Plastic Surgery Tips with Dr. Vidal
Updated: Jan 14, 2022
Miami plastic surgeon, Dr. Natalia Vidal of Pure Plastic Surgery provides great tips, live, every Tuesday. Check out this page for a summary of her live tips sessions.
Table of Contents
Body Contouring Following Massive Weight Loss - 12/07/2021
Gynecomastia and Other Male Plastic Surgery - 11/30/2021
How to Prepare for Plastic Surgery - 11/23/2021
Procedure Combinations Why & Why Not - 11/16/2021
All About Scars - 11/09/2021
January 11, 2022
Breast Lift
Dr. Vidal provides some great information about breast lift procedures with and without implants. Take home tips from this live session:
The type of lift required depends on the degree of breast ptosis, or sagging.
The three different types of breast lift incisions are the donut, lollipop, and anchor.
The anchor uses a larger incision (lollipop plus one under the breast) but allows for the greatest degree of lifting and reshaping.
An implant may also be needed depending on the look you desire, the quality/density of your tissue, and the quantity of tissue available.
Following a breast lift, it is important to not lift your arms above your shoulders for 2 weeks post-op and not lift heavy weights for 6 weeks post-op.
Other great information from this week's live session
Dr. Vidal discusses breast lift procedures, indications for the different types of lifts, use of implants with a lift, post-op course, and cancer associated with certain implant types.
Breast lift versus breast augmentation
A breast lift and a breast augmentation are two different things to address different issues. The breast lift targets reshaping the breast, lifting the nipple position, and changing the size of the nipple (areola). A breast augmentation targets and adds volume and can be used to provide a small lift to the nipple in come cases. An implant can be placed at the same time as a breast lift and whether or not to add one depends on
How much tissue you have
The quality or density of your breast and skin tissue
Your goal and the look you would like to achieve
Breast ptosis
Breast ptosis is the degree of sagging or droopiness of the breast which commonly increases with pregnancy, breast feeding, and massive weight loss. The degree of ptosis determines the type of lift that will be needed to achieve your goal safely. It is graded by the distance between the nipple and the inframammary fold (IMF) or where the lower part of the breast meets the chest wall.
Grade 1 - The nipple is at the level of the IMF.
Grade 2 - The nipple is lower than the IMF.
Grade 3 - The nipple is lower than the IMF and is pointing down.
There is another condition called pseudoptosis where the nipple is not where it is supposed to be, most likely as a result of a previous breast surgery. In this case the tissue may sag down even though the nipple itself does not. Most lifts need a reduction in size of the areola at the same time.
Types of breast lifts (by incision type)
Donut lift - This lift uses an incision around the areola and usually leaves the least noticeable scar. This type of lift, however, only allows for a very small lift of the nipple (1-2 cm) as in a Grade 1 ptosis. If used to lift more than a grade 1 ptosis, the tension on the scar around the areola will be too high causing a thick scar or wound healing issues. It also does not allow for any tissue reshaping.
Lollipop lift - This lift uses an incision around the areola as well as a vertical incision from the bottom of the areola to the IMF. It allows for a small degree of breast tissue shaping and nipple lifting.
Anchor lift - This lift uses the lollipop incision in addition to an anchoring incision under the breast along or near the IMF. While this does leave a larger scar, it is the most versatile and has several additional advantages
allows for lifting the nipple to a larger degree
removes tension around the areola allowing for better tissue healing and scar appearance
allows for a larger degree of breast tissue reshaping for a more rounded look
usually results in a better shape for grade 2-3 ptosis
Add an implant or not?
The need to add an implant depends on several factors
how much breast tissue is available
the quality/density of the breast tissue
your goal and the look you want
Breast tissue is often thin and deflated after pregnancy, breast feeding, and massive weight loss resulting in more excess skin than breast tissue. In these cases, a lift performed without the addition of an implant may leave a breast that is much smaller and that may not have a full look, especially at the upper pole of the breast. Even with a breast lift without any tissue removal, the breasts will be at least a cup size smaller than the original breast. If your goal is to keep the same size or be larger, then an implant would need to be added with the lift.
The size of the implant will depend on your goals, your desired look, and your measurements. A key issue when combining an implant placement with a breast lift is the two different forces that are created by the procedures. The lift, tightens, reshapes, and lifts the tissue upward. Adding an implant increases volume which places an opposing force or tension (out and down) on the tissue and incision used for the lift (in and up). These forces need to be in balance to avoid wound healing and scar issues. If you desire a fuller look than is safe to do at the same time as the lift, then it may be wiser to have the lift with a smaller implant and then a second surgery at a later time to exchange the implants for larger ones. When receiving just a breast augmentation without a lift, then the size of the initial implant is limited by how much your skin can stretch in one surgery.
