Double Chin Challenge- Kybella vs. Liposuction

The practice of “lipodissolve”, utilizing a mixture of fat melting chemicals injected into the area of interest, has long been controversial. The lack of regulation and standards of exact mixtures and techniques lead the ASPS to tell its members the practice was not safe. Some surgeons and even lay practitioners in spas swore by it, and Allergan launched the first FDA approved product, Kybella, for the use in the double chin area.

I underwent a training in Kybella, including an online certification as well as a hands-on observed injector training. Some of the photos are impressive, but is this product the end of submental liposuction? Let us compare.

Kybella is a nonsurgical treatment, so there are no stitches or anesthesia risks involved. You are awake and can walk out on your own after a brief observation period. No blood tests or doctor’s visits are needed before. The treatment is about 30 minutes, and consists of multiple tiny injections into the fat cells. You will experience significant swelling, especially over the first week, and can have a burning sensation. The average patient in the studies conducted received a little more than 4 treatments to achieve the results. The average cost of each treatment is currently $2500 in NYC. Therefore, for Kybella, it is a total of about 2 hours-2.5 hours of treatment time over 4-6 months to get the result at an average cost of around $10,000. There is no surgery, and less healthy patients can undergo the procedure.

Liposuction of the double chin is a surgery. I use 3 tiny incisions requiring a single stitch each (behind each earlobe and one under the chin), and testing is required beforehand. You will receive twilight anesthesia, and someone has to take you home. You will get swelling and potentially some more bruising, and we recommend some massage after to help the swelling fade faster. It is a single 30 minute procedure, though you will be in the office a little over an hour. Results can be seen in as little as 2 weeks, though small areas of swelling may persist for a few months. Average cost in NYC is $3500-$4500.

I offer both, and the choice is yours.

The Dangers of BBL

Just this past week, an alert was issued by the American Society of Plastic Surgeons regarding fat transfer to the buttocks, or BBL. After a survey of members and the literature, it was found that the incidence of death from the procedure were about one in three thousand. This is by far the highest for all cosmetic plastic surgery procedures. Clearly, this is very concerning to me, as I have done close to 3,000 myself.

The problems that occurred seem to have come from fat being injected into and below the muscles, and that fat entering the bloodstream causing pulmonary embolus and death. These findings made me feel somewhat better for a few key reasons.

When I do a BBL, I am always above the muscle in the subcutaneous plane. A death has never been reported from the procedure when the fat is above the muscle. The only limits are that you cannot always get as much volume that way, but I would rather have someone complain they are not quite as big as they hoped as opposed to someone dying.

Secondly, I always stay away from the lower inner area of the buttocks where the major blood vessels are. I clearly point this out to my patients before the surgery, so that they know where I won’t fill and why.

These findings show the importance of technique and doctor selection. Many non plastic surgeons are now doing cosmetic procedures thinking it is easy money. The experience, skill and anatomical precision required cannot be taught in a weekend course, online videos, or by spending a few months watching someone and calling it a fellowship. Be safe.

How to Fix a Tummy Tuck

In my 18 years of private practice plastic surgery. I have now done over 2000 abdominoplasties. Very few, if any, plastic surgeons have done more in an entire career. Amongst them, I have done over 100 tummy tucks on women who have had the surgery before.

When evaluating a patient for a tummy tuck, you have to look at the skin, fat, and muscle, as well as the proportion to the surrounding anatomy and prior scars. After an abdominoplasty, you also have to consider what happened to leave the patient dissatisfied.

Sometimes, the problem is that the woman had a pregnancy after, creating the same problems as before. Sometimes, there has been another big swing in weight, either up or down, to create more laxity. In the rest, the surgery just wasn’t done optimally.

In certain cases of weight gain, a liposuction is all that is needed. In other cases, a full abdominoplasty needs to be repeated. The in between cases are the most challenging, and I believe I have solved many of them.

The modified abdominoplasty is a technique that leaves the belly button attached to the skin, and allows muscle tightening and skin and fat removal. When the initial scar is too high, and the belly button is high as well, both problems are corrected easily. The patient is flat, the high scar is lowered, and the umbilicus sits in the proper place.

While some plastic surgeons refuse to see other doctors’ unhappy patients, I do not. My basic instinct is to help, even if it means dealing with unhappy people. There is often, but not always, hope. I love tummy tucks, and I love my patients. What could be better?

Smart Lipo 101

As I mentioned in a prior blog, “Is Smart Lipo Smart for You?”, the use of laser assisted liposuction has many potential problems for my latin patients. Darkening of the skin, burns, the inability to use this fat for Brazilian Butt Lifts, and the higher cost without any real scientific evidence of better results are among the most concerning of these issues.

