Author: Morgan Cosmetic Surgery

Cosmetic  Question:  I have severe TMJ. I have tried everything. Nothing works. A friend said I should try Botox for TMJ. Is this true?

Cosmetic  Answer:

Yes, it is true.  Botox can be injected into the masseter muscle for TMJ pain. TMJ pain is often caused by an over-active masseter muscle. The masseter is the chief muscle that closes the jaw. The masseter often becomes over-active because of the teeth closing better on one side of your jaw compared to the other.   The result is that the masseter keeps trying to get the teeth to close but it cannot.

Over-active masseter muscles can be caused by different things.  Tooth grinding usually related to anxiety can be one cause and it seems to be more common in some groups of people than others. For instance, over-active masseter muscles are more common in Asians and Caucasians.

Botox and other neurotoxins, e.g. Dysport, Xeomin, work for TMJ pain because they weaken the masseter muscle, temporarily. The affects last approximately 3 months.  You should make sure you choose a  Board Certified Plastic Surgeon who has a lot of experience injecting neurotoxins in the face to do your injections.  These injections can affect other facial muscles and if not done correctly you may get undesirable results.

At first it can be frustrating to get the response you want from the neurotoxin injections. The physician will have to judge how may injections you need, what kind of neurotoxin to use, whether to inject both masseter muscles or just one. So, yes Botox does work for treatment of TMJ pain if you have patience and are treated by a well qualified physician.

Learn more about TMJ and Botox in this video:

https://vimeo.com/106936119

Cosmetic  Question:  Why can’t I get silicone lip and buttock injections here in the USA?  It’s easy, it’s permament, and it’s done all over South America.

Cosmetic  Answer:

Injectable silicone for medical use is not approved in the USA because of the problems silicone will cause you a year or so later.  The lip injections look lovely at first, but in time, you will end up with hard, ugly lumps in your lips as your tissues react to the silicone.  What about buttock injections?  Read on…..

One of the common lip operations I do is removal of unsightly silicone-hardened lip tissue for women who have had these injections in Columbia and other South American countries.  Unfortunately, once the silicone is injected, it is not possible to get all of it out.  It goes into the muscle as well.  It always takes two procedures to get a good result, because of distortions caused by the remaining silicone.

It is much, much smarter to either have fillers like Juvederm in your lip, fat injections or even V-Y lip advancements instead of silicone injections.

As for buttock injections, they are a total disaster – and unfortunately, commonly done illegally by in the USA.   It is possible to buy “medical grade” liquid silicone on-line for ten dollars a kilo (quart) – and all sorts of people are willing to illegally inject it into you for money.  The consequences you will live with are unfortunate – a hard, painful, swollen buttock.  It is almost impossible to fix this.  The silicone-injected tissue can be partially removed with surgery, but it will leave your buttocks shrunken and distorted.  If there is a single liquid lump, it may be possible to remove some of it with liposuction.  In the worst cases, the silicone is injected into nerves, causing permanent disability or into blood vessels – killing you.  Liposuction/fat transfers to the buttocks or permanent soft-solid silicone implants are the only reasonable approach we have today to improve buttock size and shape – except, of course, tons of daily squat exercises.

Silicone cosmetic injections are not FDA approved for reason.  Please avoid them.

 

 

Question:  I want a breast augmentation so that I can finally look good in my swimsuit.  However, a friend had implants.  It was incredibly painful and she looks ridiculous – her implants are half way up her chest and her natural breast hangs below it.  Is this the way they are supposed to look?

Answer:

No, it is not how the result should look.  But under-the-muscle implants hurt a lot the first week after surgery and can take up to 6 months to settle in, and some never do.  This may require another operation to re-position them.

The good news is that you can have a quick recovery and immediately “pretty” result if implants are placed above the muscle.

Above-the-muscle breast implant surgery has little to no severe pain.  The implants usually settle in place immediately.  You will feel and look good in a few days.  Of course, you have to heal and swelling takes time to subside.  You should not run or do sports for six weeks, but you can have it done on a Monday and look good in your swimsuit by the weekend.

