8 RESHAPING YOUR CURVES
Your face may be the thing people notice the most about you, but you’ve got a whole lot of body left below the neckline, and many of my patients complain that they have just a little too much here, not quite enough there, and why is it all so much lower than it was a decade ago? Welcome to the aging body, and take heart: There is much we can do to shape it, rearrange it, and keep it looking improbably young.
First and foremost, I would be remiss if I did not remind you of something you probably already know: the number one thing you can do to keep your body looking younger is to exercise regularly. This isn’t just a theory or my own crazy idea. There are about a million studies that support this. Exercise actually reverses many of the signs of aging in some pretty dramatic and surprising ways. It triggers chemical processes in the body that build muscle, burn fat, maintain mobility as you age, give the brain an antiaging biochemical bath, and even make the brain bigger!31
The best effects come from an exercise habit—not exercising once a month, not whenever you remember you have a gym membership, but regularly, as in three to five times per week for at least thirty minutes. This isn’t a fitness book, and you can look elsewhere for more information about this, but just know that whether you walk, run, lift weights, do yoga, or do a little of all those things (that’s probably the best idea), you will give your entire body, inside and out, a hall pass on aging. You’ll still get older, but you won’t get older as fast, or look as old as others your age who don’t exercise. There was even a study that showed that in mice, regular exercise not only kept organs like the brain and the heart healthier, but actually kept the mice’s fur from graying as quickly, and resulted in fewer wrinkles! Follow-up human studies echoed the mouse studies, showing that among those who exercised for three hours every week, skin was thicker, had a more youthful appearance, and even appeared to rejuvenate in older subjects who exercised regularly.32
Genetics is another important factor in aging bodies as well as aging faces. Some people have genes that seem to keep them looking and feeling younger, and even shaped like a younger person, all the way into their seventies. Many celebrities come to mind, such as Audrey Hepburn, Jane Seymour, Pierce Brosnan, Denzel Washington, and Michelle Pfeiffer. However, most of the time, for most people, even those who exercise, aging eventually creeps in. Things start to sag. Fat accumulates in places where we don’t want it (like our thighs), and disappears from places where it could benefit our appearance (like our faces).
But there is hope! Start exercising if you aren’t already, sure, but there is even more you can do to get your curves in the right places again. In this chapter, let’s check in with your body. We’ll talk about fat and where it’s going, and flab and why it’s hanging, and I’ll even give you some sound advice on what you can do about aging body skin, drooping breasts, and even some options for those of you who wish your breasts or your butt was just a little bit bigger and fuller than it is right now.
FAT ACCUMULATION
Just about everybody has a beef with the fat that has accumulated in some unwanted spot. Women often tell me they want to get rid of the fat from their abdomens, buttocks, or thighs, while men are more interested in blasting their beer gut or trimming those love handles. Our bodies all deposit fat in their own individual ways, largely due to genetic propensity, and even in very fit people, there can be extra fat. Always try diet and exercise first, but in cases where unwanted fat pockets just don’t seem to respond to diet and exercise, there are some other good options.
CoolSculpting
Fat-reduction therapies have come a long way in the past several years. Just seven years ago, there was no safe, proven way to reduce fat without surgery. Today, there are over a dozen treatments that claim to reduce fat, and several that are scientifically proven to work. Let’s take a look.
As of this writing, CoolSculpting is probably the gold standard for noninvasive fat reduction. This treatment is based on the fact that the skin is more resilient to injury than the fat below it. Knowing this, the CoolSculpting device was created to freeze the skin and the fat underneath it, causing irreversible damage to the fat cells but leaving the skin unharmed. Studies show that one treatment (lasting typically an hour) reduces the thickness of fat by approximately 25 percent. The treatment is virtually painless, but results can take a month or two to show up.
CoolSculpting is a great option for people who want to modestly reduce the fat of their abdomen, hips, waist, or thighs and don’t want to undergo surgery. It definitely works and is an 
. My only reservations for this treatment are that the results aren’t nearly as dramatic as those achieved with liposuction, and it’s quite expensive. Most CoolSculpting centers charge at least $700 per area. This can add up to many thousands of dollars if you want multiple areas treated. However, the treatment is very easily tolerated and doesn’t usually necessitate any downtime or cause posttreatment pain.
Liposonix
Another scientifically proven treatment to noninvasively reduce fat is Liposonix. Liposonix uses ultrasound energy, the same ultrasound that is used to look inside a pregnant woman’s tummy at a baby inside, but turns that ultrasound energy way up to blast away fat cells. The company advertises its treatment with the promise that you need only one hour-long treatment to lose one inch or one dress size. Scientific studies show that the treatment does, in fact, destroy some of the fat cells in the deeper fat. As with CoolSculpting, the body naturally clears the fat from your body and results can take a month or two to be noticeable. Although I recommend CoolSculpting as the gold standard of noninvasive fat reduction, Liposonix is another valid option with pretty comparable results. According to RealSelf.com, the average cost of Liposonix is $2,450.
UltraShape
UltraShape, like Liposonix, uses ultrasound energy to permanently reduce fat. It’s been effectively used for many years outside the United States and was FDA-cleared in 2014 for noninvasive fat reduction. The treatment is virtually painless, and studies show it takes an average of four centimeters off the circumference of the abdomen. Not bad! One big difference between Ultrashape and CoolSculpting or Liposonix is that it takes three treatments, spaced every two weeks, for optimal results. The other treatments just take one, so for this reason I generally recommend CoolSculpting and Liposonix over UltraShape. According to RealSelf.com, the average cost of UltraShape is $2,125.
Radiofrequency Devices
Another method for nonsurgically reducing fat involves radiofrequency devices. These reduce fat by heating it with radiofrequency waves. You may remember that I already told you how radiofrequency waves can heat up and tighten skin. When these waves are turned way up, they can bypass the skin to heat and disrupt the fatty layer underneath.
