Dr. Mary Herte

It’s complicated.  I consider multiple areas of aging that occur in face: Loss of volume, skin quality, changes in elasticity, pigments problems, overactivity of the muscles that leave wrinkles when you move your face, and looseness of the skin (hanging skin in the neck, drooping of the cheeks and eyebrows). All areas need to be addressed in different ways to get the best result.  To turn back the clock, loose skin needs to be lifted surgically to remove excess skin and to reposition the skin as well as it’s deeper layers.  We have to also look at skin quality—crepiness, pigmentation, does it look soft or watery.  If you have a tight face with old skin, it will not look rejuvenated. The patient may need good skin care, topical treatments and laser resurfacing.  If we do just a lift so the skin is tight, but there is no softness from loss of volume, than the patient looks pulled and sometimes skeletal, so we have to add volume.  In the old days, we just did lifting, which made patients look pulled. The skin looked like it was stretched over bone because we didn’t have any other options.  Today, we can give patients a natural and soft appearance which is what youth looks like. Adding volume gives us that more youthful look. We can add volume to lips and cheeks; we can fix the skin with laser resurfacing and we can treat overactive muscles that distort the skin with Botox, Xeomin, and Dysport—which can be helpful in stablizing and preserving a browlift.  You have to protect your investment and keep your results. You have to start early to preserve your skin.

A mini facelift refers to a limited incision, which means restricting the incision to a short incision in front of the ears and around the earlobe a little bit.  There is less skin removal, so fewer areas of the face can be addressed.  One thing it doesn’t address is the neck. That requires an incision around the ear and up into the hair.  A lot of patients want a mini lift because of the smaller incisions, but they want to have neck improvement so they are disappointed. A mini facelift can’t address the neck, it can only address the cheeks and sometimes the jawline. The results depend on the patient’s age and how extensive the skin laxity is or how much skin damage there is.  Most people get 5 years out of them if done properly, and if there is tightening of the inner muscles layers. It’s best for patients who have very little neck laxity and mostly cheek and lower face relaxation.  Sometimes more is less. One of the things about a facelift that people fear is that they will look like they have been in a wind tunnel. When doing a mini lift, the only place to pull is directly toward the ear, so they will get a smaller scar, but not the look they wanted. If the incision is limited, there is a pull from the nose to the ear which will look artificial. They don’t realize that you have to release skin from its underpinning and pull up to look more natural. So really, the direction of gravity is from the eyebrow to the chin and not from the ear to nose. We need to make the incision longer and loosen the skin more to get a more natural draping.  In reality, limiting your procedure will actually cause you to look more artificial. We have to look at what needs to be lifted and what we are trying to accomplish.  We have to look at what the result will be, not the procedure.

The primary risks are extensive bruising, surface skin irregularity and looseness of skin (if there is too much fat removed). With laser and ultrasonic liposuction, you have to choose an experienced surgeon because of possible injury to the skin. You don’t want too much taken out because there can be blood-loss related to bruising; which can be dangerous. However, with an experienced practitioner it is a very safe and satisfying procedure.

I use pretty much the same technique equally because it works well for me; which is the modified tumescent technique with external ultrasound, unless it’s a delicate area. I like to stay really safe and effective. I always default back to what’s safe for the patient.

Breast reduction can be done with liposuction; however, it doesn’t address important issues like excess skin and laxity. Breasts are loose and droopy ordinarily.  If you just do liposuction, you have an empty bag of skin that’s not an attractive breast.  It’s very limited in how much we can remove and what the patient’s expectation is.  Another limitation is that liposuction only removes fat, not breast tissue.  Most women with overly large breasts have too much breast tissue, which is firm and is not removed by liposuction.  Sometimes they can end up with lumpiness from the internal breast tissue being revealed after the removal of the fat.

During a tummy tuck, I don’t use it very much unless I’m doing an extra area of liposuction.  We don’t use a lot of liposuction during a tummy tuck.  It can cause stress to the skin. We are surgically removing fat and the skin attached to it.  It’s mostly overhang.

I’m very safety conscious. I usually recommend patients separate them out; but it depends on how extensive the procedures are.  If they want an extensive tummy tuck, breast lift and arm lift, I recommend they split them up into three separate procedures.  When you start disabling multiple parts of the body, you start to have risks of blood clots in the legs, pneumonia, and healing problems.  Most people want to get back to normal activities, and with more than one procedure, you can’t move around properly.  So, you have to think about how much time you really have to recover.  Most people think it’s better to have a single healing time, but what they are really doing is extending that healing time.  Your body can’t handle that much trauma at one time. So it’s no longer one-to-two weeks of healing anymore for a tummy tuck, if you add a breast augmentation. You can’t move and are at the mercy of your caretakers. However, a tummy tuck with lower-eyelid surgery would be a nice combination.  Some doctors don’t think about what’s smart and safe for the patient. It’s best to keep the complication rate low, separate out the procedures and keep the surgical time short. Somewhere between 6.5 to 7 hours should be the absolute maximum.  Anesthesia time over 7 hours adds to the complication rate.