Why aren’t all breast implants done this way? After all, it’s the natural place for breast tissue. And putting implants under the muscle doesn’t make them look better – the breast shape will always change when you exercise. And the surgery itself is riskier – occasionally the lung is punctured, putting you in hospital with a chest tube!

First, if you are completely flat, the implant will look more natural, less ‘stuck on’, if it is under the muscle. Also if you have a saline implant under the muscle, future mammograms may rupture the implant. (This doesn’t harm you, but the implant has to be replaced.)  Capsular contractures are a bit more common when implants are over the muscle.  But being under the muscle doesn’t prevent these contractures – the risk is still about 1% a year. .

The trend to under-the-muscle implants began in the 1980s, when the old gel implants leaked silicone gel, causing really severe capsular contractures in at least 30% of women.  Plastic surgeons started putting implants under the muscle to reduce these contractures.  Then in the 1990s, the FDA took the old gel implants off the market, compelling plastic surgeons to use only saline implants.  Plastic surgeons started putting implants under the muscle routinely, to avoid the risk that women with little breast tissue, and their partners, would feel or see the implant outline through the skin.

Today, many younger plastic surgeons have never done an over-the-muscle implant, but it is an excellent option.  With the new cohesive gel implants that don’t leak, many surgeons like myself who know how to do over-the-muscle implants, offer this approach to every patient,  except those who are extremely flat-chested.  It makes this operation what it should be – an anatomically natural placement, easy recovery, immediate result.

Cosmetic  Question:  What is the best neurotoxin for TMJ and masseter hypertrophy?

Cosmetic  Answer:

It varies, and here’s why-

There are several neurotoxins available.  The most commonly used are Botox, Xeomin and Dysport.  Dysport is the most expensive, Botox next and Xeomin least.  Only Botox is made in the USA.  The others come from Germany and Ireland, respectively.

Depending on the research, some studies show one neurotoxin is best, some show another one is.  Since Botox is made in the USA and always available, I start with a moderate dose of Botox.

Often a person gets a response to Botox the first time with TMJ pain relief and the return of their facial shape in a week.  Then the second time, they may see less response, because our muscles are so adaptable.  So I will increase the dose until we get the look and the pain relief we want.  You may need treatment every six weeks at first, because the masseter is a big muscle.
However, Botox contains a tiny bit of protein, so  if you need frequent high doses, your body may begin to inactivate the Botox.  Then it’s time to go to Xeomin – it has no protein at all, so no interaction.

But Botox and Xeomin are very concentrated – sometimes a muscle is so big we want the neurotoxin to spread widely. Then we go to Dysport.  Because it spreads, Dysport may be more likely to affect nearby muscles and give you a funny smile, so it has to be given expertly.

It sounds like a lot to know, and it is, and of course there is much more.  The fact is, all the neurotoxins work on cosmetic masseter hypertrophy.  How to get the best result requires the knowledge and experience of an expert.  Usually these experts are Board Certified Plastic Surgeons like myself, we have the most cosmetic training, so it’s no surprise we’re likely to get the best cosmetic results for you.

Question:  I am interested in a Brazilian Butt Lift (BBL).  Someone told me it is very dangerous – is this true or a scare tactic?

Answer:

According to a recent report, a Brazilian Butt Lift appears to be more dangerous than thought.

First of all, what is it?  A Brazilian Butt Lift or “BBL” injects fat into the buttocks to enlarge them.

The fat is used for the injections is removed by liposuction from the stomach, flanks and or thighs.  The fat is washed, concentrated and injected with a cannula (blunt tube) or needle into the buttocks.

Why is it done?  A BBL is popular because silicone buttock implants have a very high rate of infection.  A BBL has a very low rate of infection and is now the routine procedure to create larger buttocks.

Results are unpredictable, and only 40 – 70% of injected fat survives.  So at first the buttocks look very large, then swelling subsides, some fat absorbs and the final result appears in 3 – 6 months.  At times, all the fat absorbs.  Results may be lumpy or asymmetric and need corrective treatment.  These problems are distressing, but certainly not catastrophic.

However, catastrophe in the form of sudden death can occur if fat gets into large blood vessels.  It then goes directly to the lungs making breathing difficult or impossible.

