves time and money is rarely a solo decision. Good news, investing in your body can really pay off. With a renewed sense of confidence, the benefits will spread to those around you. Most of our patients are so used to taking care of others that they forget about themselves. They forget how much those around them really want them to be happy.
6What exactly is Liposuction?
Liposuction is simply the surgical removal of fat that is under the skin. In our bodies, we have fat under the skin and fat that is under the muscle around our organs like our liver. Only the fat under the skin can be safely removed
7What is liposculpture?
People use this word for fancy advertising but it basically means liposuction and is not a medical term
8What is lipostructure?
This is a technique of injecting fat pioneered by Dr. Sydney Coleman
9What is 3D or 4D lipo or abdominal etching?
I am still trying to figure this out myself. I typically perform liposuction in the real world and have yet to figure out how to get to the fourth dimension. These are just advertising buzzwords. Abdominal etching is when doctors attempt to “carve out a six pack”. This procedure is risky and unpredictable.
10What does Tumescent Liposuction mean?
Tumescent means “to fill” in Latin. It is the part of the operation when you put numbing fluid into the fat before the procedure begins.
11This all sounds great but what can go wrong?
Liposuction, when done by an expert is incredibly safe but it is important to know that it is not perfect. Luckily by not putting people to sleep the major fatal risks such as blood clots are almost completely removed. From time to time we see some lumps, bumps, or contour irregularities. Luckily most of these are easily managed with a touch up. Infections are incredibly rare.
12What are the scars like?
Since the instruments I use are so small (3mm or less than a straw) the incision is basically a tiny poke like getting an IV. They are so small I do not even use sutures or stitches.
13I’m a big baby. Is it going to hurt?
During the actual procedure you will feel a bit of pressure when we put the numbing fluid in and some vibration when we remove the fat. However, the medications we give you before and during the procedure will make you feel comfortable, pain is not an issue.
14How do I prepare for my surgery to get the best result possible?
• Eat a high protein, low carb diet. Clean eating, no processed foods.
• Stop all smoking 4 weeks before (quitting is smart anyways but smoking interferes with healing)
• Exercise normally
• Stop all supplements, herbs and vitamins 2 weeks before surgery because they can cause bleeding
• Discontinued all caffeine products 3 days before surgery because you don’t want your blood pressure to rise
Discontinue all alcohol 3 days before surgery so the alcohol does not interfere with the medication
15Liposuction Peer Publication
This section is for people who want to read what plastic surgeons read. I am including my Maintenance of Certification Article I wrote for the American Society of Plastic Surgery in 2016. It’s a fancy way of saying I was asked to write a “How to Guide” on liposuction focusing on safety that all plastic surgeons around the world can use as a reference.

EVIDENCE-BASED MEDICINE MAINTENANCE OF CERTIFICATION ARTICLE: LIPOSUCTION

Introduction

Since the latter half of the twentieth century, there has been an increasing focus on the body as a vehicle for identity and self expression with a greater recognition of the role of appearance and the desire for self improvement1. In 2014, liposuction replaced breast augmentation as the most frequently performed surgical procedure with a 16% increase over 2013 and more than 1 billion USD being spent on the procedure in the United States alone2.

Pre-Operative Assessment

It is important for the physician early into the consultation to assess the patient’s motivations for surgery as well as the degree of concern they have about their current physical state in order to meet their expectations. Patients with body dysmorphic disorder (BDD) will not benefit from surgical intervention and have been observed in aesthetic surgery settings to seek surgical enhancement at a reported prevalence of 6% to 15%3. The current recommendation is for the patient to be within 30% of the ideal body mass index (BMI) but whether liposuction can be a contributing factor to weight loss in high BMI individuals is an area of controversy4. Massive weight loss patients may have persistent areas of lipodystrophy amenable to liposuction. In a recent study using multivariate regression models incorporating the interaction between liposuction volume and body mass index. The authors’ risk assessment model demonstrates that volumes in excess of 100 ml per unit of BMI confer an increased risk of complications5. The results of this study may help surgeons in surgical planning and expectation management.

Medical History

Many patients take vitamins, minerals, and supplements and do not report this to their practitioner as they feel they are inconsequential. Stopping all non-essential agents before surgery can reduce the risk of a bleeding related complication6.