I initially noticed the ability of radiofrequency to melt fat as an inadvertent consequence of skin-tightening radiofrequency treatments back in 2004. I saw a handful of patients who underwent skin-tightening radiofrequency treatments to their faces by other doctors but were left with faces that looked gaunt or hollow, and even had dents. I treated them by injecting fat into their faces to replump them. I wrote this up in a scientific article for Plastic and Reconstructive Surgery in 2007 and reported it on my blog. The company behind the radiofrequency device then had their attorney send me a threatening letter as a result. Now, several years later, the radiofrequency companies have begun to utilize what I helped discover, and are now marketing their devices as fat reducers!
Although these radiofrequency devices can, indeed, reduce fat, in general their results aren’t as proven or reliable as CoolSculpting or Liposonix. However, unlike CoolSculpting and Liposonix, these radiofrequency treatments can do more than just reduce fat. They also modestly tighten the skin and smooth cellulite. I describe these devices as “souped-up” cellulite machines to my patients. They may not be as consistently effective in reducing fat as the treatments above, but they have the added benefits of skin smoothing and tightening that CoolSculpting, Liposonix, and UltraShape lack. Unfortunately, these devices necessitate multiple treatments, sometimes as many as eight treatments spaced one week apart, for best results. Some examples of radiofrequency devices that can smooth cellulite, tighten skin, and reduce fat are the Body FX (an ), VelaShape III, truSculpt, and Venus Freeze. If you’re interested in a combination of skin tightening, cellulite smoothing, and modest fat reduction, then one of these treatments may be good for you. Costs vary, depending on the number of treatments you have and the device used, but a series of treatments for any of these devices typically starts at $1,000 and up.
Vanquish is the name of a radiofrequency-based fat-reducing device that is completely different from the ones I described above. Unlike the other radiofrequency-based fat reducers, Vanquish doesn’t necessitate any contact with the skin. It’s used primarily to reduce inches from the midsection, with one study revealing an average loss of two inches after a series of four 30-minute treatments. For the most part, Vanquish treatments are painless, although you may feel some heating of the treated areas. If you are interested in noninvasive reduction of fat from your abdomen and hips, then I’d put CoolSculpting or Vanquish at the top of your list. According to RealSelf.com, the average cost for a set of Vanquish treatments is $2,400.
Low-Light Lasers
The Zerona device was the first FDA-cleared, noninvasive fat-removing device. I was one of the first to introduce this game-changing machine on TV back in 2009. The Zerona is a strange-looking contraption that resembles Dr. Octopus from the Spider-Man comic books. It utilizes four low-light lasers, which, after six treatments over two weeks, are believed to cause your fat cells to open up and release their contents. Low-light lasers aren’t like the lasers we use to burn facial skin or that we use in surgery. They don’t create any heat, which is why they are also called cold lasers. They are better compared to the lasers in laser pointers.
Studies show that patients lose an average of three to four inches when measuring four body parts: each thigh, waist, and hips. We used the device in my office for about a year and found variable results. Some patients lost virtually nothing, whereas others lost as much as eight inches. One big drawback was the lack of control we had over where the inches would come off. The patient might have huge thighs she wanted reduced, but the four inches could instead come off her hips. The Zerona is also now cleared by the FDA for reducing arm circumference as well. In order to encourage and accommodate the body to naturally dispose of the fatty content of these cells, you’re encouraged to take niacin supplements, drink plenty of water, and exercise to complement the treatments.
Other devices that use low-light (or cold) lasers are the i-Lipo and the Strawberry Laser Lipo. In general, low-light laser treatments aren’t my top choices for noninvasive fat reduction. Although I believe they work, the results are too variable for me to strongly recommend them.
Mesotherapy
Mesotherapy is a controversial technique that involves injecting a substance under the skin that is caustic to fat. Another name for this treatment is injection lipolysis. This treatment originated in Europe and has since been practiced throughout the world. Although it sounds like a good idea, there are some major concerns regarding the safety and effectiveness of mesotherapy.
One major problem is that there is no standardization about what and how much of it should be injected under the skin to destroy the underlying fat. Basically, any doctor can concoct his or her own witches’ brew of caustic substances that may result in the fat dying off. In the mid-2000s, this lack of regulation led many doctors (mostly non–plastic surgeons who wanted to get a big name in the marketplace) to advertise their own mesotherapy treatments. Countless stories of frightening complications ensued, such as infections, tissue death, and disfigurement. Since then, several countries, such as Brazil, have banned mesotherapy.
This hasn’t closed the door on a possible safe option in mesotherapy, however. Kybella is a new injectable treatment that was FDA-approved in April 2015 for reducing the fat under the chin. It’s currently the only effective option (short of liposuction) to thin a double chin. It involves several tiny injections of a substance that is caustic to the fat, irreversibly damaging it and causing the area to gradually thin over several months. The results appear to be permanent! Up to six treatments are necessary, and as of this writing, the cost is still to be determined. Keep in mind that although it appears to be very effective in reducing a double chin, it doesn’t tighten the skin. It only removes the fat. Still, I’m very excited about this one.
By the time you read this, I expect everywhere through the United States plastic surgeons and dermatologists will be injecting Kybella. Say hello to my little friend and good-bye to your double chin!
Body Wraps
Short of diet and exercise, there really aren’t any at-home ways to permanently reduce fat. Laser manufacturers have made at-home devices for acne, skin rejuvenation, and hair removal, but unfortunately they have yet to introduce anything for the home user that effectively spot-reduces fat. The best thing I’ve seen that does work, however, is body wraps.
If you want to reduce inches virtually in an instant, such as right before an important function, like a class reunion, a hot date, or a red carpet event, or any time you really want to look a little bit slimmer than you really are, I recommend a body wrap. Suddenly Slender is one relatively popular company with franchises across the country. Although these wraps are more commonly performed in spas, they can also be performed at home. They work by draining away excess water weight and can temporarily take off inches within a matter of hours. Many of the manufacturers also claim that their wraps remove the dreaded but vague “toxins.” I suppose you sweat a lot during these treatments, and some toxins are always released in sweat. Keep in mind that the results of body wraps aren’t permanent, but they can be pretty dramatic.
