This page offers a variatey of Frequently Asked Questions and Answers regarding a variety of procedures and related topics. If you do not find an answer to your question or you require further assistance, please be sure to contact us.
General
Facelifts & Related Surgery
I don’t do facelifts on patients less than forty except in very unusual cases. There seem to be two peak age groups, the early to mid forties, and from fifty through the mid-sixties, although I have done facelifts on patients in their late seventies.
There is no evidence that doing a "mini-facelift" early makes the face age better, but many patients begin to benefit from current techniques by the early 40's. However excellent results may be achieved at any age from the forties through the seventies, when and if the patient feels it is time.
Eyelid changes may or may not be even age related. In some young patients bulging of the fat in the lower eyelids is hereditary, and the patient usually tells me his or her father or mother always had the same appearance.Surgery can be well worthwhile even in the mid-twenties. Many patients finally come to have the surgery in their thirties and forties and have had the same appearance of their lower lids since their teens.
Brow lifts, similarly, should be done when the time is right. If there are deep vertical frown lines, they can be treated by muscle reduction whenever present, and drooping of the brows is common by the mid-thirties.
What is the recovery time?
I usually tell my facelift patients to plan on ten working days away from work, but some younger, healthy patients to return to work in a week. The recovery from endoscopic forehead lifts and eyelid surgery is usually faster, and return to work in a week is the rule rather than the exception.
Part of the role of the plastic surgeon is to place the incisions in such a way
Full recovery is, however, incomplete at these times. Healing goes on long beyond the removal of stitches. Scars become a little thicker and redder during the first few weeks, and then gradually fade. After stitches are removed you can get back to wearing makeup and this may help with your return to work The final healing process takes many weeks and final settling of scars to soft, flat, pale appearance may take up to a year or longer.
Surgery always involves some form of incision and work beneath the surface, and this means some small veins and arteries must be cut. Although bruising is usually not very extensive, it varies greatly from one patient to another.
Lasers have some benefits in cosmetic surgery but using a cutting laser as a surgical scalpel seems to be of more benefit in selling an operation than it is to the patient. Studies have shown that there is no benefit in terms of bleeding, bruising, healing time, or to the final result.
We use devices to seal off any significant blood vessels but the tiniest vessels, and capillaries seal better if your own body clotting system is allowed to do the work. For this reason, anything which impairs this function, such as the use of aspirin and other anti-inflammatory drugs, Vitamin E, and some homeopathic remedies must be avoided. We will provide you with a complete list of what to avoid.
If you bruise or bleed easily, you must tell your surgeon in advance, because there may be a problem with your ability to clot. Many women describe themselves as easy bruisers, but the key is whether or not you get unexplained bruises or whether you simply get a bruise anytime you bump yourself. We may need to order certain tests to to rule out bleeding problems.
The typical response to this question has been that surgery does not stop the "clock," it merely sets back the time on the clock of aging. This answer is incomplete. Using current facelift methods, some of the changes are profound and long lasting, such as the removal of fat from the neck and re-alignment of neck muscles, and the removal of bulging fat and excess skin from the eyelids
No. You will look refreshed, relaxed, and perhaps like you have been exercising and toned up, but natural and certainly not as though you have had surgery, if current techniques are used.
To learn more, please visit our Facelifts information page.
Liposuction
Because the thickness of the "fat organ" is reduced in the areas treated, the changes are permanent. Excess food intake will, as before, result in fat accumulation, but this will occur more in other, untreated parts of the body.
I usually recommend three to six weeks, depending on the degree of skin looseness, the age of the patient, the amount of fat removed, and I examine the patient several times during the healing period. Some areas, such as the upper arms, require only a short period of support.
I encourage walking during the first few days after surgery, light aerobic exercise (treadmill or stationary bicycle) a week to ten days after surgery, and full activity after three weeks. Swimming is also fine, and can be started quite early.
To learn more please visit our liposuction information page.
Body Contour Surgery
In general, if you are planning to have more children, some of the benefits may be lost. However, if you have lost weight and have excess skin as a result, feel self conscious about your appearance, the results of surgery may justify the operation at any time.
When there is skin looseness and the underlying muscles are stretched, suction will not improve the appearnce and may worsen it. When there is significant fat and some skin looseness, suction may not give a predictable result. In some cases, it is reasonable to start with a preliminary suction operation, with the understanding that a secondary (tightening) body contour surgery may be needed.
The incision length depends mostly on how wide an area of skin is removed, and this is related to how loose the skin is. In an abdominoplasty (tummy tuck), when all the skin below the belly button is removed, the scar usually runs from hip to hip. Less looseness requires a smaller incision.
I encourage walking during the first few days, light aerobic activity at two weeks, and full exercise routine with abdominal exercises at six weeks.