The percentage of the US population using at least 1 psychotropic medication increased from 5.9% in 1996 to 8.1% in 20017. First line antidepressants include  selective serotonin reuptake inhibitors (SSRI’s). These medications along with others can compete with lidocaine for metabolism in the liver increasing the risk of toxicity8. Drugs that potentially interfere with lidocaine metabolism should be discontinued at least 2 weeks before using tumescent technique for local anesthesia when high doses of lidocaine are anticipated. If it is not reasonable to discontinue a drug that might interfere with lidocaine metabolism, then the surgery should be limited to smaller total doses of lidocaine or be done under general anesthesia9. Smoking is an independent risk factor for wound healing complications. The ameliorating effects of cessation are supported by level 1 evidence, which suggests that the optimal duration of preoperative cessation of any form of nicotine is four weeks or longer10. Diabetes mellitus (DM) is an increasingly common medical condition affecting approximately 8% of the population of the United States11. Infections account for 66% of postoperative complications and nearly one quarter of perioperative deaths in patients with DM. Fortunately, tight glycemic control has been shown to have a profound effect on reducing the incidence of many of these complications in a variety of surgical populations12. Complication rates in orthopedic surgery have been shown to be lower in patients whose HbA1c is less than 6.5%13.

Venous thromboembolism (VTE) is a serious complication with risks for short-term mortality and long-term morbidity. VTE has been shown to be the single largest cause of mortality in patients undergoing high-volume liposuction4. Caprini’s risk assessment model is a useful and effective tool to stratify plastic and reconstructive surgery patients for VTE risk even in oral sedation tumescent liposuction cases14.  Using regional or tumescent anesthesia alone has been shown to have statistically significant lower incidences of post-operative deep vein thrombosis15. If patients are on beta-blockers for hypertension it should be confirmed they are cardioselective to prevent a hypertensive crisis from an unopposed alpha vasoconstriction16. According to the American College of Cardiology/American Heart Association Guidelines, functional status is a reliable predictor of perioperative and long-term cardiac events.17.

Physical Exam

A carefully directed history and physical should look for stigmata and sequelae of chronic disease. When examining the abdomen, the physician should pay particular attention to surgical scars as potential sources of hernias. Visceral perforations are most common in the small intestine in patients with abdominal hernias18. Classification and documentation of the extent of diastasis recti and visceral fat component is essential. Skin quantity and quality should be assessed and differences between excisional procedures and liposuction should be discussed with the patients.

Informed Consent and Photography

Accurate photographic documentation has become essential in reconstructive and cosmetic plastic surgery both for clinical and scientific purposes19.  Generally, ‘‘informed consent’’ requires that the patient be informed of the risks of treatment, the prognosis, and alternative treatments before consenting to treatment. Surgical consent has evolved and is not an event or a signature on a form but is an ongoing process of communication that continues throughout preoperative, perioperative, and postoperative care.

Location of Surgery

Most surgical procedures are performed in one of three outpatient settings: hospitals, free-standing ambulatory surgery centers, or office- based surgery facilities20 . Office-based surgery has several potential benefits over hospital-based surgery, including cost containment, ease of scheduling, and convenience to both patients and surgeons. In a review of 3,615 consecutive patients who had undergone office-based plastic surgery with monitored anesthesia care or sedation there were no deaths, ventilator requirements, deep venous thromboses, or pulmonary emboli. This study helped show that office-based surgery with intravenous sedation, performed by board-certified plastic surgeons and nurse anesthetists, is safe21. Many surgeons still prefer to perform the majority of liposuction cases under general anesthesia22. Tumescent anesthesia was initially developed in 1987 by Jeffery Klein in an attempt to perform liposuction procedures with the sole use of local anesthesia23. In a review of 4,380 consecutive patients undergoing tumescent liposuction by the same surgeon, no serious complications requiring hospitalization were found24. It was found that hospital-based liposuction had three times the rate of malpractice settlements when compared with office-based liposuction surgery25. To promote its members to practice with the utmost safety and integrity as of July 1, 2002 facility accreditation is a requirement for active membership in the American Society for Aesthetic Plastic Surgery(ASAPS). Physicians should follow State specific regulations on total aspirate permitted at a surgical setting.

MEDICATIONS IN WETTING SOLUTIONS

Lidocaine

In 1943, lidocaine was the first drug of the amino amide type to be introduced into clinical practice, and its rapid onset and moderate duration of action ensure its widespread use today26. Lidocaine is rapidly eliminated by hepatic metabolism27. Any drug that inhibits CYP3A4 enzymes, any condition that reduces hepatic blood flow, along with any disease that effects liver function can reduce lidocaine clearance28. Not all patients should be treated equally in terms of lidocaine doses. For example, lower limits of lidocaine should be used in thinner patients with smaller volumes of distribution29. The maximum recommended doses typically do not take into consideration the site of injection or factors that may influence tissue redistribution, metabolism, or excretion. The Xylocaine (lidocaine hydrochloride) (Astra Pharmaceutical Products, Inc. Westboro, MA) package insert reads that the dose of lidocaine at any one time should not exceed 3 mg/kg for plain solutions or 7 mg/kg for preparations including epinephrine30. By measuring sequential lidocaine blood samples after tumescent infiltration along with graphing the peak plasma concentrations as a function of the lidocaine dosage (mg/kg), a safe maximum dosage for tumescent lidocaine was shown to be 35 mg/kg by Klein31 . While it is generally accepted that lidocaine doses up to 50mg/kg32 and even 55mg/kg33 are safe to use in tumescent liposuction, the ASPS guidelines recommend 35 mg/kg as the maximum dose.  Lidocaine may also contribute to the extremely low incidence of infection seen in liposuction due to its bacteriostatic effect. Data suggest that, for patients undergoing general anesthesia with the superwet technique, the lidocaine component may be eliminated with out an increase in post-operative pain34.