There are cases of grade 1 ptosis where using a slightly larger implant than desired size can raise the level of the nipple enough so that a lift is not also required.
The possibility of reoccurring ptosis following breast surgery depends on several factors including the size and weight of an implant, breast tissue and skin quality, and being at a young age (prior to pregnancy and breast feeing) for a breast augmentation with larger implants.
Post-op course
The post-op course for a breast lift with or without implants is similar. As with all surgeries, good hydration and nutrition are a must. Important activity restrictions include not raising arms above shoulder level for 2 weeks post-op and not lifting heavy weights for 6 weeks post-op.
Implants and breast cancer
There have been cases of anaplastic large cell lymphoma (ALCL) associated with breast implants. This type of cancer is not breast cancer but instead a type of non-Hodgkin's lymphoma (cancer of the immune system). It has only been associated with textured implants. The textured implants were found to cause a greater degree of inflammation and a small number of cases of ALCL. Initial symptoms of inflammation and possible ALCL present as a late onset (year or more) of seroma (pocket of fluid) where one breast would become enlarged. Shaped (versus round) implants were always textured. These implants have since been recalled and are no longer manufactured.
Dr. Vidal uses and has always used round (smooth) implants rather than shaped (textured) implants.
Thank you Dr. Vidal!
Visit her on Instagram: @DrNataliaVidal @pureplasticsurgery or on her website: Pure Plastic Surgery.
December 7, 2021
Body Contouring Following Massive Weight Loss
Dr. Vidal provides some great information about contouring procedures following massive weight loss. Take home tips from this live session:
Undergoing massive weight loss through gastric surgery causes changes in metabolism and ability to absorb nutrients.
Nutrition and supplements are an important focus following massive weight loss, especially prior to any subsequent body contouring procedures.
It is important to wait 6 months to a year after weight loss for body contouring procedures.
It is important to have 3-6 months of stable weight before considering body contouring.
Massive weight loss increases the risk of blood clots and other complications when undergoing body contouring procedures.
The belly, breasts, back, arms, legs, face, and neck are common areas for excess skin removal and contouring.
Since massive weight loss clients are at greater risk for surgical and post-op complications, the surgeon needs to take more care when considering procedure combinations.
Procedures best performed as a stand alone include thigh/leg lift, face and neck lift, and circumferential tummy tuck.
Upper back and breast surgery is usually safe to combine but not a back lift and other procedures.
The trifecta of arm lift, breasts, and abdomen are usually safe to combine.
Other great information from this week's live session
Dr. Vidal discusses contouring procedures, procedure combinations, and special considerations following massive weight loss.
Bariatric surgeries & resulting changes
A massive loss of body weight is a highly significant achievement and the result of a sustainable commitment to returning to a healthy lifestyle. Most massive weight loss occurs as the result of bariatric surgeries of a gastric band, sleeve, or bypass. As a result of this type of surgery and the massive weight loss, the body undergoes changes in metabolism and ability to absorb nutrients. This is especially true for iron, folic acid, and other vitamins. Before undergoing contouring procedures, it is important for clients to take supplements and to monitor and stabilize their nutrient levels with the assistance of their physician.
For safety and to ensure optimal results, clients should wait 6 months to a year following bariatric surgery (preferably a year) before undergoing body contouring and excess skin removal. It is also important for clients to have 3 to 6 months of stable body weight before having contouring procedures. Surgical results will change if someone gains or loses more weight following contouring.
Massive weight loss clients are at a greater risk over he general population for some surgical and post-surgical complications. Additional safeguards are prudent regarding procedure combinations, optimal nutrition and supplementation, and blood clot prevention.
Body contouring procedure selection
There are many procedures that are popular among massive weight loss clients. Multiple body areas are usually left with excess skin including the abdomen, back, arms, legs, breasts, face, and neck. Multiple rounds of procedures may be needed to safely accomplish a client's goals. Dr. Vidal suggests making a list of priorities and beginning with what is the most important for each individual client.
Belly
The belly (abdomen) is the most common area that clients choose to address first as the excess skin forms an apron of skin that hangs down. This apron can also cause hygiene and medical issues. This requires a tummy tuck (abdominoplasty) and usually requires a repair of the abdominal muscle for best results.