To learn more about Tummy Tucks please visit our Body Contour Surgery information page.
Breast Augmentation
While the umbilical technique may appear attractive, it has the disadvantage of not being a gentle, refined operation done with the excellent visibility of the endoscopic armpit approach, in which cutting is precise and pinpoint control of bleeding is maintained at all times. The TUBA technique tends to be done “blindly”, that is, without seeing what is actually being done, using the telescope only later, to ensure there isn’t active bleeding before stitching the incision closed. It has the disadvantages of inaccuracy and roughness, and all the consequences.
Placement of the implants can be above or under the pectoralis major muscle. But our experience has shown that if you want a long-lasting, natural-looking and feeling result, placement under the muscle produces the desired results far more readily.
All surgery carries risks of problems. We have continuously assessed the quality of our results to try to minimize risk. The following is a summary of both Dr. Gelfant’s experience at his Vancouver clinic and the general experience with breast augmentation.
Capsular Contracture: Whenever a foreign material, whether it is a sliver, a piece
of glass, shrapnel, or a breast implant is placed under the surface of the body, the body recognizes it as not part of itself, and if it cannot digest the foreign substance, reacts by forming a wall around it. This wall, which we call a capsule, is very much like scar, and may be thin and soft, or tough and thick. In the early phases of healing, all scars contract.
If the capsule contracts around the implant and the space available to the implant becomes tight, the implant comes under pressure, is forced into a more rounded shape, and becomes firm or even hard.
Vancouver Breast Augmentation - Gallery #3
Capsular Contracture of the right breast on our (screen left)
This condition, which we call capsular contracture, is by far the most common problem for both plastic surgeons doing breast augmentation and our patients. We cannot explain why one patient will get contractures and another will not, nor why in some patients one side will develop a contracture and the other will not. Nor can we predict who will get the condition. It poses no major health risk to the patient but may cause enough firmness on occasion to be uncomfortable or even painful and certainly, the more severe, the less natural they appear and feel.
Our experience parallels the experience of the plastic surgery community in general on the issue of contracture. Placement of the implants above the muscle results in contracture rates of roughly 25% by three years and this number continues to increase with time. Beginning in late 1996, we began placing all implants beneath the pectoralis muscle, and the contracture rate dropped profoundly, to less than 1% at three years, in almost 500 patients reviewed. While this has not eliminated the problem, it has reduced it to a rare occurrence.
Infection: Infection is a rare occurrence in Vancouver breast augmentation. If it occurs, it is usually present in the first week after surgery and almost always requires removal of the affected implant, cleansing of the space, and antibiotics. The implant can later be replaced once infection has completely settled. The risk of this occurring is less than 1/2%.
Post-operative bleeding: Bleeding inside the implant space can accumulate as a hematoma and this requires urgent re-operation. Prior to our change to under the muscle with endoscopic assistance (through the armpit) the risk was about 2%, the same as most plastic surgeons report. This has been reduced to once in the past 650 patients (less than 0.1%). While this is a profound reduction, bleeding can still occur. We also warn patients that if uncontrollable bleeding during surgery occurs, obscuring the lens of the telescope repeatedly, an incision in one of the traditional locations on the breast would be made, but this has never yet been needed.
Loss of feeling: or reduced feeling of the breast and nipple can occur. It used to be said this was in about 15% of patients. Although this appears to be far more than we usually see, it still occurs periodically. Although feeling usually gradually returns, it may not, or it may result in increased sensitivity for several months.
Pain: Sub or under the muscle, placement has a reputation of producing far more pain and a prolonged recovery. This is FALSE. If careful, GENTLE surgical technique is used, aided by the magnified view of the operation we have with endoscopic guidance, bleeding is minimized, the implant space is carefully prepared, and all factors are working in favour of rapid recovery. Most patients return to work within five to seven days.
Secondary surgery, bleeding postoperatively, pain, time away from work and from social activities are all minimized. Most patients are able to take only mild pain relievers by the second post operative day.
Scarring: Most incisions are 1" to 1-1/2" or less. It is rare for the scar to be visible once complete healing has occurred.
As of October 2006 the 14 year ban and limited use of silicone gel filled implants is over. Surgeons and their patients may now freely choose the implants which best fit their needs, without requesting special approval
Silicone gel filled implants were taken off the market except for investigational purposes in 1992 by the US Food and Drug Administration and Canada’s parallel body, the Health Protection Branch, soon followed with a similar ruling.
There were several concerns which prompted these rulings: possible risk of cancer,
a possible link to immune related diseases, and leakage of the implants.