Epinephrine

Epinephrine causes vasoconstriction resulting in hemostasis and delayed absorption of the anesthetic agent. This prolongs its effect, decreases the amount of anesthetic needed, and reduces the risk of lidocaine toxicity35. It is recommended that epinephrine doses not exceed 0.07 mg/kg, although doses as high as 10 mg/kg have been used safely36. The detection of peak levels between 2 and 4 hours after infusion has been found in multiple studies37,38. It has been shown that the time when the lowest cutaneous hemoglobin concentration after 1% lidocaine with 1:100,000 epinephrine is injected subcutaneously is 25.9 minutes39. This is considerably longer than the frequently quoted 7 to 10 minutes for maximal cutaneous vasoconstriction40.

Bupivacaine

Bupivacaine is a long acting amide local anesthetic, which, unlike lidocaine, does not have an active metabolite Of all the amide local anesthetics, bupivacaine is said to be the most cardiotoxic. This toxicity is seen mostly when there is a sudden increase in the plasma concentration of bupivacaine41. However, full recovery has been reported using an intravenous injection of a lipid emulsion, Intralipid 20% (Baxter Healthcare Corp., Deerfield, Ill.). It has been suggested that lipid emulsion may reverse local anesthetic toxicity by extracting lipophilic local anesthetics from aqueous plasma or tissues or by counteracting local anesthetic inhibition of myocardial fatty acid oxygenation42. In a prospective study, Swanson38 found plasma levels were slower to rise than lidocaine, peaking at 20 hours compared to 8 to 18 hours after infusion. That study also went on to show safety with 550 mg administered and 3.33 mcg/ml peak plasma concentrations.  An online survey to members of the American Society of Plastic Surgeons revealed that 7% of respondents are using bupivacaine in their tumescent solutions with no reported cases of toxicity43.

Sodium Bicarbonate

When lidocaine is used for local, subcutaneous injections patients often complain of pain thought to be related to the pH of most commercial lidocaine solutions, which are between 3.5 and 7.044,45. Some data suggest that alkalization of lidocaine does in fact reduce the level of pain associated with its injection.

Wetting Solutions

The current options for wetting solutions are dry, wet, superwet, and tumescent. The essential differences between these techniques focus on the amount of infiltrating solution injected into the tissues and the resultant blood loss as a percentage of aspirated fluid. The dry technique involves no infused fluid and results in approximately 25-40% blood loss of the volume removed. Blood loss has been estimated to represent approximately 1 percent of the liposuction aspirate volume for both tumescent and superwet techniques46. Swanson38 felt that this was a gross underestimation and has shown that there is substantial extravascular “third-space” blood loss into the interstitial tissues correlating to an approximate 2-point percentage decrease in hemoglobin for every 2500 cc of aspirate. “True” tumescent anesthesia is considered a 3:1 infiltrate to aspirate under pure local anesthesia. Most plastic surgeons report using a wetting solution that is a variation of superwet anesthesia (1:1 infiltrate to aspirate).Tissue blanching and moderate tension are considered clinical endpoints of infiltrate47.

OPERATIVE CONSIDERATIONS

Cannulas

In general, blunt tipped cannulas are used to minimize perforation risk and smaller diameter cannulas are used to minimize contour irregularities. Non-blunt cannulas are typically used for breaking up scar or discontinuous undermining.   Aspiration has been found to be directly proportional to cannula and suction-tubing diameter and inversely proportional to cannula and suction-tubing length48. Beck49 with a proprietary manufacturing process found multiport and dual port cannulas to be significantly more efficient at aspiration compared to the standard Mercedes tip cannula.

Operative Techniques

Specific depths of subcutaneous fat should be suctioned, which vary from different body locations and patient specific goals. For example, the deep and/or intermediate fat layer should be primarily suctioned22 but, in rare cases, superficial or subdermal liposuction may be appropriate50. Anatomic “zones of adherence,” present in both men and women, are important to identify preoperatively. These are areas with relatively dense fibrous attachments running to the underlying deep fascia where they help define the natural shape and curve of the body. These areas are not to be suctioned51 because of the high potential for contour deformities. Small volume procedures or procedures primarily for harvesting fat can be performed with syringe liposuction. The syringe technique employs blunt-tipped suction cannulae connected to a syringe. Drawing back the syringe plunger generates the negative pressures needed to remove fat during liposuction and replaces the electric vacuum pump and connecting tubing traditionally used for this procedure52. See surgical videos

ADJUNCTIVE LIPOSUCTION TECHNOLOGY/TECHNIQUES

Power Assisted Liposuction (PAL)

Power-assisted liposuction (PAL) is a commonly used technology that uses a variable-speed motor to provide reciprocating motion to the cannula, which in combination with the reciprocating action of the surgeon’s arm, facilitates removal of adipose tissue. The principal advantages of PAL is treatment speed, economy of motion, and reduced operator fatigue53.