One common issue with massive weight loss is not only the lower abdominal "apron," but also excess skin in the upper abdominal region. The abdominal region may be wider than the hips after massive weight loss. If a client wants to address the upper abdominal skin as well as the lower, then a Fleur-De-Lis tummy tuck will likely be needed. In a Fleur-De-Lis, excess skin and fatty tissue are removed and abdominal muscles are repaired through two incisions. One is the standard tummy tuck incision along the pubic bone, and the other is a vertical incision in the center of the abdomen. A Fleur-De-Lis abdominoplasty provides horizontal skin tightening as well as vertical skin tightening. The length of the vertical incision will depend on how high the skin laxity goes on the abdomen. This extra incision allows the surgeon to tighten skin from the sides as well as up and down, which will drastically improve the look of the abdomen when the upper abdomen has excess skin.
The Fleur-De-Lis tummy tuck is associated with an increased risk of complications, most notably incisional healing. The area where the vertical incision meets the horizontal incision is more prone to incisional opening and wound healing issues.
Breasts
The breasts are another very common priority following massive weight loss. The breasts are often left deflated and droopy and the skin elasticity is compromised. A breast lift alone often leaves the breasts looking deflated. The breast tissue gets very thin with massive weight loss and is often a cup or two size smaller with deflation of upper pole even after lifting and shaping the breasts. Implants help improve upper pole volume. A concern with implants, however, is that the tissue is not strong. This may limit the size of an implant to achieve the best result and avoid the sagging that can be caused by a larger implant. Dr. Vidal often finds that a smaller implant with reshaping and lifting the breast provides the best overall result. If a small implant starts to sag, then a client may also need to have a mesh/internal bra to support the implant.
Large or long breasts can be more difficult. If the distance between sternum and nipple is too long, this can lead to necrosis (tissue death) of the nipple. The blood supply for the nipple is in the chest so the farther the nipple is from the chest, the greater the risk. The blood supply and can also get kinked during the procedure to reshape and lift if the distance to too long. In these cases, a better outcome may be achieved by staging the procedures in 2 surgeries.
Back
In order to address excess skin in the lower back and sides, a tummy tuck can be extended or performed circumferentially to address the abdomen and back at the same time. An upper back lift is also available to remove excess skin between the bra line and the level of the belly button. An upper back lift and breast surgery can be safe to perform together, but not an upper back lift and any other procedures due to increased risk of surgical and recovery complications.
Arms
Another common area of concern is the arms, or "bat wings," that often occur after massive weight loss. An arm lift is used to remove excess upper arm skin.
Legs
Excess skin from the legs can be removed with a thigh lift. Depending on how the excess skin presents, a single incision at the groin may be enough to address the issues. If significant excess skin is present at the inner thigh, however, two incisions may be needed. In the case of two incisions, one is at the groin and the other is along the inner thing. Like the Fleur-De-Lis tummy tuck, the junction of the two incisions is at risk for closure and wound healing issues. Thigh lifts are also prone to additional complications due to the pull of gravity, swelling, and the nearness to the genital region. It is a difficult recovery, and Dr. Vidal does not perform other contouring procedures at the same time as thigh lift in order to decrease complications and increase the likelihood of a good outcome.
Face & neck
The face undergoes a lot of changes after massive weight loss. The skin sags in the neck and lower face. The nasolabial folds deepen. Marionette lines can form under the end of the lips, and there is a loss of tissue volume without elastic recall of the skin. A face lift restores volume to upper face and cheeks and also targets the neck with tightening of the platysma muscle. This creates a better jaw line and restores the volume and position of facial tissues. Nonsurgical alternatives for the face are also available. While not as dramatic, skin tightening procedures and fillers can help improve appearance without scars.
Combining procedures
Not all contouring procedures are safe to perform at the same time. Dr. Vidal recommends facial surgeries and thigh lifts be performed as standalone procedures to have the best chance for a safe recovery and best outcomes. Performing multiple procedures that require additional time under anesthesia and change of client position also increases the risk of complications. This is an especially important consideration following massive weight loss. Bariatric surgery followed by massive weight loss alone increases a client's risk of blood clots. Increased time under anesthesia for body contouring increases the risk even further.
Trifecta
Three procedures that are safe and commonly performed together are the arm lift, breast contouring, and the tummy tuck (with or without a muscle repair). These do not require a change in client position, and the additional time under anesthesia is low enough to keep the additional risk minimal. The recovery procedures for any one of these three do not affect the recovery of the others. Doing just the arms with the breasts is common and generally safe as well. If a circumferential back and tummy tuck are performed, Dr. Vidal recommends that this be performed without adding an arm lift or breast surgeries due to the length of time required under anesthesia for the circumferential lift alone.