An easy body wrap for the abdomen and hips that you can do at home is the Adonia Tummy Tone. This is a cream composed of organic essential oils and capsaicin that can create rapid (but temporary) inch loss. You generously apply the cream to your abdomen, then have someone wrap your abdomen with plastic wrap (like Saran Wrap) tightly four times around your tummy, like a tight girdle. Lie down on your bed or couch and cover the area with a warm blanket. Read a book, take a nap, or watch some TV. An hour later, unwrap your abdomen and it should be one to two inches smaller. Like other body wraps, this treatment probably works by reducing the excess water in your tissues, causing you to be temporarily smaller for a few hours. Not bad for an hour of lying down and doing nothing!
Liposuction
Yes, it’s surgery, and yes, it’s an apparently easy way to get the fat off. It’s not for everyone, but since its introduction to the world of plastic surgery in the 1980s, liposuction is still considered the gold standard for permanent fat reduction. It’s certainly not the only scientifically proven way to reduce fat, as we’ve seen. However, many of my patients are very interested in liposuction, so let’s talk about it first, just in case you really want to know.
There are three types of liposuction: tumescent, ultrasonic, and laser:
1. Tumescent liposuction is the technique that most plastic surgeons use when they perform liposuction. This procedure involves two steps. First, the surgeon makes a small incision in the skin and injects anesthetic fluid to decrease postoperative pain and limit bleeding. Next, the plastic surgeon uses a long, hollow rod (called a cannula) hooked up to a suction device to mechanically disrupt the deep fat and literally suck it out. The fat that is removed is gone. Permanently. The patient is placed into a spandex garment to decrease swelling and bleeding, which he or she wears for the next three to four weeks. This is typically a very efficient way to permanently remove fat cells from the body.
2. Ultrasonic liposuction was developed in the late 1990s and currently goes by brand names such as Vaser and Lysonix. The first step (infusion of anesthetic) is the same, and the last step (sucking out the fat) is the same as in the tumescent technique, but there is a middle step. In the middle step, the surgeon inserts an ultrasonic cannula, which looks similar to the liposuction cannula except that the end emits ultrasonic energy. This allows the plastic surgeon to melt fat and connective tissue fibers and theoretically remove fat more efficiently. It can help a surgeon more effectively remove fat from areas where it is dense and fibrous (like a man’s breast or in a person with a lot of scar tissue), but at added expense and the rare risk of burns. I rarely use ultrasonic liposuction anymore, since its benefits for most people overall are pretty minimal.
3. Laser liposuction was developed most recently, over the past several years, and goes by the brand names Smart Lipo, Slim Lipo, LipoLite, and others. In this surgery, the first and last steps (infusion of anesthetic and sucking out the fat) are the same as in tumescent liposuction, but, like ultrasonic liposuction, there is a middle step. In laser liposuction the plastic surgeon takes a thin laser fiber and passes it under the skin numerous times, in order to heat up the skin overlying the fat. Theoretically, the heat causes the skin to tighten. The big question is: How much does the skin actually tighten? It depends on whom you ask. Doctors who own the laser liposuction devices often claim that the skin tightening can be dramatic. Doctors who don’t own the devices often claim there is no tightening at all. I suspect that the truth is likely somewhere in between but probably leaning more toward the little-to-no-tightening side. My recommendation is that if you are considering paying extra for laser liposuction, choose a small area where even a modicum of skin tightening will be noticeable and worth the additional expense. This could include the skin under your chin and your arms. The Smart Lipo device arguably has the most safety mechanisms built in, so the risk of burns is lower with this device than with the others. So if you choose to have laser liposuction, I recommend that you find a board-certified plastic surgeon who uses Smart Lipo.
So should you have liposuction? Which type of liposuction is best for you? If you have small, stubborn areas of fat that are resistant to diet and exercise, and the cost and invasiveness of liposuction aren’t deterrents, then you may be a good candidate for the procedure. Ninety percent or more of people who are good candidates for liposuction do just fine with the tumescent technique, saving time and money in the process. If you’ve had liposuction before and need a second revision procedure, then ultrasonic liposuction may be right for you. If you just want to reduce fat in a small area (such as under the chin or the upper arms) and have a little loose skin, then it may be wise to look into laser liposuction, specifically Smart Lipo.
The cost of liposuction varies, typically starting at about $1,000 for a small area to $10,000-plus for extensive liposuction. Adding ultrasonic or laser to the procedure also adds costs, which could run in the thousands of dollars.
Keep in mind that liposuction isn’t a weight-loss procedure and is not a valid substitute for diet and exercise. The maximum amount of fat that the FDA recommends to be removed in one outpatient setting is about five liters, or eleven pounds of fat. Anything more than this can be dangerous, with the potential need for blood transfusions.
And did I mention trying diet and exercise first?
We’ve gone over many options to permanently reduce fat. Here is a summary of what I recommend, depending on what you are hoping to achieve:
Modest fat reduction of abdomen, love handles, hips, and waist: CoolSculpting or Vanquish
Modest fat reduction of thighs: CoolSculpting or UltraShape
Modest fat reduction with skin tightening and cellulite reduction of the buttocks and/or thighs: Body FX, VelaShape III, truSculpt, or Venus Freeze
Dramatic fat reduction for most problem areas: tumescent liposuction (in general, you can’t go wrong with this)
Dramatic fat reduction with skin tightening under the chin: laser liposuction (ideally with Smart Lipo)
CELLULITE
Cellulite is that bumpy fat just under the skin, and it is the bane of many an existence come swimsuit season. Cellulite forms because fat under the skin is separated by fibrous bands, called septae, into compartments. If the fat expands and the septae remain tight and stiff, then the fat shows up in the dimples we know as cellulite. Unlike pockets of fat that appear where you don’t want them to, cellulite tends to spread out over the backs of thighs, on the buttocks, on the tummy, or even around the upper arms. It doesn’t stick out as much as it just looks like, well… cottage cheese.