Since 1992 much research has been done to study the effects of implants on the health of women with implants. All the available evidence, which is now very powerful, suggests there is no link between the use of silicone gel filled (or saline filled) implants and increasing risk of development of breast cancer or any of the chronic diseases which were responsible for the controversy.
From April 1992 until October 2006 use of silicone gel-filled breast implants was restricted at first to an outright ban and later to permission from Health Protection in Ottawa after a request from the surgeon. In October 2006, after years of considering all the evidence presented at multiple hearings, permission was granted to the manufacturers to sell the implants to surgeons without restriction. Continued research into health and safety of these devices is a condition of this approval.
There is no question gel feels more natural when the implants are picked up from a desk top. Gel can be varied in its consistency and can be made to feel very much like breast tissue. Cohesive Gel is now being advocated as the best filler for implants. Cohesive gel is said to be more stable so that in the event of a leak or rupture, the gel will be confined to the capsule and more easily removed. It is said to cause less visible rippling, waviness in the implant which may be visible through the skin.
We are pleased to now be able to offer these implants to our patients as one of the choices available.
Although we are now using silicone gel filled implants in many cases, we continue to use saline filled implants in roughly a quarter to a third of women. Why? Saline is the most natural filler. Our bodies are over 70% saline (salt water. Rippling is more of a problem with implants which are above the muscle. Since all of Dr. Gelfant’s implants are placed under the muscle, this is less of a problem, and is mainly seen in patients who have very little breast tissue and minimal body fat. In patients with minimal breast tissue and fat, we will usually suggest silicone as a possible option, to help minimize visibility and rippling.
You should be aware, that despite claims to the contrary, gel can still result in some visible rippling. Generally speaking, this is much less than in saline filled implants, in women with lower body fat and less breast tissue.
Until 2010, we felt there wasn't a safe way to put silicone gel filled implants in through the armpit incision we usually prefer.
That changed when we became aware of the Keller Funnel, a device which allows the implant to be gently squeezed through a small incision without touching the skin, and without placing too much pressure and risking injury to the implant. Since April 2010, we have been using this method with great frequency and success
We continue to consider saline filled implants to be an excellent choice for many patients, but use gel filled implants under the right circumstances. In practice, this means at least 70% of patients opt for silicone gel filled implants.
Historically there were many methods used to determine breast implant size, but these were, surprisingly, usually dependent more on the surgeon’s sense of balance and esthetics, than on the patient’s desires. Our aim in sizing patients is to try to satisfy the patient, while not compromising safety.
First, we ask the patient to buy a bra of the size she wants to be by trying bras on wearing a sheer blouse or T-shirt, stuffing the bra cup with tissue of other fillers. She then comes in to the office and we have her put the bra on and place a device in the bra. The device is a temporary type of implant which can be filled with water until the bra cup is filled to the desired volume with implant plus her own breast.
At this point, we examine the dimensions of the patient’s chest, and if she has sufficient space on her chest to allow the placement of an implant of the size she desires (which is usually the case) we simply use that size of prosthesis. Sometimes this may require a High Profile Implant. Adjustments can be made for differences in size between the two sides. Most important, the patient determines the size, with my help. However, no guarantee of size can be made.
Inflatable implants are supplied empty, and have a range of fill volumes. For a 325cc Mentor implant, for example, this is from 325 minimum to 375cc maximum. There is a feeling, among experienced plastic surgeons, that under-filling implants, something that was done before capsular contracture was understood, increases the chance of the implant shell breaking and leaking, simply because over time there is more folding of the shell over and over again.
There is also likely to be excessive rippling visible through the skin. There is also the feeling that maximally filling (to the maximum recommended volume), reduces this risk, and that overfilling may also be worthwhile. Excessive overfill, however, leads to the edges of the implant distorting and being easily felt. We usually fill implants to as near to maximum recommended volume as possible, and don’t overfill by much, if at all. In 494 patients operated on in a recent series from our clinic, the re-operation rate for size was less than 4% overall.
Stitches: There are no stitches to be removed. Stitches are absorbable and buried under the skin. You may begin showering the day after surgery at which time the small band-aid-type dressing is removed and not replaced.
We usually see patients, in our Vancouver clinic, the first working day after surgery day and check carefully for any problems, discuss how you are feeling, and review any concerns you may have.
Activity: We encourage you to start using your arms within twenty-four hours
of surgery. You may return to most normal activity within twenty-four hours.
You may begin riding a stationary bike, walking on a treadmill or outdoors or other gentle aerobic activity within a few days. Aggressive sports and exercise should not resume for two weeks. If you work out regularly in a gym with weights, you may not feel comfortable with “lat pull-downs” “pec fly’s” or “chest press” exercises for six weeks. Our studies have shown our patients to be back to near normal muscle strength by six weeks.
