The Body Beautiful Surgeon

Breast Augmentation, Boston, and Tummy Tuck, Boston

April is here and as the days become warmer the telephone rings more frequently in the office of Dr. Richard Moss, Boston abdominoplasty specialist. Many of these calls are from women who are dissatisfied with sagging skin of their abdomen and breasts. Frequently these women are looking to reverse the results of pregnancy and the devastating effect it can have on a woman’s body.

The after effects of pregnancy is one of the most common reasons that women seek cosmetic surgery of the abdomen (abdominoplasty surgery) and breasts (breast lifts, breast augmentation, and breast reductions).

Our Boston plastic surgeon, Dr. Moss, is also receiving an ever increasing amount of phone calls from women who have lost large amounts of weight and have considerable amount of skin sag over their entire body. Often times these women have had a gastric bypass procedure but there are also some who have lost 100 pounds or more by adjusting their caloric intake. “Massive weight loss” patients usually find that their sagging abdominal and breast skin can be quite bothersome not to mention unpleasant to look at.

Patients who have lost large amounts of weight either through gastric bypass or appropriate diet management often seek cosmetic surgery afterwards to reduce the excess skin of their abdomen and breasts.

Many of these callers accurately ask for consultations that are appropriate for their situation while others have goals that are entirely unachievable. This article will focus on helping women determine what surgery will help them achieve their goal as well as what scars she can expect to have after her procedure. One fact that all patients with sagging breast or abdominal skin need to accept is that it is impossible to remove excess skin without leaving a scar. While some of these scars are hidden others are quite visible, especially when a patient is without clothing. Plastic surgeons always try to place scars in areas of the body that are hidden by clothing. Some women, however find that a scar even though it is hidden beneath clothing can be bothersome to the point that they will choose to forgo the surgery and live with their skin sag. “While there is no perfect answer to reducing skin sag,” states Dr. Moss, Boston tummy tuck specialist, “one of the most important factors in a successful cosmetic surgery outcome, is that the patient fully understands the length of the scar and where it will be placed on her breasts or abdomen.”

This article will address the skin sag of the breast and abdomen separately since the surgical options are different and a patient’s feeling about the scars on the breast can be different than her feelings about a scar on her abdomen. Dr. Moss finds that many women are far less accepting of scars on their breasts than on their abdomen. What is also factored into the decision of whether a scar is acceptable or not is the extent of sag. The more their abdomen or breast sags the more a woman is accepting of the scar from an abdominoplasty or breast lift. In addition, a woman with excessively large breasts that also sag will get two benefits from a breast reduction (smaller, more appropriate sized breasts that sag less); and therefore, is usually more accepting of the resulting scars. In addition, if she has had back and neck pain or rashes under her breasts, she often sees improvement here as well. These patients rarely complain about breast scars.

Abdominal Skin Sag: There are really no other options for abdominal skin sag other than an abdominoplasty or mini-abdominopasty, (only if a patient meets the requirements). While these scars can be extensive, Dr. Moss tries to place them as low as possible so that they can be hidden even underneath a two piece bathing suit. Patients do need to keep in mind that this two piece bathing suit needs to have some amount of fabric around the front portion to hide the scar and therefore a string bikini would not suffice. Most patients who need an abdominoplasty find that without this surgery they can’t wear a two piece bathing suit anyway.

Dr. Moss likes to point out that he performs abdominoplasty surgery using the “progressive tension suturing” technique that can often result in a better quality of scar. Because the additional suturing throughout the abdominal flap, removes some of the tension from the incision area, the quality of the scar may be better. While “progressive tension suturing” will not reduce the length of the scar it may reduce the thickness of the scar.

These pictures demonstrate what the scar might look like within the first year after abdominoplasty surgery.

Breast Skin Sag: Skin sag of the breast is more complex and there are more choices depending on the situation. The following paragraphs outlines the options available to women with breast sag, medically referred to as breast ptosis. It is important to understand that a patient needs to be a clinically acceptable candidate for each individual option and cannot simply chose the option she finds most desirable. In some situations she may be a candidate for more than one option and she will need to weigh the advantages and disadvantages of each.

Women who have breast fed may find that their breasts have more sag after they stop breast feeding than women who did not breast feed. Sometimes if the baby favored one breast more than the other, the favored breast will sag more than the non favored breast.

