All the buzz about body positivity is certainly not putting a damper on demand for major body-modification surgeries. More Americans got breast implants and liposuction in 2017 than they did the year before (300,378 and 246,354, respectively). "We talk a lot about being health conscious, but the truth is we’re also increasingly appearance conscious," says Steven Teitelbaum, a plastic surgeon in Los Angeles. "The stigma of plastic surgery is going down, the procedures themselves are getting better, and the economy is very strong right now."
An entire generation that grew up hearing people talk openly about plastic surgery — rather than seeing it as taboo — now has disposable income. And the more interest there is in these procedures, the more incentive there is to perfect them. These are the most game-changing innovations in breast augmentation and liposuction — straight from the surgeons who are scrubbed up at the front lines.
Cosmetic breast implants used to have one job: make your breasts bigger. Now shape and proportion, not size alone, are what matter. "My patients have been requesting Kate Hudson's breasts quite a bit lately. It was a surprise at first," says Julius Few, a plastic surgeon in Chicago, who means no disrespect to Hudson — it's just that the sudden infatuation with her not-triple-D chest (Google "2018 Golden Globes Kate Hudson" for a visual) represents a paradigm shift in the way we're approaching augmentation.
"The U.S. is catching up to the rest of the world in using anatomical implants," says Rosalyn d’Incelli, vice president of clinical operations and medical affairs for Sientra, a major international implant manufacturer. Instead of a traditional round shape, anatomical implants are slightly fuller at the bottom than at the top. The most popular sizes aren't exactly conservative — in general, the best-selling implants are in the 300- to 450-cc range, which take most patients up approximately two to three cup sizes. But they look more like real (albeit perfectly symmetrical and masterfully shaped) breasts.
My patients have been requesting Kate Hudson's breasts quite a bit lately. It was a surprise at first.
Beyond these new teardrop shapes, implants now also come in more sizes and widths for surgeons to work with. "We can better choose ones to uniquely fit each body," says Melissa Doft, a plastic surgeon in New York City. Surgeons often start by picking an implant that’s the same width as your natural breast. "From there, we can decide exactly how much we want the implant to project off the chest and vary the shape to flatter your frame," says Jeffrey M. Kenkel, a plastic surgeon in Dallas. Implants are also getting lighter: The B-Lite weighs up to 30 percent less than standard silicone implants and could cause less skin stretching over time. It's currently in clinical trials and could be approved by the FDA later this year.
And thanks to new technology, saline implants — which were popular in the 1990s but were eclipsed when silicone got FDA approval in 2006 — are making a comeback. The Ideal Implant has internal dividers to prevent the saline from slosh- ing around. "That's what caused the old saline implants to ripple, which in turn made your skin look rippled," says Lisa Cassileth, a plastic surgeon in Beverly Hills, who, last year, was one of the first surgeons in the U.S. to use Ideal Implants. By most estimates, less than a quarter of all breast implants today are saline, but that number could be poised to grow.
Surgeons are also rethinking breast lifts, given that their popularity has risen a whopping 99 percent since 2000. A lift entails removing excess skin to tighten surrounding tissue, thereby raising and firming the breast. But until recently the procedure could be, well, a letdown. "You’d lose some of the results to gravity within weeks of getting off the table," says Bruce Van Natta, a plastic surgeon in Indianapolis.
But now doctors are starting to use Galatea Bioresorbable Scaffolds, an absorbable mesh shaped like a demi cup that gives internal sup- port to make breast lifts last longer. Van Natta, who treated patients for the clinical trials, is bullish on longevity: "I have patients out almost six years who are maintaining their results," he says. The scaffolds add about $1,500 to the cost of a breast lift (which can already run $4,500) and can be used on their own or with an implant. "It's being studied for new indications, like butt lifts, for the future," says Van Natta.
I always tell patients who want breast augmentation that their initial procedure is unlikely to be their last.
For all the advances, none of these changes last forever. "I always tell patients who want breast augmentation that their initial procedure is unlikely to be their last," says Adam Kolker, a plastic surgeon in New York City. After eight or 10 years, about 20 percent of silicone implants have to be taken out. They may have shifted (data shows larger implants move more), and as many as 45 percent of patients experience capsular contraction: scar tissue forms around the implant, which can become uncomfortably hard or, in rare cases, make breasts or nipples look disfigured. In mild cases, removing the implant and scar tissue typically fixes things, but more serious reconstructive surgery could be required to address deformities.
And because you can't tell if a silicone implant has ruptured just by looking at it, the FDA recommends getting an MRI three years after surgery and every two years after that. Routine MRIs aren’t usually covered by insurance, though, so many patients postpone it until year seven or 10 instead. In the meantime, a silicone leak can lead to infection and inflammation. Silicone can also accumulate in lymph nodes and show up on mammograms, worrying patients. Saline implants, on the other hand, last 20 years, have lower long-term rates of complication, and any leaks are safely absorbed by the body. "Saline is hydrating — if you were stranded in the desert, you could stab your boob, and you just bought yourself another day," says Cassileth.
But even with these advancements, it's unlikely saline will eclipse silicone anytime soon. "Saline just doesn’t feel as good as silicone. Think TempurPedic mattress versus waterbed," says Cassileth. "People want their breasts to feel like the real thing."
Breast augmentation costs anywhere from $6,000 to $14,000, depending on your provider. As for the recovery process, the worst pain — which is acute — lasts one to five days; swelling may persist for a few weeks. You have to rest for several days to avoid internal bleeding around the implant and can only work out after surgery with your doctor’s permission (usually after about six weeks).