Considerations for recovery
To reduce the risk of complications, especially blood clots, Dr. Vidal insists on the importance of getting out of bed as soon as possible and walking. Compression pumps for the lower legs and compression socks can help as well. It is also important to stay consistent with supplements including B12 and iron as well as good nutrition in general. Clients should wait at least 3 to 6 months in between procedures as it is very important to be completely healed from one procedure before having the next.
Thank you Dr. Vidal!
Visit her on Instagram: @DrNataliaVidal @pureplasticsurgery or on her website: Pure Plastic Surgery.
November 30, 2021
Gynecomastia and Other Male Plastic Surgery
Dr. Vidal provides some great information about gynecomastia and other male plastic surgery. Take home tips from this live session:
Gynecomastia
Is the outgrowth of breast tissue in males
It can be idiopathic (just how your body grows)
It can be normally related to 3 times during the life cycle (baby, puberty, or older age)
It may be caused by a treatable reason such as hormone imbalance
It ranges in severity from mild to severe
Surgical treatment is determined by tissue type, severity, and client preference
Liposuction post-op course includes compression and MLD, just like for females
Other body liposuction and facial procedures require surgeon experience to provide the appropriate contour for a masculine physique or look
Other great information from this week's live session
Dr. Vidal discusses gynecomastia and other male plastic surgery.
Gynecomastia versus fat outgrowth
Gynecomastia is the outgrowth of breast tissue in males. It is different than fat accumulation or outgrowth, but they often occur together. Causes of gynecomastia can be idiopathic (just your body) or it can be normally related to 3 different times during our lifecycle:
In male babies, residual maternal hormones can cause a temporary outgrowth of breast tissue. This is benign and will resolve on its own as the mother's hormones are cleared from the baby's body.
During puberty for anywhere from a couple of months to years, gynecomastia may occur because of fluctuating hormone levels during this time. It is important to wait at least 12-18 months to see if it will resolve on its own (usually does) before considering any surgical options.
In the elderly population of males, gynecomastia may occur due to obesity or other factors.
Evaluation of potential causes for the gynecomastia
When evaluating a client for gynecomastia intervention, the surgeon must investigate a client's history and look for any changes in health, medications, changes in activity or diet, or substance use. The use of marijuana has been associated with gynecomastia in some males. Any potential causes must be addressed before considering surgical intervention. The surgeon also needs to assess for the presence of lumps or masses in the testes as these can cause changes in hormone levels. Other signs that may indicate a hormonal imbalance may include hair growth patterns, lack of hair growth, or feminizing features.
Evaluation of the type of excess tissue
After ruling out treatable causes of gynecomastia, the next step is for the surgeon to determine:
The amount and type of tissue - breast tissue versus fat. Breast tissue is typically more lumpy and dense while fat tissue is typically soft.
The surgeon then grades the tissue
Grade 1- mild, localized overgrowth of tissue but without excess skin
Grade 2 - mild to moderate overgrowth of tissue expanding the width of the chest
Grade 3 - moderate to severe overgrowth of tissue with sagging and excess skin
Grade 4 - Significant or severe overgrowth of tissue, sagging, and excess skin
Selection of treatment plan
After determining the grade of gynecomastia, the surgeon has different options. The goal is to select a treatment plan that is the least invasive or with the smallest incisions.
Liposuction alone can be used if the excess tissue is primarily fat tissue and there is no excess skin. Unfortunately the denser breast tissue outgrowth cannot be removed with liposuction.
If there is a combination of breast and fatty tissue but no excess skin, then liposuction with a small incision at the base of the areola to remove the denser breast tissue is an option.
In the case of Grades 3-4 that have excess skin, a longer incision is needed near the tissue fold to excise both the excess tissue and skin. A nipple graft is usually also performed to move the nipple to a better position. In the case of a graft, the tissue is flat and without sensation. This is usually acceptable to most male clients. In order to retain sensation, a larger mound of tissue has to be used to preserve blood and nerve supply, and the appearance would not be flat.
For Grade 3 gynecomastia it may be possible to stage two surgeries in hopes that the second would not be needed. In some cases liposuction and a small incision through the areola for tissue removal may be enough, and the excess skin may retract on its own with compression. If it does not retract, a second procedure to just remove the skin could be performed. Dr. Vidal presents the different options to a client and allows the client to choose based on their preference.
Post-op course
Liposuction crates tunnels so compression is still required for best outcomes 24/7 for six weeks and then part-time for up to an additional six weeks. Post-op manual lymph drainage (Dr. Vidal calls it massgae) is also important following liposuction. A nipple graft requires a dressing for about one week. No weight lifting should be performed for 6 weeks after surgery.
Other male procedures
Additional liposuction such as 360 or to arms and/or legs can be performed. Care needs to be taken during liposuction to the flanks to avoid a more feminine shape, unless desired. Liposuction can also be performed on the neck and face but usually needs to be combined with a skin retracting procedure such as radio frequency. The thinner skin on the face and neck does not retract well.
Abdominal etching, a form of high definition liposuction, is popular as well.
Males can receive a BBL, but the effect is usually less dramatic than for females because the skin of males is typically tighter than the skin of females.
For a male rhinoplasty it is important for the surgeon to have experience in order to avoid feminizing the nose (unless desired).
Male facial surgeries can include a face lift and eye lid surgeries or just fillers if a more defined jaw line is desired.
Thank you Dr. Vidal!
Visit her on Instagram: @DrNataliaVidal @pureplasticsurgery or on her website: Pure Plastic Surgery.
November 23, 2021
How to Prepare for Plastic Surgery
Dr. Vidal provides some great information about pre- and post-op plastic surgery care. Take home tips from this live session:
Educate yourself and research your procedure
Choose your surgeon with care
Be able to talk to your surgeon
Be able to trust your surgeon
Optimize your body
Optimize your health
Adopt a healthy lifestyle
Consult with your surgeon about goals
Receive 60-day pre-op consultation
Have help after surgery
Trust the process!
Other great information from this week's live session
Dr. Vidal discusses best practices for preparation for plastic surgery and good post-op processes.
Educate yourself and research your procedure
Learn about good before and after surgery care as well as details of your specific procedures. Learn about potential complications and risks as well as how complications are treated.
Be careful about information found on social media
Harder to find reliable and helpful information
Need to put this information into perspective and be aware of the potential for edited pictures
Follow surgeon social media accounts and accounts that focus on education
Reliable sources of information
Real Self Website - Unbiased website that offers information about procedures and doctors as well as reviews.
American Society of Plastic Surgeons (ASPS) - https://www.plasticsurgery.org/ - Provides a lot of information for patients and procedure expectations.
Miami Society of Plastic Surgeons no longer appears active but may have merged with Florida Society of Plastic Surgeons (FSPS) which provides a patient information section.
Choose your surgeon with care
This can be difficult, but you want to look for a surgeon specifically trained in plastic surgery – not general surgery or dermatology for example.
Ideally someone board certified in plastic surgery.
Ideally a surgeon that has experience doing the procedure you would like performed.
Ideally a surgeon that is well trained and well-rounded to be able to adapt to your needs and handle any surgical and post-surgical issues and complications.
The ASPS and FSPS both have search tools for surgeons.
Talk to your surgeon
You want to be sure you can talk to your surgeon about what you want to accomplish and change and about your specific goals and desired outcomes.
Trust your surgeon
You need to feel comfortable trusting your surgeon and their specific protocols, their way of doing surgery, and their expected post-surgical care. You need to trust your surgeon’s process for recovery rather than information from other sources or the way other surgeons may do things. You also want to feel safe and know that your surgeon is performing your procedures in an accredited facility.
Optimize your body prior to your surgery
Be at your optimal weight. This is especially important for body contouring procedures such as breast surgeries, liposuction, and tummy tuck.
Understand that plastic surgery is NOT weight loss surgery. Being at your ideal body weight first will help ensure optimal results. Losing or gaining weight after surgery can change your result because your procedure will be based on your biometrics at the time of surgery.
Remember that plastic surgery should be the last thing in your body transformation journey.
Optimize your health
Surgeons have different criteria that they want met prior to surgery. One of the most common is Body Mass Index (BMI). You can use the online BMI calculator to calculate your BMI. Many surgeons have an upper limit of a BMI of 30. Dr. Vidal has an upper limit of 35. She prefers a BMI of under 30 for optimal results but considers the increased risk of complications to be minimal with a BMI of 30-35.
Dr. Vidal has found that some people with a BMI of 30-35 can use surgery as a bridge toward their body transformation goals. In these cases, additional work to improve health and weight may be needed following surgery to achieve a healthy BMI.
Adopt a healthy lifestyle
Adopting a healthy lifestyle before surgery and maintaining if after surgery will help you optimize your results.
This may require a significant mental outlook change for many people and includes both a healthy activity level and healthy eating habits.