Saline versus silicone is a personal choice. I personally prefer silicone gel because it’s longer-lasting and more natural looking. If someone is extremely thin, you can see rippling and fluid movement with saline. Also, when a saline implant wears out, it deflates and then it is a social emergency.  It’s not convenient for many patients.

Many women, when considering a breast lift, want to keep scars to absolute an minimum; but that is a way to end up with worse scars.  There is always an incision around the areola. When it’s made all by itself, the white skin around it is removed and the areola is inset into that and lifted.  This causes it to be stretched to the new shape and lifted and gathered. Sometimes limiting the incision to just the areola will make the areola really large and the scar lift.  I recommend doing the full-anchor approach or a lollipop (with no under-the-breast incision). You need a vertical incision to take the pressure off of the areola. Sometimes more is less.  If I can do the proper incision and move tension off of the scar that is most visible, then they will have a better scar that is less visible.  Otherwise, the scar will be so bad you will be unhappy.  You have to look at the dynamics of the breast and the scar tissue and how the skin pulls.  Sometimes this requires adding additional scars that take tension off the scars that are most noticeable. It’s making a trade. In a breast lift, we are trading scars for shape. If someone is truly unhappy with the shape of their breast, then they have to be willing to accept a trade to get the benefit they are looking for.  It is worth it. Scars tend to look good with time.  If not, we can improve them with scar management treatments. There are topicals, injectables and laser treatments that can make scars look as best as possible.

As with any surgery, there are, but they are fairly minimal and fully discussed with the patient.  The biggest surgical risks are hematoma (a localized swelling filled with blood), which requires reoperation; but it’s not very common. There will be bruising, swelling, and scars. The most common issue is the hardening of the breast, where the scar tissue shrinks and contracts around the implants. This is minimized by following-up with patients. I work hard to get patients to be good at breast compression massage which keeps them from tightening up. Implants will also break someday.  We can’t guarantee that they last forever. Saline implants last 7 to 10 years; and silicone gels on average last 15 to 25 years. They all need to be replaced. It’s a personal choice when to replace them. I do not necessarily recommend them being replaced pro-actively; but like a car, I want to change the tires before there is a blowout. Most patients want to be as safe as possible; and they don’t want to have to adjust their life to accommodate a social emergency.  If you have silicone implants, start planning to have them replaced at 15 years.  We have to be more proactive with silicone gel because of the concern of having a broken implant in your body; and they will wear out at some point.

A lot of people go for that type of lift because the marketing is fabulous. It’s an example of doing less because think you will get a great result because of the photographs. But it doesn’t address the problems they are looking to fix.  They are choosing a type of lift based on the procedure, and not considering the problems that they have; so it’s the wrong choice. You have to choose the right procedure for the right problem. An experienced board certified plastic surgeon needs to be the guide to help patients make the right choice for themselves instead of slick marketing. A common thing in plastic surgery today is that procedures have been made into commodities, that they are something you buy. But in reality, they’re not products, but procedures that require someone with experience to get the results to make you happy—whether it’s Botox or a facelift.  It’s the techniques used that get good results and not all are created equal.

I think if you have deep furrow s between your eyebrows or a strong smile, the number one thing to do is Botox to keep from pulling your brow down.  Then you won’t need a browlift later on.  I do much fewer of them today. Botox is keeping patients from having their brows descend as aggressively and it keeps the upper lids from looking heavy. You can treat the muscles around the eyes so you won’t have crow’s feet that can close your eyes. If not treated early, they will etch permanent lines in your skin. You also need a good medical skin care system and a good sunscreen to prevent damage.  If you are concerned with your skin, or if you have any problems with your skin, you have to go to an SPF 25 or 30 physical block with more titanium and micronized zinc. They are more reflective and good for sensitive skin (as opposed to chemical sunscreens). Use topical chemicals to stimulate your skin, and have deep cleansing treatments in your doctor’s office like glycolic, lactic or salicylic acids combined with something else. But, if I had to pick one cosmetic to use, it would be sunscreen. Use it every day and reapply it if you are going to be out for a while.

Rhinoplasty that involves changes in the bone structure usually requires a splint or cast because the nose bones are broken and moved.  The patient will have a splint or cast in place for 7 to 10 days to ensure the bones are sticky and in place and secure before the cast is removed.  If just the tip of the nose is adjusted, then a cast or splint is usually not necessary; and usually the nose is just taped.  Recovery will vary with the specific surgeon.  Generally speaking, if there are nasal packs (which is the worst part because you can’t breathe out of your nose) you will have them 2 to 7 days, and a cast for 7 to 10 days if nose bones were broken.  The worst thing with rhinoplasty is that, although you will see some shape changes while recovering, swelling occurs right away and takes a long time to resolve.  You won’t see the final result until 6 to 12 months in the future.  You have to be very patient. The most annoying thing is that the nose is stuffy afterwards and the swelling shifts around like when you have a cold.  Occasionally, nose bleeds can occur in the first 2 weeks; and you can’t strain or lift anything heavy. You have to be gentle with your nose. It’s very fragile afterwards.  Most surgeons don’t let you wear glasses for 3 to 6 weeks if the nose bones were adjusted.