CELLULITE ANATOMY
Companies have been coming up with anticellulite treatments for years, and most of them don’t work very well. However, there are a few that do work. But first let’s talk about the surgical option. You may not go for this, but I want you to know it exists.
Cellulaze
Cellulaze is the first and only FDA-approved surgical treatment for cellulite reduction. The procedure entails use of a small laser fiber that is tunneled underneath the skin. The laser fires its beams sideways, causing the fibrous septae that cause cellulite to be disturbed. By breaking apart the fibers that make the fat form into dimples, you get a smoother surface. The fat is still there, but it looks more like cream than cottage cheese, which is a much more preferable option for many people. The results appear to be long lasting, and while there is no permanent cure for cellulite, so far this seems to be the closest thing we have to it. This is surgery, however, and it can be a costly procedure. According to RealSelf.com, the average cost of Cellulaze is $5,825.
Heating Technology
If you would rather have a professional tackle your cellulite but you don’t want surgery, you have a few good options, and all of them are based on the same principle: combining a warming up of the underlying fat and a deep-tissue massage to stretch the septae. Where the treatments differ most is in how the fat is heated:
SmoothShapes heats the fat with lasers.
Dermosonic heats the fat with ultrasound.
VelaShape, Venus Freeze, truSculpt, and Body FX heat the fat with radiofrequency.
Endermologie doesn’t heat the fat at all. Instead, it relies on deep massage using a specialized body suit.
The good thing about these in-office treatments is that they don’t hurt, have no downtime, and actually are effective. The bad thing is that results are temporary and necessitate multiple treatments spaced one to two weeks apart. This can get costly.
Still, I like some of them. The newest treatments, as I mentioned earlier, are even creating skin tightening and some modest inch loss as well.
Wellbox
This is another cellulite treatment device, but this one you can use at home. It’s similar to Endermologie in the way it works. This involves a deep-tissue massage on your thighs and buttocks, causing them to smooth within a few treatments. There are no permanent cures for cellulite, but this can be a nice substitute for thousands of dollars of in-office cellulite treatments. The device costs about $1,200 to $1,500, depending on where you get it.
Adonia LegTone Serum
You’ve probably seen cellulite creams at the drugstore and wondered whether they worked. Frankly, many of them don’t do much of anything, but there are a few that I think offer some nice results, even if they are less dramatic than some of the options I’ve talked about already. One of my is Adonia LegTone Serum. It smooths cellulite with visible results in just nine minutes. It’s composed of plant-derived stem cells and twenty-three organic essential oils. You need to apply it twice a day for the first two months, after which your cellulite should be significantly improved. After this, apply only once a day. The company’s studies show a 47 percent reduction in cellulite after just two applications, and a 72 percent reduction in cellulite after six weeks of use. My employees pooh-poohed this cream, but after using it they were surprised at how well it worked! You can purchase a sixty-day supply online for about $80.
DIY Cellulite Treatment
Caffeine can reduce the swelling that accentuates cellulite, so for those of you who like to try DIY treatments, try a scrub made out of coffee grounds. Massage a half cup of brewed (and still wet) coffee grounds onto your skin. Apply plastic wrap over this area, allowing it to hold some of the grounds against your skin for ten minutes. It should have an immediate and temporary but relatively long-lasting (six to ten hours) result.
THE SKIN ON YOUR BODY
We all tend to focus on the quality, tightness, color, smoothness, and softness of the face, but we have a whole lot of other skin that can get rough, discolored, droopy, and wrinkled, which can accentuate or even change body shape in a way we may not like. As we age, skin takes a beating, especially the skin exposed to the sun and elements, as well as the skin that gets stretched out through childbirth or weight gain, or droops after childbirth or with massive weight loss. Body skin can get rough patches and age spots and even calluses and a rough, wrinkly texture, and that can make anybody look older. Once they reach their sixties, many people who have aggressively fought aging all their lives may decide to throw in the towel when it comes to fighting drooping and aging on areas other than the face, especially the breasts, tummy, and hands.
However, there are ways to rejuvenate the skin on the body. Plastic surgeons lift these areas with breast lifts, tummy tucks, and lasers to the hands, but this is more difficult with loose skin and sun damage on the legs, back, arms, buttocks, and (ahem) genitals. I’ve joked with my patients that if I could invent a full-body laser that tightened up the skin head to toe, then I would make a fortune. It would be crafted like a CT scanner; a person’s entire body would go through the device, which would tighten up the skin as it went. I can see just how it would work! Alas, there is no such thing, and no laser company is interested in developing the device and giving me credit. Fortunately, we do have some other options for improving the skin on your body. First, let’s talk about skin quality, color, and softness.
KojiLac-CHQ Pads
This product is my for improving the smoothness of the skin of our bodies, and it also helps eliminate dark spots. These are sold only in the offices of certain doctors, but if you can find a physician (probably a plastic surgeon or dermatologist) who carries them, I recommend giving them a try. These pads are specifically made for body rather than face skin. They look like larger versions of those acne pads you buy in jars, but these are infused with a potent combination of kojic acid and hydroquinone, both skin lighteners, as well as the antioxidants vitamin C and green tea, and lactic acid, which is an alpha-hydroxy acid. These ingredients reduce age spots, exfoliate the skin, and fight off free-radical damage so the skin on your body looks younger. Not bad for an over-the-counter product!
DIY Body-Beautifying Baths
An all-natural method for improving the skin quality of the whole body is a green tea bath. Although this won’t actually change your shape, it can make your skin look younger. Steep five green tea bags in your bathwater, then soak for fifteen to twenty minutes. The antioxidants in the tea will rejuvenate your skin, and the caffeine can provide a nice temporary tightening effect as well. If you throw in a few lemon slices, you get the added benefit of an antioxidant boost from vitamin C.