Achieving and maintaining a healthy body also includes adequate hydration and a good cardiovascular status.
Having a healthy body at the time of surgery helps to decrease the risk of surgical complications, improves the speed of recovery, and optimizes both short- and long-term results.
Consult with your surgeon about goals
Dr. Vidal uses a virtual consultation process that includes online forms for height, weight, medications, and medial and surgical history as well as pictures of your body. It is important for your surgeon to develop a plan of treatment based on your individual goals.
Receive 60-day pre-op consultation
This process will vary by surgeon, but Dr. Vidal’s pre-op coordinator calls you to discuss various aspects of your pre-surgical preparation in order to help you get your body optimized for surgery including
Medications and supplements to avoid prior to surgery. Some act as blood thinners which can complicate surgery and safety.
Which supplements to regularly take such as iron and folic acid (to stabilize hemoglobin) and vitamin C (important for wound healing).
Blood work (labs) and needed studies (such as EKG).
Items required for medical clearance from your primary care physician.
Have help after surgery
It is highly important to have help from another person for at least the first night and 24 hours after surgery. This is needed to maintain your safety during this critical time. Common symptoms following surgery can include dizziness, lightheadedness, and nausea.
Someone needs to be present to be sure you do not fall or hurt yourself when trying to walk or change position, to help you maintain hydration, and to help you take pain medications at the right times.
Someone must be present to receive you following surgery. You cannot be released unless you have someone with you.
Trust the process
It takes time and many people often ask themselves at the beginning of recovery “why did I do this?". It may be hard to do, but “Try to Relax.”
Answers to questions from the audience
A healthy pre- and post-op diet includes sufficient fiber and adequate hydration. It is important to switch over from sugary drinks to water. For BBL recovery it is important to include sufficient healthy fats after surgery to have the healthiest fat grafts. Healthy fats include things like avocado, nuts, dairy (unsweetened), and salmon.
Following a BBL, Dr. Vidal advises to rest from working out for the first 6 weeks following surgery, and then to focus on weight (strength) training rather than cardiovascular exercise to avoid burning fat from the BBL fat grafts.
A BMI of 24 is usually adequate for a BBL but can depend on your goals and your body type.
Dr. Vidal’s “signature” is client-oriented goals and results. She tailors your treatment plan based on your goals and “wish pics.”
Dr. Vidal requires her clients to stay in Miami for at least 5 business days following surgery so that she can do a post-op consultation with you and remove drains. This is unique to the Miami area where many people come from out of town to Miami for their surgeries.
Some medical conditions, such as diabetes or thyroid conditions, require additional pre-op labs. Dr. Vidal does not require a mammogram prior to surgery but recommends the guideline of having annual mammograms starting at 40 years old.
Seromas (fluid that fills up an empty cavity) can be a complication of any surgery but are more common after plastic surgery procedures. This is because of the “empty spaces” that the surgeons have to create such as the separation of most of the abdominal tissue over the muscles to do a muscle repair or the tunnels caused by the liposuction cannulas.
You can minimize the risk of seroma and other post-op issues by using compression and having manual lymph drainage sessions, ideally 10-20 total. Placing surgical drains also helps to avoid excessive fluid buildup and seroma. Production of fluid is part of the healing process, however.
A surgery can be cancelled for several reasons such as abnormal blood work, presence of nicotine in the blood (adversely affects wound healing), a change in BMI, positive result on a drug screen, or pregnancy.
Thank you Dr. Vidal!
Visit her on Instagram: @DrNataliaVidal @pureplasticsurgery or on her website: Pure Plastic Surgery.
November 16, 2021
Procedure Combinations - Why & Why Not
Dr. Vidal provides some great information and tips about which procedures are safe to perform at the same time and which are not. Take home tips from this live session:
Face lifts with eyelid surgeries and fat grafting are usually safe to be performed together.
A rhinoplasty is best performed as a standalone procedure.
Multiple breast surgeries such as a reduction or a lift with implant placement are usually safe to be performed together.
Combining breast and abdominal surgeries pose a low increase in risk (mommy makeover).
Combining an arm lift with a breast surgery or a mommy make over (known as "Trifecta Perfecta") is usually safe.
Ab etching is a more technical form of liposuction that can be used during abdominal liposuction procedures to give a more defined or muscular look to the region.
Adding arm or leg liposuction is usually not an issue to add to open procedures in other areas (e.g. breast or abdomen)
Combining a Brazilian Butt Lift with breast and/or abdominal surgeries is not a good choice.