Breast Augmentation: A woman who has always had small breasts (A-cup) may find that after pregnancy and breast feeding that while her breasts sag, the skin envelope of the breast remains relatively small and they are best served by having breast augmentation surgery. These women really don’t have skin sag as much as they have deflation of the breast or loss of breast tissue after pregnancy and especially breast feeding. Breast implants will very nicely replace this lost breast tissue. The good news is that the scars are minimal with breast augmentation surgery. Dr. Moss, Boston breast augmentation expert, offers patients two choices for scar surgery. He can make his incisions through either an inframammary incision or a periareola incision. Either one of these incisions is well hidden after surgery and healing takes place.

It is important that patients understand that breast implants do not lift the breasts but rather fill them out. While this often sufficient enough to aesthetically make the breasts more attractive, some women may decide to have a breast lift at a subsequent surgery.

The following pictures demonstrate a patient who had breast sag prior to breast augmentation. The breast implants filled out the breasts sufficiently that a breast lift would not be necessary.

Breast Lifts: A breast lift, medically referred to as mastopexy, reduces the amount of skin sag but does not increase the size of the breast. For women who are bothered by the amount of sag to their breasts, but are satisfied with the size of their breasts, Dr. Moss will offer a breast lift. Because the scarring is much more extensive (anchor scar), than that of a breast augmentation, breast lift surgery is not as popular as breast augmentation surgery. Patient’s also need to factor in that breast lift surgery does not provide the patient with a permanent result as her breasts may sag again with time.

Besides the rather extensive scarring that breast lifts result in, breast lifts do not provide a patient with the “perky” breasts of a teenager. So often patients are pushing their entire breasts up to their upper chest region and stating “this is what I want!” Unfortunately, this is not achievable, and in many instances an under wire push-up bra might give her more of this result. Women with sagging breasts have usually lost the support of internal ligaments called “Cooper’s ligaments.” It is Cooper’s ligaments that normally support some of the breast tissue and fat in what is medically referred to as the “superpole” (upper) region of the breasts. While breasts that have been surgically lifted almost always have a much nicer overall shape than before the lift, they will not have the “perky” shape of a young breast. It is also important to note that when performing a breast lift, the surgeon will also reposition the nipple in a higher more aesthetically pleasing position.

These pictures demonstrate a patient who was an excellent candidate for a breast lift and abdominoplasty. Her breasts were not too large (a B cup), she had breast ptosis (sag) and her abdominal skin sagged as well. In addition she was at her ideal body weight.

Dr. Moss always addresses the issue of how long a breast lift will last during his consultation with a patient. He states “While it is impossible to accurately predict the length of time a patient’s breast lift will last, it could be months, it could be years, there are some factors that can influence the duration of the result. One is the size of the breast that is lifted. A smaller breast such as a B-cup will most likely retain its result longer than that of a full C-cup or a D-cup. I always recommend that a woman with a large C-cup or D-cup who is contemplating a breast lift also consider a small reduction as well,” he further elaborates. “Unfortunately, some of these women, especially the C-cup women do not want this and so in the end do nothing. Many of them find that the trade off of scars and smaller breasts outweigh the benefit of reducing the sag and in the end decide that doing nothing, at least for the present, is the better option.”

Another factor that influences the longevity of a breast lift is the elasticity of the skin. A woman’s breasts that have not been stretched to a much larger size at one time are more likely to retain the result than breasts that have been stretched due to pregnancy, breast feeding or large amounts of weight gain and loss. Also age can be a factor. A younger woman’s skin that has more elasticity than an older woman’s skin is more likely to retain the result of a breast lift.

Breast Reduction: Breast reduction surgery is very similar to that of breast lift surgery, except that breast tissue is removed as well as breast skin. These patients obtain the same type of correction in skin sag as that of a breast lift. In addition, the nipples are repositioned, as in the breast lift. The scars are often identical to that of a breast lift (anchor scar).

Although the scars from a breast reduction are as extensive as those from a breast lift many of the breast reduction patients are more tolerant of them. This is because they are so bothered by the large size of their breasts that they are more than accepting of the scars in order to have their breasts made smaller.

This patient was an excellent candidate for a breast reduction. Her breasts were large (32DD) and she was at her ideal body weight.

There are also situational factors that can influence a woman’s acceptance of scars on her breast or abdomen. Generally, younger women are more sensitive to their appearance and therefore less accepting of scars. At the same time these young women, often young mothers who have had a child at a very young age, are very troubled by their bodies after a pregnancy. Dr. Moss finds that most of these young women who seek him out for abdominoplasty surgery do proceed with a tummy tuck because they are so unhappy with their bulging bellies and abdominal skin sag they are willing to accept the scar.

