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Category: Plastic Surgery

The Skinny on Liposuction: There’s only so much I can do

While visiting my parents in Los Angeles last week, we toured the famous J Paul Getty Museum, which houses a number of famous paintings and sculptures. My wife photographed one of these for me with her iPhone:

As a wood and marble sculptor myself, I certainly appreciate the artist’s skill. As a plastic surgeon, the bronze sculpture got me thinking about—yes, you guessed it—liposuction. Since the sculptor, Rene Magritte, has very purposefully and dramatically divided the sculpture into thirds, let’s categorize these:

Lower third: The preoperative liposuction appearance

Middle third: The actual postoperative result.

Upper third: The desired postoperative result.

Unfortunately, it is very difficult to take the lower third and turn it into the upper third (i.e. if you are significantly overweight, liposuction will make you smaller, but it won’t make you skinny). On the other hand, if you are starting with only a modest amount of excess fat (middle third), then achieving the upper third may be more realistic.

Also bear in mind that the two of us (plastic surgeon and patient) working together are much more effective than either of us working alone. Liposuction with postoperative dieting and aggressive exercise can take a middle third result and push it closer to an upper third result. Liposuction with postoperative binge eating can take a middle third result and push it closer to a lower third result.

Liposuction (liposculpture) in a realistic, motivated patient is generally quite effective. In the unrealistic, unmotivated patient, it is a waste of time and energy.

I am unsure whether the artist was referring to the unrealistic liposuction patient—or perhaps the overzealous plastic surgeon—when she aptly titled her sculpture, “Delusions of Grandeur.”

Before After 5.4 Liters (Post-Op 1 Month)
DSC07080 DSC09419
DSC07088 DSC09433
DSC07090 DSC09431

** This 27 year old woman from McKinney presented to Dr. Friedman requesting liposuction of her abdomen, flanks, upper back, inner thighs, mammary folds, and arms. She underwent 5.4 liters of liposuction and at her 1 month follow up she demonstrates improved contour of all regions including a flatter stomach and smoother waist line.


Ronald M. Friedman, M.D.

Director, West Plano Plastic Surgery Center

Former Chief of Plastic Surgery, Parkland Memorial Hospital, Dallas

Going Bigger With Breast Revisions

Breast enlargement, including breast augmentation revision, is the most frequently requested procedure in my practice.  Now in practice in Plano for 18 years, I am on track to perform about 150 breast augmentations this year.  In large studies, approximately 95% are happy with their choice to undergo surgery, which makes breast augmentation one of the more successful cosmetic procedures.  However, as with any other surgery, there are certainly risks, such as infection, bleeding, implant deflation, and capsular contracture.

Although most women are afraid of going “too big,” many become accustomed to their new, fuller breasts and wish they had gone even larger.  The downside is that this requires another surgery.  The upside: assuming that a. the only purpose of surgery is to go larger (i.e. you are otherwise happy with your results), b. you are not choosing an “out-of-control” size, and c. you have smooth-surfaced implants:

1. The procedure is generally straightforward.  I remove your existing implants (usually through your existing scars) and place new, larger implants.

2. The results are predictably good.  The existing capsules of scar tissue that surround your implant will limit further descent of the implants.  What does this mean for you?  More cleavage and more fullness of the upper breasts.

3. The recovery is easy.  We are simply doing a “software exchange,” so the pain is limited to the site of the incision.

4.You do not have to worry about the implants starting “too high.” To a large degree, what you see is what you get. Why?  The tissues overlying the implants were already stretched by the previous surgery, so no further stretching is necessary.

Now let me emphasize, once again, that the upsides listed above only pertain if we make three assumptions:

a. You are otherwise happy with your results.  If you are dissatisfied with your implant position, breast shape, or something else about your breasts–besides the size, the surgery may be more complicated.

b. You are not choosing an “out-of-control” size.  Remember that your body has formed capsules of scar tissue that surround and support your implants. If you choose a size that is larger than your existing scar capsules can contain, you will require a capsulotomy (surgical cut in the capsule) to make more room.  While this is certainly feasible, it increases the complexity of the surgery and reduces the predictability of the results.

c. Your existing breast implants have a smooth surface.  Smooth surface implants will not “stick” to the surrounding capsule, so there is generally room for further enlargement.  Textured implants (the surface is textured like wallpaper) do stick to the surrounding capsule, so further enlargement will require a capsulotomy (see b. above).

The bottom line: assuming that a capsulotomy is not required, further enlargement of the breasts is generally a straightforward procedure with predictably good results and a smooth recovery.

Breast Augmentation Revision going to larger Saline Implants

Before / After

Before / After

Before / After

Before / After


**Initial breast implants placed by another surgeon

Breast Augmentation Revision going to larger Silicone Gel Implants


Before / After

Before / After

Before / After


**Initial Implants placed by another surgeon.

Ronald M. Friedman, M.D.

Director, West Plano Plastic Surgery Center

Former Chief of Plastic Surgery, Parkland Memorial Hospital, Dallas

Belly Button After Tummy Tuck

“It’s all about the belly button”

A full tummy tuck involves tightening of the abdominal wall with removal of excess skin and fat.  Contrary to popular belief, we do not need to make you a “new belly button.”  Instead, you will keep your existing belly button (umbilicus), but all the skin around it will be removed and replaced with skin from the upper abdomen (see tummy tuck video).

Plastic surgeons vary widely in their techniques for reshaping the belly button.  This variation in technique creates a similar variation in results.  As you compare plastic surgeons for your tummy tuck, spend time looking at their patients’ belly buttons.

Belly button after tummy tuck performed by Dr. Friedman.

Belly button after tummy tuck performed by Dr. Friedman.

Belly button after tummy tuck performed by other surgeons.

Belly button after tummy tuck performed by other surgeons.


If you have any questions or wish to schedule a consultation call our office at 469-467-0100.

Dr. Friedman is the Founder and Director of the West Plano Plastic Surgery Center on the campus of Presbyterian Hospital of Plano.

Are My Breast Implants Too High? (Part 2)

“Dr. Friedman, aren’t my breast implants still too high?”

If you read part 1 of this blog, you already know that breast implants placed below the pec major muscle tend to look too high for up to six months to a year after surgery.  This is normal and generally resolves with stretching of the muscle.  But what if you had breast augmentation performed over a year ago and your implants still look too high?  Here are the possible causes and treatment options:

1.     The implants really are too high.  Most implants eventually end up in the right place, but some really do stay too high.  This can involve one or both breasts.  After a year, it is unlikely that the implants will descend much further without surgery.  The surgery involves removal of the implants, release of the lower part of the capsule of scar tissue below the implants (inferior capsulotomy), and placement of new implants.

Before / 1 year After Surgery / After Capsule Release

Before / 1 year After Surgery / After Capsule Release

This patient’s left implant position remained too high at a year after her breast augmentation. Dr. Friedman released the lower part of her capsule and placed a new implant which allowed the implant to fall to a more desirable position.

2.     The breasts are too low.  Sometimes the implants are in good position, but the breasts are too low.  There are two possible reasons:

a. The breasts started out with some sagging, and you may have benefited from having a breastlift or mastopexy at the time of your augmentation

b. Your breasts may have fallen in the years following your breast augmentation, perhaps due to childbirth or weight changes.  If your implants remain in good position but your breasts have descended, the implants will look high relative to the breasts.

Regardless of the cause (a or b), the proper surgery is a breast lift.  It would be unwise to release the capsule under the implants, causing them to drop to the level of the breasts.  Instead, it would be better to raise the breasts to the level of the implants.


Before / After (1 month)


Before / After (1 month)


 This woman had breast augmentation performed elsewhere (before). Dr. Friedman performed a breast lift resulting in significant improvement in the contour and symmetry of her breasts (after).

3.   You have capsular contractures.  It is normal and desirable for your body to form scar tissue around your implants.  This “walls-off” the implants from the surrounding tissues and helps support the weight of the implants on a long-term basis.  However, if the capsule becomes too thick and tight (capsular contracture), it will cause one or both implants to look too high, tight, and firm.  The treatment of capsular contracture involves releasing (capsulotomy) or removing (capsulectomy) the capsule and placing new breast implants.

Before / After (2 weeks)

Before / After (2 weeks)

Before / After (2 weeks)

Before / After (2 weeks)


In order to achieve a more natural appearance of the breast, Dr. Friedman released her capsules and replaced her breast implants.

Some women will present with one or more of these problems (implants too high, breasts too low, capsules too tight) and will require a combination of procedures to address their concerns.

Before / After (2 weeks)

Before / After (2 weeks)


Before / After (2 weeks)

This patient underwent prior breast augmentation by another plastic surgeon with 270-cc subglandular saline implants complicated asymmetry, bottoming out, and bilateral capsular contractures. Dr. Friedman performed capsulectomies and conversion to 390-cc total submuscular saline implants and mastopexy.

Are My Breast Implants Too High? (Part 1)

“Dr. Friedman, aren’t my breast implants too high?”

I am asked this question at least a couple times a week.  And the answer is “Yes, they are too high.  But don’t worry; it’s normal.”

All breast implants placed under the pectoralis major muscle will start out too high and tight.  It takes time for the muscle to expand in response to the stretch of the underlying implants.   Not only is this normal, it is also exactly what we want.  All implants will fall after a first-time breast enlargement surgery.

If your implants start out too high, they will probably end up in good position within six months to a year.

If your implants start out in good position, they will probably end up too low within six months to a year.

The before-and-after breast augmentation photos below illustrate the normal descent of submuscular saline and silicone gel breast implants following breast augmentation.

Saline Breast Implant Sequence:


Before / 1 week / 1 month / 7 months

Silicone Gel Breast Implant Sequence:


Before / 1 week / 1 month / 7 months

Breast Augmentation with Lift Sequence:


Before / 1 week / 7 months / 2 years


Before / 1 week / 7 months / 2 years

If you’re wondering whether the implants keep falling after a year, the usual answer is “no.”  Why not?  The muscle has been maximally stretched by the implants, and your body has formed a capsule of scar tissue around the implants that prevents further descent.

If it has been over a year since your breast augmentation and your implants are still too high, read my next blog for an explanation of possible reasons and treatments.

© 2018 Ronald M. Friedman, M.D., P.A.

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