Another option is the milk bath. Add one or two cups of powdered milk to your warm bathwater. The lactic acid in the milk will provide for very gentle chemical exfoliation. If your skin is oily, use nonfat powdered milk. If your skin is dry, try powdered whole milk. For even greater benefit, add those green tea bags to the water, too.
LOOSE TUMMY SKIN
Improving skin quality is great, but sometimes you need a more powerful effect than you can get through exfoliation and moisturizing. When skin droops, it is a sure sign of aging (or at least of some big experience, like childbirth or a huge weight loss), and of all the places that droop, tummy droop seems to distress people the most. But can you do anything about it?
The skin of the tummy (and the underlying muscles and tissues surrounding the muscles) gets stretched out during pregnancy or with excessive weight gain, and in most people, it never completely shrinks back into place after birth or weight loss. In mild cases, it can cause an accordionlike look to the skin when bending over, due to the multiple folds the loose skin produces. In the most severe cases the skin can hang over the pubic area, otherwise known as the dreaded pannus or panniculus. This can happen after pregnancy as well as after massive weight loss.
I can’t tell you how many women have asked me for a nonsurgical solution to loose tummy skin. Lasers and other devices like radiofrequency treatments have been used to tighten this skin, all with disappointing results. Theoretically, these devices would tighten body skin in the same way they tighten the skin of the face, but the problem is that the only ones that seem to have even moderately noticeable results are both painful and expensive. The ones that don’t have any pain associated with them have minimal or no results, in my experience. As of this writing, I’m still waiting for the body-tightening laser that actually is worth the money. I hate to tell you this, but I want you to know the truth: At this time, the only effective solution for loose tummy skin is an actual tummy tuck.
Tummy Tuck
A tummy tuck may sound awesome—a simple surgery to get rid of your droopy stomach? Before you sign up, though, there are some things you should know. The tummy tuck is an invasive surgery that takes anywhere from two to four hours to perform and has a two-to three-week recovery period. This surgery, usually performed under general anesthesia, allows the surgeon to perform two main tasks: removing the excess skin and fat from the tummy and tightening the underlying muscle layer.
Here’s how it works: The plastic surgeon removes all the skin from between the pubic area and the belly button by making a hip-to-hip incision (and resulting scar), lifting the skin and fat off the underlying muscle layer, cutting off the excess skin and fat (typically everything between the belly button and the pubic area), and pulling the skin above the belly button down to the pubic region. The belly button is retained but is now surrounded by skin that used to be much higher on the tummy. The muscle tightening involves using permanent or semipermanent sutures to stitch the stretched-out muscles back together, kind of like an internal corset. This part of the surgery causes the most discomfort. Like I said, it’s pretty invasive.
The tummy tuck leaves a hip-to-hip scar and a round scar around the belly button that are both permanent. These scars never go away, even when you reach your ninety-fifth birthday. A good plastic surgeon will do his or her best to position the lower scar so it is hidden underneath clothing, like shorts or even a two-piece bathing suit. I call my tummy tuck a Hidden Scar Tummy Tuck for this very reason. However, these scars will always be visible to you, and could be to anyone else who sees you without clothing.
TUMMY TUCK
Interestingly, however, although tummy tucks are one of the more invasive cosmetic surgeries that plastic surgeons perform, they also have one of the highest satisfaction rates. For some patients, getting rid of the excess, hanging skin of the tummy is well worth the expense and discomfort of the surgery. Until we develop my incredible skin-shrinking laser, it’s either tummy tuck or nothing. (Attention, laser companies: Call me!)
AGING, SHRINKING, OR DEFLATED BREASTS
Unfortunately, aging, and especially aging combined with a history of childbirth, does a number on a woman’s breasts. Skin loses elasticity with age, and the thick, firm breast tissue of youth gets replaced by soft, shapeless fat, especially after having children and going through menopause. Breast-feeding can cause the breasts to undergo massive fluctuations in size, which stretches out the skin. Gravity works every second of every minute of every day to pull breasts downward. That’s why, when you’re young and your breasts are perky, it’s important to wear a supportive bra. This helps prevent gravity from exerting its influence on your breasts all day long.
As you age, however, bras can help but only so much, and when you take them off, all bets are off. Aging breasts can definitely contribute to looking and feeling older, especially if your breasts look nothing like they used to. Aging changes all body parts to some extent, but most of my patients who come in for breast-related issues are women over thirty (and some in their seventies) who just want to reclaim some of what their breasts used to look like. They aren’t twenty-two-year-olds who want double Ds. They just want to feel like themselves again.
There are several key issues with aging and breasts. Let’s start with drooping.
Droopy Breasts
If your breasts seem to be sinking closer and closer to your navel with every passing year, you have a very common condition. Gravity and weakening skin often lead to drooping. In fact, just about every woman over the age of fifty with a C cup or higher has droopy breasts. This is just part of nature and time. If your breasts are droopy, what can you do about it? Here are some options.
CAFFEINE
You can attain a more modest lift at home simply by using a skin-tightening cream containing caffeine. There are many commercially available creams that contain caffeine and are used as firming creams for the thighs and buttocks, but that also work on the breasts. One popular cream, Fat Girl Slim, can be purchased at Sephora. If you can get over the irreverent name, you might want to try it. I’ve seen caffeine products result in improvement that you should be able to see and feel. Keep in mind, though, that the tightening is temporary. The only way to get a permanent lift is with surgery (and scars). Bummer, right?
Beauty Secret
Although cosmetics can’t make your breasts perkier or larger, they can enhance the overall effect. Try this cosmetic fix:
1. First, get your breasts at the level you want them—boost them up by putting on a cleavage-enhancing bra.
2. Using a bronzer product or a foundation a few shades darker than your skin, brush or blend a subtle arc over the top of your breasts and along the inner cleavage, from cleavage to bra strap, giving the illusion of more fullness.