Laser Assisted Liposuction (LAL)

Goldman and colleagues showed histological evidence of coagulation of small blood vessels, rupture of adipocytes, reorganization of the reticular dermis, and coagulation of collagen in fat tissue with an updated 1064nm wavelength Nd:YAG laser54. In a prospective, randomized, double-blind, controlled clinical trial comparing outcomes between suction-assisted lipoplasty and laser- assisted lipoplasty in patients where the authors randomly allocated half a body part for each modality, no major clinical differences for suction-assisted lipoplasty versus laser-assisted lipoplasty was seen55. Although there is no conclusive evidence for the use of lasers in liposuction the recent adoption of the 1440nm laser may prove to be efficacious for emulsification. The longer wavelength has twenty times more absorption in adipose tissue than the 1064- nm/1320-nm and forty times more absorption than 924-nm/980-nm wavelengths56.

Ultrasound Assisted Liposuction (UAL)

Vibration amplification of sound energy at resonance (VASER; Solta Medical, Inc., Hayward, CA) is another modality that was introduced to the United States with great fanfare after early utilization with mixed results of hollow probe ultrasonic liposuction in the 1990s57. Nagy and Vanek58 compared VASER-assisted lipoplasty and suction-assisted liposuction. They evaluated 2 objective end points: skin retraction in which VASER showed a 6% increase and blood loss, which also showed a minimal benefit of 3cc per 100cc of aspirate. Both surgeons and patients were unable to tell the difference between sides treated with either system59. With the growth of autologous fat transfer, the use of ultrasound to selectively target and dislodge fat cells from the fatty tissue matrix may help improve fat viability and retention60.

Radiofrequency Assisted Liposuction (RFAL)

Paul and Mulholland introduced radio frequency assisted liposuction and soft tissue contraction technology showing that energy could be delivered to the dermis while heating the deep adipose and subcutaneous tissue to much higher temperatures without compromising skin safety61. Using the BodyTiteTM (Invasix Ltd., Israel)  device in an industry sponsored in-vivo study linear contraction observed at 6 months follow-up was much more significant than reported with any other technology and varied from 12.7 up to 47% depending on patient and treatment variables62. Chia and Theodorou63 in a study on arm contouring with RFAL used 3 independent plastic surgeons’ evaluations of the preoperative and postoperative photographs and showed improvement in arm contouring be 8% excellent, 72% good, 18% moderate, and 2% poor. They determined the degree of skin tightening to be 11% excellent, 46% good, 38% moderate, and 5% poor.

Water Assisted Liposuction (WAL)

WAL utilizes a dual- purpose cannula that emits pulsating, fan-shaped jets of tumescent solution, followed by simultaneous suctioning of the fatty tissue and the instilled fluid . In a single surgeon study using the Body-Jet (Human Med, Eclipse Ltd., Dallas, Texas) the amount of blood loss was negligible, with lipocrits estimated at less than 1.0% in both small and large volume liposuction cases64. There was no comparison to other modalities and since no thermal energy was applied there was no discussion of skin tightening or emulsification. In a study comparing grafted lipoaspirates from WAL compared to SAL the water-based group had better weight retention, less apoptosis, and greater angiogenesis65.

Separation, Aspiration, and Fat Equalization  (SAFE Lipo)

Created by Dr. Simeon Wall Jr. this three-step process has been proposed to reduce irregularities, bruising, and increase skin retraction. Fat separation is performed without suction, using an angled 5-mm exploded tip (basket) cannula (Microaire, Charlottesville, VA, USA). Aspiration of the separated fat is performed with an angled 3-mm or 4-mm Mercedes cannula, to be used in areas with thinner or thicker areas of fat, respectively. Fat equalization (post-tunneling) of the previously treated areas is performed with the angled 5-mm exploded tip cannula, without suction. The contour of the areas is assessed by a rolling pinch test while passing the cannula, with the end point of a completely smooth rolling pinch test without thick or thin areas of contour. This process leaves behind a layer of separated fat that can be considered as local fat grafts66.

Markings

Areas to be suctioned are typically marked with a circle in a topographical pattern. Zones of adherence and areas to avoid are marked with hash marks67. Some authors advocate grid markings to standardize resection and reduce contour irregularities68. Incisions should be placed in natural creases to minimize visibility and some recommend placing bilateral access incisions asymmetrically to avoid scars that appear planned. It is important to review all markings and access incision locations with patients in front of a mirror before they are medicated.