A recent survey of plastic surgeons in Mexico and Columbia, showed that one in every 30 plastic surgeons had had a patient die on the operating table or in 24 hours after surgery from a BBL.  Autopsies showed that the deaths were caused by fat injected into the blood vessels in the muscle going to the lungs, suffocating the patient.  These were voluntary reports of patient deaths – there may be many more BBL deaths than we know.

This suggests that fat should NOT be injected into the deep buttock muscle, where blood vessels are large.  Results may be poorer though, because fat survives so well when injected into the muscle.

Fat injections in general may be more risky than we think – a recent USA report found that fat was the most dangerous filler to inject in the face, more likely to get into the blood vessels and cause blindness, compared to other fillers.

Why? It isn’t clear, but it may be that fat is thicker and can do more damage, wherever it is injected.

So how dangerous is the BBL or any fat injection?  Truthfully, we don’t yet know.  Thousands are being done across the USA all the time – some by well-trained plastic surgeons, and some not.

If you are going to have a BBL, I personally suggest that you only have a Board Certified Plastic Surgeon do the procedure and that the procedure be done slowly and carefully with the smallest possible cannula.  This won’t make it risk-free (nothing in life is!) but it will make it a reasonable procedure to have done.

Question:  When can I exercise after a tummy tuck?

Answer:

There isn’t an exact answer, because some people recover faster than others.  There is a general guideline, however.  Tummy tucks typically cause 3 – 5 days of severe muscle spasm.  This kind of pain is very tiring.

Week 1:  You will want to walk slowly around the house.  You will have severe pain when you cough or sit up.

Week 2:  It is a good idea to get out of the house, but know that you will tire easily.

Week 3:  If you have a desk job, you can go back to work, but you may have to leave early because of fatigue.

Week 4:  You will by now have the energy for house work and walks.

Week 5:  Your energy should start getting back to normal by this point.

Week 6:  This is the week you may begin doing weights and other exercise.  It is important to start at 10% of what you did before.  However, no running, and definitely no crunches.

Week 7:  You may try a short jog or a few crunches .

Week 8:  Finally, you will be able to do any kind of exercise, but you will not be back to pre-surgery strength and fitness.  This will take time, but will happen gradually.

You can speed up your recovery if you have the pain killer, Exparel, injected into the stomach muscles during surgery.  Exparel is a long-lasting anesthetic.  It prevents muscle pain and spasm – less pain means a faster recovery.  You still can’t do crunches or run for 6 weeks, but you will be walking easily from the start and have much less fatigue.  This means you  can return to a desk job  at 2 weeks rather than at week 3.

Question:  How soon can I go back to work and exercise after liposuction?

Answer:

Everyone is different and recovery is faster for small liposuctions and slower for larger ones, but here is a good general guide to liposuction recovery after removing 3000 – 5000 cc of fat, which is fairly standard.

• Day of surgery
  • You go home groggy, stiff, sore and perhaps in pain when you move.
  • You are able to be up and around but moving slowly.
  • You are wearing a surgical garment for support.
• Day 1
  • You drain fluid for 24 hours – usually pink, sometimes dark pink or red.
  • You can take ibuprofen for pain and may not need any narcotic except to sleep.
  • You are tired, stiff and sore, especially when you first get moving.
• Day 3
  • You can remove the garment, shower, wash and replace the garment after drying.
• Days 1 – 5
  • You usually need a narcotic pain killer or two to get to sleep
  • You are still sore – some areas may be lumpy and especially tender.
  • Energy is a 5-6/10
• Day 5 – 7
  • You can work from home or work if you have a short commute to work and a desk job.
  • If you do not wear the garment, you will be exhausted.
• Day 7 – 10
  • Most people are back to work.
  • Those with physically demanding jobs will be very tired and may need to leave early.
  • Without the garment, sitting or physical work will be much more tiring.
  • Because of swelling, you may still feel and look ‘fatter.’
• Weeks 2-6
  • The garment is work for comfort – it usually relieves aching and swelling.
  • Walking and other non-impact exercise is allowed as comfort allows.
  • Swelling begins to subside, result begins to appear
• Week 6 –
  • Most people stop wearing the garment – some will continue for comfort
  • Running, jumping, boxing etc can resume – but slowly
  • The final result beings to appear
• Months 6 – 12
  • Final result – tissues soft, feeling has returned, scars have faded.