3. Using highlighter, brush above and below the bronzer and in the space between your breasts, so it looks like a shadow. Blend everything gently so it doesn’t look fake.
4. Cover with a layer of shimmery powder to dazzle the eye and further blur the makeup lines.
5. Go out on the town—your cleavage looks awesome!
Step 1. Wear a cleavageenhancing bra.
Step 2. Brush bronzer over the tops of your breasts and along the inner cleavage to outline them.
Step 3. Brush highlighter above and below the bronzer, and in the space between your breasts. Blend it gently.
Step 4. Cover with a layer of shimmery powder.
ENHANCE BREASTS WITH MAKEUP
BREAST LIFT
Of course there is also a surgical option, and it has proven quite popular in Hollywood. Nobody needs a breast lift, also called a mastopexy. You can always boost the “girls” with a supportive bra as you get older and leave it at that. However, if your drooping breasts really bother you, if they have moved significantly south on your chest and you are constantly feeling the urge to pull them up and you really do think surgery would help, you should know what you are getting into first. The mastopexy is typically a two-to three-hour operation. During it, the surgeon removes the excess skin of the droopy breasts, and the nipples and remaining breast tissue are repositioned up the chest where they once were. This might sound fairly straightforward, and the surgery definitely works well, but there is one catch. One big catch. You get major scars from this surgery.
The scars from a breast lift vary in length depending on just how droopy you are. If your droopiness is fairly minimal, sometimes the lift can be done with a scar that just extends circumferentially around your areola (the colored circle around your nipple). With moderate droopiness, a lollipop scar can be used, where the scar extends circumferentially around your areola but also extends vertically downward to the crease under your breasts. Severe droopiness often necessitates an “anchor” scar, which is a lollipop scar plus a horizontal scar extending along the crease under your breasts. These scars can be quite extensive, and they are also permanent. They will never go away. When you are eighty-five years old, the scars from your breast lift you got in your forties will still be there, albeit likely quite faded.
Many women ask me if breast implants can lift their breasts. Unfortunately, implants do not have magical hovering properties. In fact, they do the exact opposite. Breast implants make your breasts heavier, causing gravity to pull them downward even more, which results in your breasts drooping even more quickly.
In other words, breast implants make your breasts larger but don’t lift them. Breast lifts will lift your breasts but won’t make them bigger. Deciding to have breast surgery means deciding what your priority is.
CIRCUMAREOLAR LIFT
LOLLIPOP LIFT
ANCHOR LIFT
TYPES OF BREAST LIFTS
BREAST AUGMENTATION
If your problem isn’t so much droopiness as it is flatness—the deflated breasts that so often come with age, where breasts lose volume, fullness, and roundness, you may be one of the many women interested in breast augmentation. Or maybe you have always had small breasts and always wished for more, and now that you are more established in your career, you can finally afford the breast augmentation surgery you always wanted. Small breasts are, of course, perfectly lovely and many people prefer them. They stay perky longer and don’t droop as easily, they don’t get in the way when you exercise (or sleep on your stomach), and many people like the way they look. For some people, however, small breasts don’t feel right or balanced for their bodies, and they truly believe they will feel better with an adjustment.
Before you consider surgery, you should know that short of gaining weight and hoping it goes topside, there is one nonsurgical breast augmentation option that works fairly well.
Brava: Brava is the only scientifically proven, FDA-cleared method of breast enhancement without surgery. Studies show it can add 150 cc of size to each breast, which is about one-half to one-third the size of an average breast implant. It’s a modest gain and not as dramatic as surgery, but it is measurable.
Brava works by the process of tissue expansion. The device has two large suction cups that attach to the breasts and apply constant suction to the breasts, causing them to be stretched larger. Studies show they can actually cause new breast tissue to be created. However, you must wear the device at least ten hours each night. Studies show that after ten to fourteen weeks you can get an average of a one-cup increase in breast size. It’s tedious and difficult to stick with the program, though. If you miss just one night, then you lose a significant portion of the results. The cost of Brava is about $1,200.
Some doctors are combining this treatment with fat injections for a much greater increase in breast size. However, the fat injections entail actual surgery, and there is some controversy regarding whether the fat injections may alter mammograms. For this reason, it’s not something I recommend unless breast implants just aren’t an option.
This may sound like too much work and expense to you, and I agree. Brava can work, but this is one of the few cases where surgery really does give results far and away better than nonsurgical treatments. But what about creams or natural methods of breast enhancement? There really isn’t an effective way to make your breasts bigger using natural, at-home ingredients. And the many creams sold online that claim to make the breasts bigger don’t seem to work, either. They simply aren’t worth the money.
For some people, surgery is.
BREAST IMPLANTS
Surgery certainly isn’t everyone’s choice, nor should it be. However, breast augmentation surgery is the most popular plastic surgery on the planet. For women who get a modest augmentation, it is straightforward and often looks very natural. It comprises about one-third of my plastic surgery practice, and I perform over 150 breast augmentation surgeries every year. According to the American Society for Aesthetic Plastic Surgery (ASAPS), each year more than 300,000 women undergo breast augmentation surgery. That reveals a lot of discontent about breasts, and a lot of effort and money to increase their size. Many celebrities have even come forward and admitted having breast implants, including Kelly Rowland of Destiny’s Child, Denise Richards, and Jane Seymour.
Maybe you are one of the many women interested in this procedure. I’m certainly not going to try to convince you that you should get this surgery, or that you shouldn’t. Breast size and fullness are very personal matters. However, I know from my practice that many women have considered this, especially as they age and their breasts change. If this is you, then I want to give you the information you need so you know exactly what you are considering. So let’s talk, surgeon to reader, about breast augmentation.
Size Matters: First of all, you should know what size you want to be. Contrary to popular belief, almost no one asks for gigantic breasts. Most women want to look natural, with the most common request going from an A cup to a C cup in size. That being said, women start and end at all sizes. However, implants don’t come in A, B, C, and D cup sizes like bras. Instead, they are measured in milliliters.