Fat transfer is long lasting but cannot be considered permanent unless your weight and fitness level remains stable at all times.  Any weight loss or fat loss in the body can shift out of the area that you want stay plumped up with your fat grafts!  The other problem with fat grafting is that the fat may or may not actually attach itself to its new location and survive the transplantation process.  Whatever you have as a result at about 5 months, I have found, usually is going to persist in place. Weight loss, of course can unbalance the smoothness of contour and reduce the overall results.

If you have problems with achieving a healthy weight, you may need to consult a physician who specializes in weight loss management to help you to address whatever is blocking you from the healthy body and weight that you are striving for.  Many weight loss programs are available to kick start your weight loss and support your progress. If you have a healthy (for you) weight and lifestyle and you still have figure problems with localized areas of fat that just won’t budge despite diet and exercise, you are an excellent candidate for body sculpting with liposuction to achieve a more balanced and smooth figure.  Many people look to liposuction as a weight loss technique, but is really best used as a sculpting technique to smooth disproportionate areas of fat that cause bulges or an uneven silhouette.   I always ask my patients what weight they would like to be at to be their personal best.  If that weight is really an attempt to get rid of that “last problem area” and my patient  is happy with all of her other body areas, then I will recommend liposuction for that last fat deposit and try to get the patient to stop stressing over her weight!

Once you are healed and off all medications, you should be safe to attempt to get pregnant.  However, if you are anxious to have another pregnancy as soon as possible, it might be smart to wait until all of the negative fat deposit and skin stretching effects of that pregnancy are completed  and you are in a resting phase between pregnancies or totally finished with your babies before going forward with your surgery.  Especially in terms of breast lift, each pregnancy will cause re-stretching of the breast skin and then loss of the pregnancy and breast feeding volume of the breast causing skin laxity and drooping again.  Each subsequent pregnancy may (or may not) require additional lifting to keep your breasts looking their best.  Hormonal changes of pregnancy, as well as the weight gain that goes along with any normal pregnancy, can cause shifts in your  fatty deposits and may also unbalance your figure despite the most beautiful pre-pregnancy liposuction results.  Additional liposuction contouring may be required post pregnancy.

Fat transfer is long lasting but cannot be considered permanent unless your weight and fitness level remains stable at all times.  Any weight loss or fat loss in the body can shift out of the area that you want stay plumped up with your fat grafts!  The other problem with fat grafting is that the fat may or may not actually attach itself to its new location and survive the transplantation process.  Whatever you have as a result at about 5 months, I have found, usually is going to persist in place. Weight loss, of course can unbalance the smoothness of contour and reduce the overall results.

If you have problems with achieving a healthy weight, you may need to consult a physician who specializes in weight loss management to help you to address whatever is blocking you from the healthy body and weight that you are striving for.  Many weight loss programs are available to kick start your weight loss and support your progress. If you have a healthy (for you) weight and lifestyle and you still have figure problems with localized areas of fat that just won’t budge despite diet and exercise, you are an excellent candidate for body sculpting with liposuction to achieve a more balanced and smooth figure.  Many people look to liposuction as a weight loss technique, but is really best used as a sculpting technique to smooth disproportionate areas of fat that cause bulges or an uneven silhouette.   I always ask my patients what weight they would like to be at to be their personal best.  If that weight is really an attempt to get rid of that “last problem area” and my patient  is happy with all of her other body areas, then I will recommend liposuction for that last fat deposit and try to get the patient to stop stressing over her weight!

Once you are healed and off all medications, you should be safe to attempt to get pregnant.  However, if you are anxious to have another pregnancy as soon as possible, it might be smart to wait until all of the negative fat deposit and skin stretching effects of that pregnancy are completed  and you are in a resting phase between pregnancies or totally finished with your babies before going forward with your surgery.  Especially in terms of breast lift, each pregnancy will cause re-stretching of the breast skin and then loss of the pregnancy and breast feeding volume of the breast causing skin laxity and drooping again.  Each subsequent pregnancy may (or may not) require additional lifting to keep your breasts looking their best.  Hormonal changes of pregnancy, as well as the weight gain that goes along with any normal pregnancy, can cause shifts in your  fatty deposits and may also unbalance your figure despite the most beautiful pre-pregnancy liposuction results.  Additional liposuction contouring may be required post pregnancy.

When a patient comes to me looking tired and worn and asking to look younger, we work together, balancing the patient's aesthetic goals and lifestyle with today's many choices for facial rejuvenation, from laser resurfacing to fillers to facelift surgery. We modify procedures to make recovery easier and strive for the ultimate goal of a natural, more rested appearance without changing who you are.