Another situation that is often a factor in a woman’s acceptance of a scar is whether or not she is already married or in a committed relationship. These women generally feel more secure about their bodies and are less concerned about a scar. Frequently, they have already discussed it with their significant other and he has relayed to her that a scar does not bother him. Women who are not married or in a committed relationship are sometimes more anxious about a scar because they feel a man might be less attracted to them in the future. Dr. Moss states that “There is no right or wrong decision about a woman’s acceptance or unwillingness to accept a scar. The most important thing is that she is aware what the resulting scar will be and then she makes her own decision.”

Another factor that sometimes influences whether a patient elects to go forward with surgery is the predictability of the quality of the scar once the skin has healed. “Women with darker complexions are more likely to have more noticeable scars. Also women who have some natural redness to their hair color and skin tend to scar more poorly,” Dr. Moss says. “Women with blue eyes and fair skin (not redheads), generally have better quality scars. However, I always point out to patients that scarring is not in the hands of the surgeon, and it is what it is, and patients need to accept this before proceeding with surgery. The good news is,” he further elaborates, “is that scars tend to fade with time. Although they do not disappear, I am often impressed with how much they have faded when a patient returns years later for some other surgery. I usually don’t have the opportunity to evaluate my scars beyond one year and most of my post operative pictures are at one year or at six months. I am often impressed with the improvement in the scar when I see these patients years later.”

The following pictures demonstrate that a scar from an abdominoplasty does fade with time.

Tummy Tuck before	Tummy Tuck 1 month after	Tummy Tuck 6 months after	Tummy Tuck 2 years after

“Another issue that is most important,” Dr. Moss further elaborates, “is that a patient doesn’t choose a surgery that doesn’t correct her problem, solely for the reason of avoiding a scar. We have many women calling in who inquire about liposuction of the abdomen because they think it will eliminate their abdominal sag without a scar. Not only will the skin sag not be reduced or eliminated, it will be made worse.” Dr. Moss emphasizes. “My staff always tries to redirect potential patients to surgeries that are appropriate for their problem and instill realistic expectations before they are given an appointment. It is a waste of time to spend thirty minutes with a patient reviewing all the details of abdominoplasty surgery with her, if the only thing she can think about during the consultation is the scar. I would rather wait and see a patient like this only after she is willing to accept that to reduce her abdominal skin sag, she will have a scar on her abdomen. Although the scar is permanent it will fade with time.”

“My staff members also relay to me that often women ask to see me in consultation for breast augmentation surgery,” Dr. Moss relays. “In asking the patient about her situation they discover her breasts are often at least a C-cup with considerable sag. When they bring up the subject of a breast lift they are told by the caller that they find a breast lift unacceptable because of the scars. However, they really are happy with the size of their breasts but not the amount of sag. Somewhere in this caller’s mind she has come to think that a breast augmentation will lift her breasts. This is basically a misinformed caller that my staff members try to better educate. Sometimes I think what happens is that these patients spend hours on the internet scrolling through hundreds of before and after pictures and they prefer the after pictures of the breast augmentation patients compared to the breast lift patients, so they just assume they can have a breast augmentation and obtain the same result of a patient who had no sag before surgery. This is not the case. Appropriate patient selection for any surgery is as important as a surgeon’s technical skills. And a patient needs to have realistic expectations. This is why a consultation with a board certified plastic surgeon like myself is so important. Realistic expectations for the correction of a given body deformity, need to be in place for a patient to have a satisfactory result.”

Patients sometimes inquire as to whether there is anything that they can do to help improve the quality of a scar. “First and foremost I would recommend that patients not expose the area of incisions and surgery to the sun or a tanning booth at least two weeks before or six months afterwards. I am not a fan of tanning in the first place as it is well known to increase a patient’s chances of having skin cancer, but it can also worsen the quality of scar tissue,” states Dr. Moss.

There is also a product that patients can purchase in Dr. Moss’ office called Scarguard ScarCare. This product combines hydrocortisone, Vitamin E, and silicone in a clear liquid that brushes on, dries quickly and forms a nearly invisible protective film over the wound. This product is one of the most popular products with plastic surgeons for the treatment of scars. No treatment will “erase” a scar, but Scarguard ScarCare will minimize the risk of a poor scar. Dr. Moss will usually allow patients to start using this product at about one month post-operatively.