Fluid Management

Under or over fluid resuscitation remains a critical issue with regard to liposuction. Empiric formulas have been suggested. Rohrich et al. suggest intraoperative fluid ratios near 1.8 for small-volume reductions and 1.2 for large-volume aspirations69.  Pitman et al. recommend that the total volume of fluid administered should equal twice the volume of total aspirate70. Matarasso recommends the total intake of injected, intravenous, and postoperative fluid is 2 to 3 mL/mL aspirate over the course of the two days after surgery71. The aim of intravenous fluid administration is to replace the preoperative deficit and provide maintenance fluid. With awake tumescent liposuction the patient is able to drink normally the night before and the day of surgery eliminating the need to replace deficits minimizing the risks of over or under hydration.

Post-Operative Care

Traditionally, prolonged use of elastic compression garments was advocated. The general rule of thumb was for patients to wear the garment for one week for every decade of life (40 year old patients would wear garments for 4 weeks). Prolonged compression can cause skin creases, hyperpigmentation, pain, and swelling. Some ways to minimize swelling and post-operative compression included minimally traumatic surgical technique, not suturing the incisions as recommended by Toledo and Mauad and applying bulky absorbent dressings for the 1st 24-48 hours to allow the excess remnant fluid and serous reaction to flow out72. Klein73 advocates for bimodal compression. During the first stage of bimodal compression, a high degree of compression is maintained for as long as drainage persists. The second stage of bimodal compression begins 24 hours after all drainage has ceased, and employs either moderate compression or no compression.

COMPLICATIONS

Local

With appropriate patient selection and minimally traumatic techniques many complications can be avoided. Overly aggressive liposuction can lead to seromas. The collection of serous fluid in a treated area may lead to extensive breaking of the fibrous tissue network leading to a single cavity formation74. The lower abdomen in patients with high BMI is a common area for seromas. Infection is extremely uncommon (less than 1% incidence)75. This may be due to a combination of sterile technique, small incisions, and the anti-bacterial effects of lidocaine. The most common post-operative complication is contour irregularities with an incidence of 2.7%76.  Illouz recommends that as a rule the contour should be slightly under-corrected to allow for post-operative fat lysis, which will amplify the result77. Using small cannulas, not performing superficial liposuction, turning the suction off when exiting incisions, crisscrossing areas, constantly analyzing areas(visual and tactile), proper positioning, can all help reduce the chance of contour irregularities. Autologous fat transfer at the time of surgery or 6 months post-operatively can be used to help correct deformities. Toledo and Mauad recommends routine harvesting of a few syringes of fat prior to SAL so that it may be re-injected in cases of inadvertent over-liposuctioning in any area72. Relatively infrequent skin conditions such as hyperpigmentation, necrosis, and erythema abigne can be seen. Underlying connective tissue disease, smoking, along with superficial aggressive liposuction may contribute to these complications78.

Systemic Complications

The most frequent potentially lethal complications associated with liposuction are pulmonary embolism, fat embolism, sepsis, necrotizing fasciitis, and perforation of abdominal organs. Grazer and de Jong4 in a North American survey of American Society of Aesthetic Plastic Surgery (ASAPS) members found a fatality rate of 19.1 per 100,000 liposuction procedures. The major cause of death was pulmonary thromboembolism. Even though dermatological studies of true tumescent liposuction have reported the risk of death from liposuction procedures to be zero in a series 66,00079 cases there are reports of deaths in true awake tumescent liposuction75. Major risk factors for the development of severe complications are poor standards of sterility, the infiltration of multiple liters of wetting solution, permissive postoperative discharge, and selection of unfit patients75.

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  1. Prado A, Andrades P, Danilla S, Leniz P, Castillo P, Gaete F. A prospective, randomized, double-blind, controlled clinical trial comparing laser-assisted lipoplasty with suction-assisted lipoplasty. Plastic and reconstructive surgery. 2006;118(4):1032-1045.
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  4. Nagy MW, Vanek PF, Jr. A multicenter, prospective, randomized, single-blind, controlled clinical trial comparing VASER-assisted Lipoplasty and suction-assisted Lipoplasty. Plastic and reconstructive surgery. 2012;129(4):681e-689e.
  5. Matarasso A. Discussion: a multicenter, prospective, randomized, single-blind, controlled clinical trial comparing VASER-assisted lipoplasty and suction-assisted lipoplasty. Plastic and reconstructive surgery. 2012;129(4):690e-691e.
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  7. Paul M, Mulholland RS. A new approach for adipose tissue treatment and body contouring using radiofrequency-assisted liposuction. Aesthetic plastic surgery. 2009;33(5):687-694.
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  25. Housman TS, Lawrence N, Mellen BG, et al. The safety of liposuction: results of a national survey. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]. 2002;28(11):971-978.

NEUROTOXINS

1What are compression garments and what do they do?