A thigh lift is best done as a standalone procedure.
Implants are a better choice than fat grafting for breast augmentation.
Other great information from this week's live session
Dr. Vidal weighs the balance between risk and benefits when considering a combination of procedures during one surgery session. She wants to ensure her clients have a safe and smooth recovery. Risk of complications increase the longer a client is in the operating room and under anesthesia and can include bloods clots and blood pressure issues. Combining procedures, especially ones that require a change in the client position, as well as opposing forces on the skin can cause recovery complications and suboptimal results.
Surgeries that work well together and pose minimal additional risks include
Face lifts with eye lid surgeries and fat grafts:
Face lifts include rejuvenation of the face from the cheeks down. It almost always includes the neck, but may occasionally include only the face. This facial surgery lifts the muscles, deep tissues, and fat compartments; reshapes and re-volumizes the face; and improves the contour of the neck. It is very common and safe to include eyelid surgeries and fat grafting to the face to rejuvenate the whole face and neck. Fat grafting to the face is much longer lasting than using fillers.
Breast lift with breast augmentation:
A breast lift and breast augmentation usually work well together. The lift reshapes and lifts the breasts, and implants shape the look and projection of the breasts. There is a slight risk of doing both together as the procedures create different directional forces on the skin as the skin is lifted vertically with the lift and pushed out and down with the augmentation. If the look someone wants requires a lift and large implants, it may require two separate surgeries as large implants can put too much pressure on the incisions/scars required for the lift. There can be increased risks of asymmetry and incisional complications in this case.
Breast reduction with breast implants:
A breast reduction removes tissue and can address back, neck, and skin issues. It also reshapes and lifts the nipple/areola. It can sometimes be combined with small implants to achieve a desired look or shape.
Breast lift and/or augmentation with abdominoplasty (tummy tuck):
Known as the mommy makeover (MMO), combining breast surgery with tummy tuck is the second most common combination of procedures. It may also include a muscle repair and liposuction to the flanks. Of special note is that in the state of Florida, liposuction is legally limited to 1 liter of fat when combined with an open procedure to the same area. The combination of breast procedures with a tummy tuck does not require a significant increase in operating room time, and the surgeon does not have to change the position of the client.
Arm lift with breast surgery or a MMO:
An arm lift in combination with a MMO is often called the "trifecta perfecta" and are usually safe to combine. There is some additional risk of combining the arm lift with other procedures as the combination leads to the need for a longer healing and recovery time.
Ab etching with a BBL:
Abdominal etching can usually be combined with a BBL because it is not really a different procedure from the liposuction that is needed for the BBL. Ab etching is a form of high definition liposuction that just adds technical aspects to the procedure. There is removal of more fat in some areas of the abdomen to give the effect of more defined musculature and shape.
Adding arm or leg liposuction:
Arm and/or leg liposuction can usually be added to most open procedures on other areas such as the breast and abdomen. The extra arm or leg liposuction does not add to the 1 liter limit in Florida since it is in a different area. However, the 1 liter limit would apply if it was in combination with another open procedure in the same area such as an arm or thigh lift. Another consideration with arm and leg liposuction, however, is skin laxity. The skin is thinner and does no retract as well skin on the trunk. A treatment that uses radio frequency can be applied on the inside of the skin during arm and leg liposuction to assist with skin retraction.
Surgeries that do not work well together and pose significant additional risk or recovery complications include
Rhinoplasty (nose job):
This surgery is best performed as a standalone procedure as it involves multiple delicate tissues including bone, cartilage, and skin. It needs significant focus and detailed attention.
Brazilian butt lift (BBL) with breast or abdominal surgeries:
Dr. Vidal does not perform or recommend a BBL with breast and/or abdominal surgeries. A large amount of fat from liposuction (360 lipo most commonly) is usually needed for a BBL. When combined with breast or abdominal surgery, the legal limit of 1 liter of fat in Florida is usually too low for a good BBL result. Combining these procedures also poses increased risk of complications due to the need for longer operating room and anesthesia time as well as the need to change the position of the client during surgery.
Recovery and an optimal result are also usually compromised because of opposing ideal recovery positions. After breast surgery and/or tummy tuck, a client cannot lie on their stomach, but the best recovery position for a BBL is lying on the stomach and avoiding lying on the hips or butt. Suboptimal recovery positioning can lead to suboptimal results. The large amount of liposuction required for the BBL also causes a greater degree of inflammation and longer healing time that can cause complications of the recovery of breast and abdominal surgeries.