Exercises to keep the implant soft and mobile are reviewed after about one week. Barring any problems or concerns, we usually have another visit six weeks later and at six months, and then annually if possible.
With placement of the implants under the muscle, especially when the armpit incision is used, the breast itself is not disturbed. There is usually no interference with the function of the breast gland, and as long as there is some sensation to the nipple (it is rare for complete loss of sensation to occur) nursing is possible. However, not all new mothers are successful at nursing even without implants, so no guarantees can be made.
Saline filled implants placed under the muscle interfere least with examination of the breasts by mammography; although there is still some reduction in how well the breast can be seen, this is much less than with silicone gel filled implants placed under the breast. Detection of cancer by self examination is not made more difficult by augmentation.
One of the most common questions we are asked is “DO I need a lift??” and this is important because a breast lift is quite different from augmentation and involves more incisions and therefore more scar than a breast augmentation. Plastic surgeons think backwards about this. Some patients feel they have developed droop but the nipple and areola are still above the level of the fold under the breast; in this type of case, the cause is generally loss of breast volume alone and placement of an implant is the usual recommended treatment.
In most cases when the patient complains of drooping, the nipple and areola are still above the level of the fold, but the upper breast has lost its fullness so the breast looks collapsed. This requires filling out the breast volume, an augmentation, not a lift.
Reduce muscle spasm and pain after breast surgery. See our early range of motion exercises for breast augmentation below:
Progression 1: Scapular Wall Slides - Download the Full PDF
Progression 2: No Money Drill - Download the Full PDF
Progression 3: Scapular Floor Slides - Download the Full PDF
Thank you to Carmen of Human Motion for providing the PDF documents.
Answering all your questions about breast augmentation is beyond the scope
of this site. At consultation we will go into extensive detail and be sure you are thoroughly familiar with the entire subject so you can make a well informed decision.
Saline implants are not new. They were also used from the early 1960’s, but were used less frequently than silicone gel implants. The implants have a very good long term safety record and were the only implants available from 1992-2002. In 2002, gel implants became more freely available in Canada, although each case had to be be approved by the Health Protection Branch in Ottawa. In 2006, HPB Canada and the FDA in the USA gave full approval for the use of silicone gel filled implants, and made the decision as to whether to use saline or silicone up to the doctor and patient only. Today, over 70% of the implants in our practice are silicone gel filled.
We will be happy to discuss all possible options with you at consultation, and to do what is best for you.
Although saline implants can leak, collapsing in the process, this is very uncommon. When leaks occur, deflation is quite rapid, and harmless. Removal of the implant and replacement is generally a simple procedure, so periodic replacement before leakage occurs does not seem to be worthwhile. The leak rate is about 4% over ten years per implant, so your chance of having intact saline filled implants at ten years is over 90%. The manufacturers guarantee the implants against failure, so I suggest replacement only if there are problems.
Gel filled implants can also leak, but leaks are not as obvious. Current implant models are tougher than those used in the mid-1970’s through mid 1980’s, when early leakage was very common. When leaks occur, the gel is what is referred to by manufacturers as “cohesive” or “memory” gel, meaning that the gel is not semi-liquid and will remain as one collection of filler, without spreading elsewhere. There will be little external sign of the leak. For this reason, the FDA in the USA strongly suggests regular MRI ( magnetic resonance imaging) to screen for “silent” ruptures, beginning three years after surgery and every two years thereafter. IN CANADA, and in most other countries, there are no such stipulations, although we feel it may be worthwhile having a screening MRI sometime about eight to ten years after surgery
Yes. There is no change in the pressure within the implant at altitude or underwater, so there is no increased risk of rupture.
To learn more please visit our Breast Augmentation information page.
Breast Lift
This depends on how much smaller your breasts are than prior to your first pregnancy, and how much distress the shape of your breasts causes you. If you have lost a lot of breast volume an augmentation with lift will give you significant improvement, and might only require a smaller secondary tightening if you become pregnant and lose some of your shape again.
Most of the time, changes in feeling are mild, if any. Numbness, or even excess sensitivity are possible, but usually improve with time.
The function of the breast is not usually changed by lift surgery.
To learn more please visit our Breast Lift information page.
Cosmetic Nose Surgery
It is usually safe to operate when the facial bones have stopped growing, which in girls is between fourteen and sixteen and in boys is usually between sixteen and eighteen and, of course, when the patient is emotionally mature enough for the procedure.
This depends partly on your own response to surgery, but mainly on how much bone work must be done.
This depends on the shape of your own nose. We do not break, we cut the bone, and this is necessary for several reasons, including as part of straightening the nose, to narrow a wide nose, and to bring the bones together after a large bump has been removed from the bridge.
To learn more please visit our Cosmetic Nose Surgery information page.