I use garments (think SPANX on steroids) to squish out the extra numbing fluid and to help reduce swelling in the first week. That is basically it.

Here is a video on garments:


2What is a Neurotoxin?
Neurotoxins are FDA approved injections to improve the appearance of both moderate to severe facial wrinkles between the brows and crow’s feet in adults. It is also used for forehead wrinkles, to treat sweating, and many other medical conditions. It contains tiny amounts of a highly purified botulinum toxin protein which cause the muscles in your face to relax, therefore creating a smoother and wrinkle-free appearance.
3How does it work?
Neurotoxins when injected in or near a muscle prevent the impulse from the nerve to the muscle thus allowing the muscle to be in a relaxed state. When using the appropriate amount of toxin the muscle can still move which prevents a frozen look.
4How do I prepare?
Make sure you don’t have an important social event to attend within 3 days post neurotoxin injection in case bruising occurs.
5How long does it last?
Neurotoxin injections last anywhere from 3-4 months. It does not turn off like a light switch, it’s more like a dimmer. Some patients will chose to have it re-done every 3 months and some every 6 months or longer.
6How long does it take?
15 to 20 minutes.
7Does it hurt?
Any injection can hurt, but the needles used when performing neurotoxin injections are very small, so pain is usually minimal. The area can be numbed with a topical anesthetic cream or cold pack for 10-20 minutes before the injections are given.
8Will Neurotoxin injections make me look like I’ve had work done?
No. You will not lose the ability to show facial expression.
9What to do after
Remain in an upright position for at least 4 hours post neurotoxin injection. Avoid strenuous physical activity and rubbing/massaging the injected areas for 24 hours because you don’t want to make the neurotoxin spread.
10Risks to having Neurotoxin injections
No Complications are rare, but the injectable can cause side effects for some, such as, weakened muscles, allergic reactions, or neurotoxins spreading to areas outside the injection site. The most common reaction is a mild headache.
11How much does it cost?
National average is $10-$20 per unit or $400-$800 per area.

DERMAL FILLERS

1Who should do it?
A Board Certified Plastic Surgeon or Dermatologist will be well trained in the products and the anatomy, along with specific injection techniques.
2What is a Dermal Filler?
Dermal Fillers are a group of FDA approved gel substances widely used to add volume to your face, plump up thin lips, and reduce the appearance of wrinkles, fine lines and folds that gradually appear on your face and neck overtime. They can also be used to correct any deformities in the chin and nose. Dermal fillers are made up of Hyaluronic acid, which is a naturally occurring substance in the body that is responsible for regulating cell growth and their renewal.
3How does it work?
The filler is injected under the skin to add volume to your face that has been lost due to ageing and to give your skin a smoother and youthful appearance. The filler will also attract water, bringing hydration to the treated area leading to a revitalized fresh and supple skin.
4How do I prepare?
Make sure you don’t have an important social event to attend within 3 to 7 days post-dermal filler injection in case bruising and swelling occurs.
A week before you get injected, stop taking:
• Aspirin
• Ibuprofen, either generic Advil, Aleve, or Motrin
• Exedrin
• St. John’s Wart
• Vitamin E
• Fish oil or Omega-3s
• Ginko Bilboa
• Ginseng
This will minimize any potential post-dermal filler injection bruising. Also, avoid drinking alcohol a few days before you get injected.
5How long does it last?
The effects of Dermal filler treatment are not permanent, they are long lasting though, generally lasting from six to twelve months, and gradually fading over time. Duration of the effectiveness depends on several factors such as the area that requires treating, patient’s skin type, skin condition, and the individual’s lifestyle and age.
6How long does it take?
This depends on how many areas you are having treated. Time frame will range from 10-30 minutes for the entire appointment.
7Does it hurt?
Any injection can hurt, but the needles used when performing dermal filler injections are very small, so pain is usually minimal. The area can be numbed with a topical anesthetic cream or cold pack for 10-20 minutes before the injections are given, so you may not feel much pain, if any.
8Will Dermal Fillers make me look like I’ve had work done?
This depends on the look you desire. If you prefer a more conservative look than it’s important you communicate that to your injector. If you prefer a bolder and more dramatic result, it’s important you communicate that as well.
9What to do afterwards
You can continue with your routine life right after getting the treatment. However, do not expose the treated area to direct sunlight for at least 2 to 3 days after getting the dermal filler treatment. Also avoid putting on heavy makeup, because some cosmetic products may react with the injectables. You may continue to apply a cold ice pack to reduce swelling.
10What are the risks associated with Dermal Filler injections?
The most common side effects associated with Dermal Fillers are slight bruising and swelling at the injection site. But these symptoms go away in a couple of hours without any special medical attention. Some relatively serious issues related with these anti-aging injectables include accumulation of the blood underneath the skin, or hematoma. Infections may also occur, and in some severe cases the infection may lead to tissue death. It is pertinent to mention here that most of the times these potential risks occur when the fillers are administered by inexperienced physicians.
11How much does it cost?
National average is $400-$1200 per syringe.
12Are there different kinds of Dermal Fillers?
Yes! Restylane®, Juvederm®, Perlane®, Radiesse®, Belotero®,, and Sculptra® are all FDA approved.