Thigh lift:
Dr. Vidal recommends that, like a rhinoplasty, a thigh lift be performed as a stand alone procedure. It is a difficult recovery by itself.
Other topics from this weeks tips
Fat transfer for breast augmentation:
Based on a question asked by her audience, Dr. Vidal discussed that fat transfer is not the best or safest way to achieve breast augmentation. While the procedure is safe, it requires a large amount of fat and often 3-4 separate procedures of fat transfer to achieve a change in cup size. The breast tissue does not have a large amount of blood vessels like the butt region so a lower percentage of fat is incorporated by the body when compared to a BBL. There is also an increased risk of cysts and fat necrosis in the breast tissue. On mammograms these often look like lesions and may require increased need for additional scans and biopsies of the tissue to rule out breast cancer. Dr. Vidal feels the risk versus benefits of fat transfer makes the use of implants safer for breast augmentation.
Capsular contractions of the breast from implant placement:
A capsule of tissue forms around breast implants as the normal reaction of the body to a foreign body. An uncommon complication of breast augmentation with implants is a painful thickening of this capsular tissue that can be anywhere from mild to severe pain, asymmetry, and deformation. Increased risk of a capsular contraction is related to
Having a post-op infection
The presence of bacteria in the area even if it is not enough to cause signs of an outward infection
Using an incision around the areola for implant placement because it is so close to mammary ducts that harbor bacteria
Placing implants under the muscle
Having a previous capsular contraction
Treatment for capsular contracture varies depending on severity. At worst it may require removal of the capsule and implant.
Consideration for needing a breast lift
When considering the need for a breast lift with augmentation, Dr. Vidal discussed the position of the nipple/areola versus the inframammary fold. If the nipple is at or above the inframammary fold, then implants alone may be enough to give the desired result. If the nipple is pointing down or is below the inframammary fold, then a lift will also likely be required to give the desired result.
Thank you Dr. Vidal!
Visit her on Instagram: @DrNataliaVidal @pureplasticsurgery or on her website: Pure Plastic Surgery.
November 9, 2021
All About Scars
Dr. Vidal provides some great information and tips about plastic surgery scars. Take home tips from this live session:
Start scar care at 2 weeks post-op if scar is healed and has no open areas.
Use silicone tape or gel - both work equally well.
Choose tape or gel based on your preference and ability to be compliant.
If using tape, leave it on for 23 hours/day.
If using gel, apply 2x/day and massage into the scar.
Do this for a year after surgery for best results!
Other great information from this week's live session:
Tension is one of the main things that affect scar appearance and thickness. Things affect tension on the scar include
layers of sutures - tension decreased by multiple layers of sutures from inside out
suture type
suturing method
activity following surgery - avoid postural tension for 1-2 weeks. For example, after a tummy tuck try to walk bent over a bit. After breast surgery, do not raise your arms above shoulder level.
There is a difference between hypertrophic and keloid scars. Hypertrophic scars are elevated and can resemble a keloid, but they do not spread into surrounding tissues (beyond the border of the scar), are rarely painful, and improve with time. Keloid scars, on the other hand, grow beyond the border of the scar into the surrounding tissue.
It is normal for a scar to be itchy, especially one that is hypertrophic. Steroid injections by your plastic surgeon or dermatologist may help.
The biggest risk factor for keloid scars is genetic history. If you or your family have a history of significant keloid scarring, you may want to talk to your plastic surgeon about options that do not involve long scars such as a tummy tuck.
Your plastic surgeon may be able to treat scars with an unacceptable appearance to you with several methods including steroid injection, excision, excision followed by radiation, and/or tissue rearrangement. Tissue rearrangement may help make the scar less noticeable or improve range of motion.
Your risk of an incision opening (wound dehiscence) increases with
diabetes
nicotine use
BMI >30
post-surgical infection
If an incision does reopen, it will, in all likelihood, need to heal by secondary intention (from the inside out) as it cannot usually be re-sutured. It can, however, be revised at a later date. In order to reduce the risk of infection, surgeons often give their clients a dose of IV antibiotic just before surgery and oral antibiotics for a week following surgery.
Necrosis (tissue death) is caused by an issue with blood supply, either during or after surgery. The combination of an abdominal muscle repair with liposuction can lead to an increased risk of necrosis. Plastic surgeons can limit this risk by limiting the areas of liposuction on the abdomen when they are also performing a muscle repair.
Thank you Dr. Vidal!
Visit her on Instagram: @DrNataliaVidal @pureplasticsurgery or on her website: Pure Plastic Surgery.