The easiest way to determine what size is right for you is to use a tester, or sizer implants. Most plastic surgery offices have implants of all different sizes that you can put into a bra to determine how they will look on you. I recommend that you put a plain T-shirt over the bra to really get a good idea of how you will look afterward.
The other way women are deciding implant sizes is with computerized 3-D imaging. This is a specialized device that takes a 3-D picture of your chest and allows you to see an estimation of how your chest will look with various-sized implants. Their accuracy in predicting your outcome is usually pretty good. The most popular 3-D imaging devices are the Vectra, the Axis 3D, and the Crisalix.
When choosing the appropriate size of breast implant for you, keep in mind that the bigger the implant, the quicker it will droop. I’ve seen many, many women with really large breast implants put in by other doctors that have resulted in premature drooping of the breasts. Plastic surgeons sometimes call this bottoming out. So choose your size wisely, and don’t go bigger than you need to!
Just Your Type: The next thing to consider is what type of implant to use. This is the most common question I get. Back in the 1980s and early 1990s, most women underwent breast augmentation with liquid silicone implants. These implants had two major problems. The outer shell was really weak, causing them to break quite often, and the silicone inside the implants was a liquid, which would ooze out of any break in the implant shell. When this occurred it created a mess, sometimes with excess scar tissue and inflammation.
Because of this, many women were concerned that their implants were causing various diseases, such as lupus, arthritis, and even breast cancer. In response to this fear, in 1992 the FDA banned the use of silicone breast implants, allowing them only in strictly controlled studies. However, these studies showed no connection between silicone breast implants and any disease, prompting the FDA to lift the ban on silicone implants in November 2006.
Today, the implants are much improved. The outer shells are much stronger, and very resistant to breakage. The silicone inside the implants is no longer a liquid but a cohesive gel. This is a gel that sticks together and doesn’t leak out like the older, liquid silicone implants. For these reasons, we are not as concerned about the new style of breast implants as we were with the older ones. People like this style of implant, because it is soft and feels very natural. However, if the silicone implant does break, it can be very difficult to tell and could require an MRI to diagnose the break. MRIs can be very expensive (costing in the thousands of dollars), and most insurance plans don’t cover MRIs to solely look for a broken breast implant.
Another new style of implant is the gummy bear breast implant. The scientific term is “form-stable.” These implants are also made out of silicone, but they are firmer and made to hold their shape, hence the popular term gummy bear. The silicone is more of a solid than a liquid. They aren’t as firm as an actual gummy bear, though. Instead, they are made to feel like real breast tissue. The benefit of the gummy bear implants is that the risk of silicone leakage is definitely minimized. They also keep their shape nicely, which can be particularly beneficial for people with little supportive breast tissue to hold the implants up. The downside is that these are the most expensive types of implants. They also don’t feel as soft as silicone gel, and if they do break, they can be even harder to diagnose, again possibly necessitating an MRI. Currently, these implants are used most commonly in the United States for breast reconstruction after mastectomy. Some well-respected plastic surgeons use the gummy bear implants for most of their cosmetic patients, too, but my experience is that they feel a bit firmer than most of my patients want.
A third style of implant is the saline implant. These implants are popular because they are less expensive, and because they are filled with salt water, it is easy to tell when the implant breaks and easy to remove and replace them. However, saline implants don’t look or feel as natural as the new silicone and gummy bear–style implants. Saline implants tend to have more wrinkles and ripples. Sometimes you really do get what you pay for.
In general, the surgeon, operating room, and anesthesia costs are the same no matter which type of implant you choose. The cost of the actual implants, though, varies. A rule of thumb is that saline implants are the least expensive, cohesive silicone implants are about twice the cost of saline, and gummy bear implants are about three times the cost of saline. According to RealSelf.com, the average cost of breast augmentation surgery is $6,425. Expect to pay a little more for silicone and a little less for saline.
If you aren’t thrilled about any of these options, you may want to consider the newest breast implant on the market. I consider it the ideal implant, and that is actually its name: the Ideal Implant. This is a saline-filled implant, but it contains inner chambers that are designed to limit the wrinkling and rippling of the implant. It was designed by a plastic surgeon who noticed that while flying in a plane, the ice cubes in his glass of water seemed to limit the sloshing around of the water when the plane hit some turbulence. He discovered that this idea could be applied to breast implants as well.
Some surgeons believe this implant can give the natural feel and look of a silicone implant with the safety of a saline implant. It was approved by the FDA at the end of 2014. Time will tell whether the Ideal Implant will truly live up to its name, but I am very optimistic that it will!
Other Decisions: There are just a few other breast implant decisions you will need to make:
Textured shell versus smooth shell: The outer surface of an implant is made of a type of silicone rubber. The shell can be produced to have either a smooth surface or a rough, textured surface. For most of my patients, I choose smooth surface implants, because they tend to feel softer and more natural. The smooth surface allows the implant to glide around inside the breast pocket. However, textured surfaces are designed to adhere to the implant pocket. This prevents the implant from moving around. I prefer textured implants in patients undergoing breast reconstruction, where the breast tissue has been removed during a mastectomy. The textured surface can help prevent the implant from drooping prematurely, especially since the breast tissue that normally holds an implant in place has been removed.
Low versus moderate versus high profile: Implants come in all different levels of roundness. The low profile is the flattest, widest implant, followed by the moderate, moderate plus, and high. There are now ultrahigh-profile implants, which are really round. You know, in case you are going for that beach ball look.
Anatomic versus round: Implants are also made in two shapes: anatomic (or teardrop) and round. I prefer round implants with smooth surfaces in most first-time breast augmentation patients. The anatomic implants all have textured shells and are made to stick in place. All gummy bear–style implants are textured, anatomic implants. Once again, these can be better for women who are having breast reconstruction after a mastectomy for breast cancer. One main problem with these implants is that if one becomes displaced or turned upside down, you may need another surgery to put it back in the correct position.