Not to mention the fact that a large number of the providers advertising Smart Lipo and other laser assisted devices are not Board Certified Plastic Surgeons, but Ob/Gyn’s, Anesthesiologists, Family Practitioners, and other MD’s with no formal training in plastic surgery other than the company sending them to watch another doctor do the procedure a few times.

Does Smart Lipo really tighten the skin as they claim? I have yet to see convincing long term scientific studies to back up these assertions. I will say that after liposuction, loose skin can be a problem in certain cases. While I am a Board Certified Plastic Surgeon with experience with thousands of cases of liposuction, there are some cases in which a little skin tightening would improve the results.

Now we have a safe skin tightening laser specifically designed for Hispanic skin. My technique, Smarter Lipo, involves careful liposculpture so that the complications of laser assisted liposuction can be avoided, followed by lymphatic drainage massage and then external laser skin tightening as needed. It provides an even result, and you only pay for the laser you need if you need it at all.
We invite you to come in and see for yourself.

Is Smart Lipo smart for you?

For the last year, there has been a lot of hype surrounding Smart Lipo, a laser assisted liposuction technique that has since had other companies produce machines like Slim Lipo among others. The marketing plan of the company is certainly smart, promising direct advertising to the public and referrals to all the doctors who buy the machine from them. Because they sell them all over the country, they can afford a national ad campaign, and it results in patients for anyone who has the machine. The real question is does it offer benefits for you the patient?
As of my writing of the blog today, I am not aware of any convincing long term study that shows improved results over traditional liposuction. I am aware of many cases of skin burns and permanent contour irregularities as a result of inexperienced doctors performing Smart Lipo. Let me explain why.

The company that sells the machine wants to sell as many machines as possible. They will sell to any doctor, regardless of his/her training or certification. That means your ob/gyn, family practitioner, or internist who wants to make money can buy the machine and get the referrals as a Smart Lipo expert. The only training they get is to watch a doctor do it in his office before doing it on their own. Additionally, laser assisted liposuction has a much higher complication rate of burns and fluid collections.

This is not to say that the procedure is bad- the major problems are with the doctors. As in my prior blog entry “Is your cosmetic surgeon a plastic surgeon?”, never assume just because a doctor does cosmetic surgery that he is a board certified plastic surgeon. Ask “Are you certified by the American Board of Plastic Surgery?” if you want to be sure.

In my opinion, Smart Lipo is smart for the doctor, not the patient. You pay more for a riskier procedure that is possibly done by a less well trained physician with no benefit of better results. Just because something is new and well advertised does not make it better. Be a smart consumer and do your homework.

Let it Snow, Let it Snow, Let it Snow

Like the rest of you in the Northeast, I am quite tired of this endless winter of snow. It is cold, inconvenient, and disruptive. Many schools close, businesses as well. As a Plastic Surgeon, my cases are elective, so technically I can choose to reschedule. The problem is, my patients can’t reschedule their lives.

I have never cancelled a surgery day, despite blizzard conditions. If my patients can make it to Yager Esthetics safely, as well as get home without undue risk, I will walk to my office through the night to make it happen. I am that committed.

When a patient plans surgery, they are often taking time off from work or school that is not easily changed at the last minute. Only a certain number of days are granted each year, and only at very specific times.

Childcare is also an issue. Many of my patients have family flying in from out of the country to help, and this too is an effort to be coordinated. Some send their children out of the country, and these flights cost money to change.

Preoperative testing is also only valid for a short period of time, and often your insurance won’t pay to repeat it in a certain amount of time. Getting another appointment with your primary care physician is also difficult at times.

From my end, surgeries are booked months in advance, and anesthesia and nursing must be arranged. I have a limit to the number of cases I can do expertly in a day, and simply adding the patients on to the next surgery day is unsafe at times.

I can’t control the snow, but I can make every effort to not let it ruin our plans. Let it snow, I will be here as promised. And thank all of you for doing the same.

Liposuction is More Than Removing Fat

While having a rare free moment the other day, I was flipping through a Spanish language newspaper. I was surprised by the number of ads offering liposuction. The majority of the doctors offering the service were not Board Certified Plastic Surgeons. Some were ENT’s, others Ob/Gyn’s, and even a Family Practice doctor was touting her skills as an expert. This information wasn’t stated in the ads, and if you were not very diligent in researching or careful in asking, you would have no idea.