• Smaller liposuctions have a much faster recovery, but the swelling/healing process is the same.
• Liposuctions larger than 5,000 are usually avoided because of a higher risk of bleeding and longer recovery. People who are significantly overweight may need several sessions of liposuction if they want to treat more than 1-2 areas.

 

Cosmetic  Question:  I hate my fat cheeks. What is involved with buccal fat removal?

Cosmetic  Answer:

Buccal fat removal removes excess fat in the cheeks. An incision is made inside the cheek, excess fat is gently removed, avoiding nearby nerves. It is a minor procedure that can be done in the office.

Your cheeks will swell quite a lot – in 2-6 weeks, you will see the result – hollower cheeks.

The main risk is damage to nearby facial nerves.

Research shows that women start to lose facial fat by our mid-twenties. This is one reason that we age earlier than men. Fillers and fat transplants are all aimed at restoring fullness to areas that have lost this fat. So if you are under age 25 – I suggest you postpone buccal fat removal at least to then.

If you have heavy cheeks because you are overweight, try vigorous swimming, running, dancing or other aerobic exercises. They often rapidly slim the face. You may also want to have your thyroid checked – a chubby face is a common early sign of hypothyroidism.

Question:  I have heard of a breast lift and breast reduction being done without any scars. Is this possible?

Answer:

The breast can be reduced with a minimal scar, using liposuction. There are scars, but they are very small.

The “scarless” breast reduction is effective if your breasts have a lot of fatty tissue – it is ineffective if you have dense breasts largely made of glandular tissue. Glandular tissue cannot be removed with liposuction, the way fat can be removed.

Liposuction is done through several small incisions in each breast. These leave scars and the vibration of the liposuction cannula can thicken and darken these scars, especially in women with darker skin. This can be prevented by using skin lightening cream on the breasts two times a day for 4 weeks before surgery.

Insurance will not pay for liposuction breast reduction. It is considered cosmetic, like any other liposuction procedure.

Will the fat return? After liposuction, fat does appear in new areas unless you lose weight – usually about ten pounds.

And like any liposuction, the skin may be loose after removing the fat – so your breasts may be smaller and lighter, but they will not be lifted.  Incisions are still needed to lift and tighten the breast. These incisions have gotten much smaller – a lollipop incision may be needed or just an incision around the areola, depending on how much extra skin there is.

It is wonderful to have choices for your care. Most women are very happy with their breast surgery.

Give us a call to find out more!

 

 

 

 

 

Question:  I hate my cellulite! My thighs are all puckered. Is there anything that actually works?

Answer:

Yes. Cellulite is caused by fibers that connect the skin to muscle. They don’t lengthen with time, but skin and the fat under the skin do change with time. Skin loosens and we tend to gain weight. The result is the puckering of skin around these fibrous bands.

This is chiefly on the buttocks and thighs, where we tend to put on fat. It can be a few dimples or lots of indentations. Liposuction does not break down the fibers – it goes around them, so liposuction can make cellulite worse. We can, however, treat cellulite in the office.  Here’s what’s involved –

The cellulite dimples are marked. The tissue is injected with local anesthetic. A tiny incision is made and a tiny blade is placed under the skin. The fibers are cut and the skin smoothes out.

Does this work?  Yes, it does – not on every single band, but on most. It is an office surgical procedure. You usually will be lightly sedated and need a ride home – no sports or exercise for 2 weeks.

Other machines available today don’t work – we have had 20 years of disappointing cellulite treatments that only worked temporarily. There is a machine called Cellulaze which uses laser heat to cut the fibers.  The heat is effective, but it can damage the skin.

There is a new machine on its way call Celfina that does work – because it does exactly what plastic surgeons have always done:  local anesthesia, tiny incisions, cutting of the fibers.

This machine, however, is very expensive, so cellulite treatments with the machine will cost twice as much as those done without. Either way, with the machine or without the machine, cellulite can be treated with local anesthesia and a minor procedure done in the office.  You don’t have to live with the hated puckering any longer!