SKIN TIGHTENING

1Who should do it?
A Board Certified Plastic Surgeon or Dermatologist will be well trained in the products and the anatomy, along with specific injection techniques.
2What is the Venus Legacy Machine?
Venus Legacy is a non-invasive, no downtime device used to treat wrinkles, tighten skin, reduce cellulite, reduce stretch marks and circumferentially reduce fat. The procedure uses multi-polar radio frequency and magnetic pulsed fields to the skin to produce a dense and uniform heat matrix. This causes collagen synthesis and contraction by heating the deep layer in the skin, activating the body’s repair response to make and remodel collagen. Over time, this process reduces the appearance of loose, saggy, lax skin. Skin Tightening can be provided quickly and comfortably with no downtime, while still allowing for sun exposure immediately after each treatment if desired. The end result is a more youthful appearance. Most patients describe it as “a warm stone massage.”
3How does it work?
As our skin ages, its base foundation known as the dermal matrix begins to lose its tight, interwoven structure as some of its elastin and collagen strands become stretched. There is also a decreased production of collagen and elastin. The Skin Tightening procedure utilizes radio frequency energy to deeply heat collagen in the dermis. The heat also initiates the body’s natural healing or repair process, which creates a renewed collagen foundation leading to increased skin firmness. Powerful cooling maintains the outer surface of your skin at a cool temperature before, during, and after each pulse providing the patient a comfortable and safe procedure.
4What areas can be treated?
Treatments are safe for all skin colors and can be performed on any area of the body where an improvement in your skin firmness is desired. Popular areas include the face, neck, abdomen, thighs, hands and arms. You should consult with Dr. Neinstein regarding the treatment options that are best for you.
5How many treatments will I need before I begin to see results?
6 treatment sessions for the face and 8-10 treatment sessions for the body are often recommended to achieve maximum collagen rebuilding and skin firming, but Dr. Neinstein can work with you on a personalized treatment plan. Patients may see immediate firming results right after treatment, but the full effect of improvement is achieved with several sessions as collagen continues to rebuild.
6Can I have filler and neurotoxin performed at the same time as a face and neck tightening session?
Yes, these are all complimentary
7How long does it last?
Skin tightening treatments do require regular maintenance. Once you have completed your treatment regimen it is suggested that you come every 6 months for a single treatment in order to help maintain your initial results.
8How long does it take?
This depends on how many areas you are having treated. Each area can range from 10-30 minutes. This time will increase if you are having multiple areas done at once.
9Does it hurt?
No. Actually patients enjoy and look forward to our skin tightening treatments and refer to them as a “warm stone massage.”
10Will Skin Tightening treatments make me look like I’ve had work done?
Absolutely not. You will notice a slight improvement with each treatment, allowing for an overall natural looking result.
11How much downtime will there be after the treatment?
None! The treatment is non-invasive so there is no downtime. Patients are able to immediately resume their normal activities and even apply makeup or sunscreen after each session with no visible signs of treatment. You may experience some mild redness in the treated area, but this will fade away within minutes post treatment. This makes Venus an ideal pick-me-up before special occasions or events.
12What to do afterwards
It is important to maintain a healthy lifestyle during and after your treatment plan, including diet and regular exercise. This will help enhance your results.
13What are the risks associated with Skin Tightening treatment?
When performing the Venus treatments, it is important to reach the target temperatures within the deeper skin tissues in a safe and reliable manner. Temperatures too high can lead to undesirable side effects including localized nodules, internal scarring and surface irregularities. Because of these concerns, the Venus Legacy treatments provide superior safety with a built in temperature gauge.
14How much does it cost?
National average is $400-$900 per treatment. Packages can range from $1500-$3500