The actual breast augmentation takes about one to two hours and is usually performed under a general anesthetic. Recovery time takes between several days and several weeks, depending on the size of the implant used and the technique the surgeon employs. I prefer a technique called Rapid Recovery Breast Augmentation, which combines a less traumatic surgical technique with reasonably sized implants. Using a combination of these factors, I find that most of my patients take only a handful of pain pills (if that) and are back to most normal activities within forty-eight to seventy-two hours.
However, not all plastic surgeons employ a rapid recovery technique, so make sure to inquire with your potential surgeon to see whether this may apply to you. Choose your surgeon carefully. See examples of previous work. You’ll want to feel comfortable with the person you choose, and you’ll want someone with a lot of experience. Know that there are many satisfied women out there. You could be one of them.
DROOPING OR FLATTENING REAR END
Butts are in. There is no question. The public fascination with the booty began with Jennifer Lopez and has been continued by Kim Kardashian, Beyoncé, Nicki Minaj, and Iggy Azalea. Even Pippa, sister of Princess Kate, has gotten into the act. The dress she wore for the royal wedding in April 2011 reportedly created a spike in butt-enhancement operations, including one Miami-based plastic surgeon coining the term “the Pippa Butt Lift.” Now it seems everyone wants to get their butts bigger and more shapely.
However, in many cases, just as with breast augmentation, the patients who come in complaining about their rear view aren’t just twenty-year-olds who want to channel J.Lo. They are women in their thirties, forties, and fifties who have noticed that they have lost volume and height back there. Their butts are sagging, drooping, or going curiously flat, and they want to know what they can do to get back some of the volume they used to have.
Of course, you can shape your butt with diet and exercise. Muscle toning alone can do a lot of good back there, but the women who come in asking about rear-end enhancement aren’t usually the ones who tend to gain weight in that area with extra cupcakes or super squat sets. They are the ones who have butts that are more naturally flat and that go flatter with age. The first option to try is shapewear, which turns out to be all the lift and volume some people want.
Butt Shapers
Aside from good gluteal exercises or gaining a lot of weight, there really isn’t an effective, nonsurgical way to permanently enlarge your butt. However, there are a plethora of girdlelike body shapers that can temporarily give you a ba-donka-donk. They typically come in two types: girdles that have a big hole for each butt cheek to stick out of, or girdles with bike-shorts-like padding to make your buttocks look larger.
For the girdles with holes, Bubbles Bodywear makes their “Double O” buttock lifter. These tight undergarments feature a double-O opening, allowing your butt cheeks to protrude out to look round and full.
For the girdles with padding, my friend and famous Dr. 90210 plastic surgeon Dr. Robert Rey has a shapewear line that features his Bottom Enhancer. This elastic undergarment tightens up the lower tummy and thighs but comes with removable foam pads to enlarge the buttocks. It’s as good as any other similar ones of its kind, but keep in mind, of course, that once you strip down for your Kim Kardashian–style photo shoot, those pads will be cast aside and you probably won’t be able to balance a champagne glass back there. (I really don’t know anybody who could. Let’s be realistic.)
Butt-Enhancement Surgery
If shapewear simply isn’t good enough for you and you really do want to add some permanent volume to your backside, there are, as you may have guessed, some surgical options. They aren’t the best surgical options, but they are out there.
The first technique involves the insertion of a solid silicone butt implant. It’s like a breast implant for your derriere. These large, half-grapefruit-shaped rubbery implants are inserted through an incision in the vertical crease dividing your two buttocks. The surgeon places the implant either above or below the gluteus maximus muscle. It’s not a very common surgery and has a relatively high rate of complications. One dreaded complication is infection, because, let’s face it, that area is not considered the cleanest part of the body, and do you really want to be hospitalized for a butt infection?
Other complications that can occur include implant displacement (meaning it moves outside of your buttock cheeks into another part of your body, like your lower back), and excess scar tissue around the implant, causing it to feel like a real grapefruit in your booty. A couple of years ago, a woman placed a video on YouTube that showed her buttock implant freely moving around. She could move it side-to-side and even flip it over. The video went viral and she subsequently told her story on the E! network’s Botched.
One final thing to consider with buttock implants is that it might feel like you are sitting on George Costanza’s overstuffed wallet (from the show Seinfeld). This is not a pleasant sensation for many people. Perhaps you can tell that I am not a fan of the butt implant.
The other way to enhance the buttocks is with a Brazilian butt lift. I’m not sure why it’s called a butt lift, because technically it is a buttock augmentation. It doesn’t lift the butt at all; it just fills out the butt with your own fat. For this procedure, the plastic surgeon liposuctions fat from one part of your body (typically the tummy, hips, and/or thighs), purifies it, and reinjects it into your behind. Not all of the fat will stay in place, however, as an average of 30–70 percent of it will likely reabsorb and disappear, depending on the technique the doctor uses. This surgery is probably the best way to get a fuller, rounder butt, though, and is performed by many more plastic surgeons than buttock implant surgery.
The drawback to this procedure is the longer surgery time and the fact that your buttock won’t necessarily feel firmer after surgery, just bigger. Also, skinny women need not apply. You need a significant amount of fat available to properly plump up the butt. You will also need to avoid sitting on your butt for about a month after the surgery. Yes, this can disrupt your plans to take a long car ride or go to the movie theater, not to mention work at a desk. So do you really need surgical butt augmentation? Probably not. But if you really want it? Now you know the facts.
Your shape is a highly personal matter, and only you can decide what you feel good about, what you can live with, and what you absolutely have to change. Now you know your options. How about a trip to the gym while you consider them? One other benefit of exercise is that it improves both mood and self-esteem. Enough of it might help you not to worry so much about the size of this or the relative volume or height of that. Make exercise a habit, and you just may find that body shape modification isn’t as crucial as you thought it was.