I have spoken to a few of these practitioners, and the answer to why they are doing it is simple- making money. None of the doctors I spoke to had any training during residency in their fields. The company that sells the equipment allows them to “train” by watching someone else with experience for either a few cases, or has a weekend seminar outside the US or somewhere by a resort. Amazingly, this is perfectly legal as of now. This is potentially disastrous.

I am a Board Certified Plastic Surgeon, and did my first liposuction as a medical student in 1989. I have done many thousand procedures at Yager Esthetics, and do many hundred every year. Liposuction is not simply removing fat. Patient selection is very important, and the quality and texture of the skin, the technique used, and a comprehensive knowledge of fluid management is essential. This can not be learned in a few days.

Please do your homework and directly ask your liposuction provider if he or she is certified by the American Board of Plastic Surgery, as no other board with a similar name is the same. You can go to and check for yourself. You do not have to come to me, but please be smart and safe.

Spring Cleaning

Although it may not feel like it outside, spring is upon us. The renewal of the grass, flowers, and trees makes me think of personal renewal and rebirth. It is also a very busy time at Yager Esthetics. With the combination of income tax refunds, spring break and vacations, and the warmer weather signifying more revealing clothing, patients turn their attention to body issues, as well as personal grooming.

The spring procedures are always laser hair removal, liposuction, breast implants, and tummy tucks. As we get ready for bikini time, all of these areas come to the forefront. Trying to keep up with the demand, but never doing more than I can safely, I have increased the number of surgeries weekly, and have added an extra day of consults here and there to prevent too much waiting time. Sixteen years ago, I could never have imagined this problem!

I would urge you all to remember, as always, that sunscreen should be applied every day, as the harmful rays can penetrate clouds. We have some great renewal treatments for the skin of the face and body that I would also recommend. The Silkpeel can refresh your skin surface, and treat mild discolorations and acne. It can also help with the skin of the body. The Revitalize Peel is also a great spring cleaner, and an appointment with our Estheticians is advised.

A new treatment for 2013 is our safe Asclera injections for spider veins and small varicose veins. We have 2 highly trained specialists to let you show those legs this season. The laser vein treatments are great as well.

Spring has sprung, and we hope you let us show you how we can get you ready for the best one yet.

Your Plastic Surgeon is not your Parent

Many patients visit me at Yager Esthetics looking for answers to their cosmetic  concerns.  They want to look better, have heard good things about my office from friends, family, other doctors, or on television, and they see me for a consultation.  What surprises some is that I do not make any of the decisions, I leave them to the patient.

To clarify, this does not mean I do what the patient asks of me regardless of what it is.  It is my job to educate you, give you the benefit of my experience, and review the risk and benefits of your options with you. I will let you know if I disagree with your choice, and explain why it may not be your best option as well.  I am not your parent, I am your experienced guide and teacher, a partner in care who will help you decide what the best choice may be.

I hear stories of consultations in other offices where the doctor pops in, looks at the patient, and tells them what they need, and leaves it to his staff to answer questions and try to make you commit to surgery.  I do not think this is adequate.  Each patient is unique, and just because you plastic surgeon is partial to a c-cup, this might be either too big or small for your taste.  One size does NOT fit all.

I encourage you to come to my office for an education on your safe options for improving your appearance.  I will do my best to guide you through the process so that we may come to a mutually agreeable decision as to how to realize your esthetic dreams.

Is Plastic Surgery a Good Investment?

With tax season upon us, and many of my patients receiving refund checks, the question arises as to how best to spend the money.  Obviously, family and financial needs must first be met.  But what if there is a little bit more that you could use?  Is plastic surgery a good investment?

I am a Board Certified Plastic Surgeon, not a financial planner or a business person, so my observations are from my 15 years at Yager Esthetics.  I will lay out for you the potential benefits, and you can decide whether it makes sense to you.

Plastic surgery can boost your self esteem and enhance the way you feel about your body and your sexuality.  The confidence it brings can change the clothing choices you make, the activities you will participate in, and even the way you interact with others both socially and in business.

A refreshed appearance can make you look younger, more energetic, and less tired to potential romantic interests as well as potential employers.  It can also help those who feel young on the inside feel better about looking in the mirror and seeing what they want to see.

Cosmetic Plastic Surgery can be empowering, especially to women after having had children or massive weight loss.  It can  be a fresh start to a healthier lifestyle, as when you look better, you tend to take better care of yourself through improved diet and exercise.

All of these benefits are enjoyed every hour of every day no matter where you are or what time it is.  Yes it is a “me” thing, but if you have worked hard you deserve to do something for yourself.

If the numbers add up for you, it may turn out to be the best money you have ever spent.