BREAST IMPLANT

1Who should do it?
A medically licensed person that is adequately trained on the procedure and risks.
2What are the type of breast implants available?
In the United States there are saline and silicone breast implants. Both shells are made out of silicone but in saline implants the inside of the implant is filled with salt water. Implants can be round or anatomic (tear drop shape) and they can have a smooth surface or a rough (textured surface)
3Which impant type is best for me?
Silicone implants tend to feel more natural and be more durable than saline implants. Saline implants can be placed through tiny incisions and if they deflate the patient tends to notice immediately
4Should I get Round or Anatomic?
Round implants tend to give a rounder or fuller upper portion of the breast and anatomic implants which originally were used more in reconstruction can give a more natural appearance to the breast
5Should I get Smooth or Textured?
Most implants will have a smooth surface. Textured implants are seen in anatomic implants
6What are the incision options?
Implants can be placed through the armpit, the areola, or through an incision under the breast
7Should I get the implants above or below the muscle?
In general if the patient has very little breast tissue the implant will be placed below the chest muscle to provide more coverage of the implant, however, woman who exercise a lot may have thick muscles which can move the implant. Above the muscle is a good fit for woman with a good amount of breast tissue to start and who are dedicated to exercise
8How long is the surgery?
One hour
9Downtime?
Patients recover in 3-4 days, back to work in one week, back to the gym in 3 weeks
10How do I get a Natural Look?
Soft tissue-based planning means that measurements are taken of the soft tissues (breasts), the tissue characteristics (elasticity, fullness, firmness) are assessed and from this a systematic determination of implant size is made based upon information derived from thousands of previous breast augmentations. Using this method the optimal implant for the individual can be found
11What are the risks?
• Anesthesia risks
• Bleeding
• Infection
• Changes in nipple or breast sensation
• Poor scarring of skin
• Wrong or faulty position of the implant
• Implant leakage or rupture
• The formation of tight scar tissue around the implant (capsular contracture)
• Fluid accumulation (seroma)
• Wrinkling of the skin over the implant
• Pain, which may persist
Possibility of revisional surgery
12Do breast implants life the breast?
Breast implants will not give a significant breast lift
You May Want Breast Lift If….
Typically, you may benefit from a breast lift if you have one of the following conditions:
– You are bothered by the feeling that your breasts sag, have lost shape and/or volume
– Your breasts have become elongated
– Your nipples fall below the breast crease
– Your nipples and areolas point downward
– You have stretched skin and enlarged areolas
– One breast is lower than the other
13Do implants need to be changed every 10 years?
There is a common misconception that implants will only last 10 years. This is not true. If you have no problem with your implant then nothing needs to be done with them. The only reason you would change an implant is if there is a problem with them. The most common long term problem is implant rupture. The risk of a rupture is 1% a year.

ABDOMINOPLASTY/TUMMY TUCK

1How much does breast augmentation cost?
The cost of breast implants can vary widely depending on a number of factors (silicone vs. saline, sizing, hospital, surgery center, board certified anesthesisa vs nurse anesthesia etc.). If you would like to get a more precise cost estimate, it would be best to schedule an in-person consultation with a highly qualified, board certified plastic surgeon. National average is $5000-12 000.
2What is abdominoplasty?
Abdominoplasty or tummy tuck is a surgical procedure that removes excess skin and fat from the abdomen. It repositions the belly button and tightens the muscles as well
3What is the difference between liposuction and a tummy tuck
Liposuction is designed to remove fat, adding more technology helps tighten the skin but it does not replace actually removing excess skin in patients who have a significant amount of excess skin
4Am I candidate for abdominoplasty?
If you are in good physical health and have realistic expectations you are likely a good candidate
5At what age is abdominoplasty usually performed?
Ideally we wait until woman have had all of their children or weight loss patients get to their ideal body weight. There is no specific age cut off
6What are the different techniques for abdominoplasty?
The types of procedure relate to the extent of the incision. Mini tummy tucks, full tummy tucks (hip to hip) and body lifts (360 degree tummy tuck) can be performed
7What should I expect post-operatively?
The first week is relatively painful. The pain will be controlled with oral medication. You will be up and walking day one to prevent blood clots but it will likely take a week to stand up straight. Your sutures will all dissolve on their own so wound care is minimal. The incision will take 6 months to a year to fade
8What is the down time?
1 week off of work, back to the gym in 3 weeks. Surgery is performed as an outpatient.

BREAST LIFT

1What is the cost?
If you would like to get a more precise cost estimate, it would be best to schedule an in-person consultation with a highly qualified, board certified plastic surgeon. National average is $7000-15 000.
2Breast lift vs breast augmentation?
A breast lift or breast tightening procedure that tightens up a breast that has a loose skin envelope and has become droopy. Breast lift’s alone or designed to restore shape not volume.
3What kind of breast lift leaves minimal scars?
There are three types of breast lifts. Starting with the least amount of scarring moving to the most amount of scarring. The droopier the breast the more scars are required to lift the nipple and reshape the breast. A periareolar or donut lift, a vertical or lollipop lift or the wise pattern or anchor lift.
4Can breast lift and breast augmentation procedures be performed on the same surgery?
Yes, augmentation combined with a breast lift can be done at the same time. This is performed when a patients seeks a lifted but rounder and larger breast. I typically ask patients if they want a round upper part of the breast, if the answer is yes they will need an implant to achieve the goal
5What is the down time?
1 week off of work, back to the gym in 4 weeks. Surgery is performed as an outpatient.

General

1What is the cost?
If you would like to get a more precise cost estimate, it would be best to schedule an in-person consultation with a highly qualified, board certified plastic surgeon. National average is $9000-18 000.