Saline is hydrating — if you were stranded in the desert, you could stab your boob, and you just bought yourself another day.
But the process that surgeons use to put implants in is better than it was a decade ago. A device called a Keller Funnel allows surgeons to "make a smaller incision, which is less painful to heal and leaves a smaller scar," says Doft. The sterile tube picks up the implant and "bloop — pushes the implant through the tube into your breast," explains Cassileth. "It never touches breast tissue or ducts, so it lowers your chances of picking up bacteria." You really do not want your doctor touching your implants, even with sterile gloves, she says: “Implants can be infected or carry biofilms, which can make you feel chronically tired or sick until they’re removed."
"The ways we remove fat are evolving so quickly that a technology that's four years old feels like it’s 30 years old; it's like dog years, but lipo years," says Kenkel. That was not always the case. "For decades, liposuction didn't really change that much," says Simeon Wall Jr., a plastic surgeon in Shreveport, Louisiana — and he should know. His father was one of the first surgeons in the U.S. to perform liposuction, in the '80s. "We used to take out fat by sticking in a cannula and sucking, which made long tunnels that could create strange contours and ruts." Over time, though, cannulas got smaller and better. In some lipo procedures, instead of slurping out solid blocks of fat, surgeons can now melt the fat first to remove it more evenly.
This melting usually involves radio frequency or thermal energy emitted from a cannula that a surgeon moves around underneath your skin. A new technique called BodyTite also uses radio frequency in conjunction with liposuction to tighten skin. In the past, surgeons could remove fat with lipo, but if a patient had poor skin elasticity, they'd need a lift to remove excess skin. That's a whole other surgery with its own scars. And it doesn't take much to have poor skin elasticity — we're talking about most patients who've had a baby, are over 40, or have sun damage. BodyTite firms skin anywhere from 10 to 40 percent, which is enough to help skin bounce back if you’re looking to lose 10 to 20 pounds with lipo. It won’t firm enough to accommodate more dramatic weight loss, but lipo, in general, is best for removing small pockets of fat, not for major transformations.
But with thermal energy comes new issues: Because heat damages and burns tissue that you're not removing with liposuction — in other words, tissue that is meant to stay alive — there's an inherent risk of creating internal inflammation and damaging the skin and blood vessels. "When that happens, scar tissue can form under the skin, and you wind up with divots and ripples," says Wall. It looks like cellulite, only deeper — not the effect you want after submitting to a painful, expensive surgery.
For decades, liposuction didn't really change that much.
SafeLipo, a tool developed by Wall after decades of lipo revision surgeries, uses rapidly vibrating cannulas to emulsify fat without the potentially damaging heat, so there's less risk to skin tissue and blood vessels. This heatless lipo is a game changer, says Teitelbaum. "It creates tiny low- and high-pressure zones, and the fat seeks out the low-pressure and low-resistance areas," Wall explains. "As that happens, the fat is emulsified so it’s the consistency of a smoothie and can be removed so much more evenly and gently, without bleeding. Some of the remaining fat serves as local fat grafts, so the skin redrapes smoothly."
With these seamless results, surgeons can now make patients' shapes look more like hourglasses (you've probably seen Wall's and Teitelbaum's handiwork on the red carpet). They can also explore new territories. "Some women get a bulge of fat just outside of their bra near their armpit," says Teitelbaum. "Removing even a little bit [with lipo] makes a huge difference." It's done under local anesthesia (other forms of lipo are done under general) and involves removing a walnut-size amount of tissue from the area. Julius Few credits the athleisure trend: “Sports bras compress the breast, causing a pouf of fat that shows through fitted tops."
So fitspo and its focus on athleticism hasn't made us turn away from liposuction, but it has morphed how we're using it. "Fashion changes, and the plastic surgery pendulum swings," says Van Natta. Some surgeons are even using laser-assisted lipo to remove lines of fat from patients' stomachs to fake six packs — it's like drawing, but with a laser on fat instead of a pen on paper.
Not surprisingly, it's not the best idea: "I'm seeing patients who [were treated by other doctors and] now have weird shapes and geometric designs that don't look attractive," says Wall. "Most of the patients who had bad abdominal etching aren't fixable." In general, ab liposuction has risks: The skin there doesn't always tighten after lipo, so you wind up with ripples. “Unless the removal is restrained and the skin has good elasticity, there is a significant risk of contour irregularities," says Teitelbaum.
Fashion changes, and the plastic surgery pendulum swings.
Liposuction costs anywhere from $4,000 to $12,000, depending on your provider. As for the recovery process, it's worse than breast augmentation, which is to say it hurts like a mother for up to a week; it may take several months for the swelling to disappear completely. "It's a major surgery," says Kenkel, "and while there have been some technical advances, equally important are rapid recovery programs using nonnarcotic medications to help patients recover."
A slow-release pain medicine called bupivacaine can now be injected during surgery and gives you 48 to 72 hours of relief afterward. (It can be used in any procedure, including breast augmentation, but lipo tends to require more post-procedure pain medication.) "We recognize that there is a national crisis surrounding narcotic addiction," adds Kenkel, "so anything we can do to prescribe less of them is beneficial."
This is all to say: Do your research. If you’re considering liposuction, or any plastic surgery, go to abplasticsurgery.org to make sure your doctor is a board-certified plastic surgeon, find out how long they've been offering the procedure you're interested in (the correct answer is over 10 years), and do not fall for deals of any kind. "We get that plastic surgery is expensive,” says Van Natta, "but it is not where you want to be discount shopping."
More on plastic surgery:
Now, see how plastic surgery has evolved within the last 100 years: