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Q & A With Dr. Tom Pousti – San Diego Plastic Surgery Specialist

Dr. Tom J. Pousti of Pousti Plastic Surgery understands that individuals considering plastic and cosmetic surgery may have questions about their desired procedure. To help individuals gain answers to their questions, Dr. Pousti is pleased to share many of the frequently asked questions as well as his responses to many of the most popular plastic and cosmetic surgery procedures. RealSelf Q&A with Tom J. Pousti, MD, FACS

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How should I select a surgeon? It is important to establish rapport with the surgeon since you place total confidence in that doctor’s ability. Select a surgeon who compares alternatives, explains clearly what will be done for you and the rationale for the approach selected. Be sure he discusses convalescence and possible risks. Choose a surgeon who communicates and has a clear understanding of your desired result. You should carefully evaluate the proposed surgery and the surgeon himself before proceeding. Insist on certain qualifications. Ask specific questions about the doctor’s training. Is the surgeon Board Certified? Has he fellowship training or specialized training in the procedures you want performed? A specialist does the same procedures far more often and therefore has greater experience and skill than most surgeons. Does the surgeon have aesthetic taste compatible with yours? These questions can be answered through referrals to other patients, and physicians. Click to See Dr. Pousti’s Credentials Why should I choose a surgery center? A surgery center offers high quality in the nursing team, anesthesia and post-op care available. Having surgery in a surgery center gives you peace of mind that every detail has been checked and checked again. Our Surgery Center What should I know about anesthesia? When necessary, twilight sleep or light general anesthesia is administered by a competent anesthetist or anesthesiologist. The level of anesthesia will vary with the needs of each patient. The type of anesthetic is clearly described at the time of consultation and is tailored to the patient’s needs for surgery. The patient will remain in the recovery area until able to be discharged. Your surgeon will ask you to have a friend or family member to drive you home after the operation.
What are the risks? Although complications are possible, they are very rare. Most patients accept the risks after consideration. A full description of every possible complication is beyond the scope of this text, but risks specific to each procedure will be discussed in the appropriate section. How long will my recovery be? The period of recovery depends on the surgery performed. After surgery strenuous physical activities are limited. You can resume normal activities within a few days depending upon the surgical procedure. In some cases there will be temporary swelling, bruising and discomfort. The most common concern is an uncomfortable feeling, not pain. Pain is surprisingly minimal and easily controlled with medication. Mild analgesics are used in most cases, but stronger medication is given when necessary. The surgeon will discuss your postoperative visits for removal of dressings and sutures. Special arrangements are made for patients who are from out of town and arrangements are usually available for patients who do not live in the area, or choose to spend a few days after surgery away from their families. Care is taken to place the incision in the natural skin creases or skin folds along inconspicuous areas so they are not visible when the healing process is completed. The incision may be pink for several weeks postoperatively, but is easily camouflaged the day after suture removal. Complete maturation of the surgical area takes more than one year, though in most cases after one or two weeks, only the patient and physician can detect the surgical incision. Time is the single most important factor in the healing process.
How are fees determined? In general cosmetic surgery is not covered by insurance. Insurance will only pay when the surgery is done for reconstruction of deformities caused by accidents or when surgery improves function which is impaired by a physical deformity such as a septal deviation in rhinoplasty (nasal surgery). If an insurance company is to be billed for the surgery, the doctor’s office staff will usually submit the insurance claim forms and documents to your insurance company for payment. Fees are generally determined based on each patient’s needs. Fees are clearly explained to the patient at the time of the first consultation.

Why should I schedule an initial consultation? At the time of your visit the extent of your surgery will be carefully discussed and an evaluation made. A consultation helps to clarify the patient’s desires and the surgeons plan. There is no standard operation which applies to the same patient. An operation will be designed during this consultation specifically for you and all of the details will be explained. The most important goal of the consultation is to clearly communicate. Caution is advised in looking at before and after photos. These can often be misleading and may not reflect your particular needs. To help bridge the gap, computer graphics are often employed. Some surgeons are using this tool to show patients what they will look like after surgery. In general, the consultation helps the patient understand what can be achieved. It helps the doctor understand the patient’s desires and, most importantly, it gives the patient an opportunity to ask valuable questions and decide if surgery is right for them.
Why are pictures taken before and after surgery? Pictures are taken prior to surgery to help plan the procedure. They are useful guides which surgeon will use in planning and preparing for your procedure. In addition, postoperative photos are taken to enable you and the surgeon to evaluate the results of the procedure. Informed Consent You will be asked to review and sign a form that clearly describes your desired operation. This informed consent is a legal document and your authorization allows the surgeon to perform the surgery.
TUMMY TUCK SURGERY Q: What if I get pregnant after Tummy Tuck surgery? A: Safe pregnancy after tummy tuck is possible, but I would suggest that you complete pregnancies prior to tummy tuck surgery. As you can imagine, it is impossible to predict exactly what changes will occur ( after pregnancy). Pregnancy after abdominoplasty may cause CHANGES that MAY require further surgery to correct. I would also suggest that you do not waste your time/resources on any procedure at this point (besides tummy tuck surgery if you so choose); it is unlikely that you will be pleased with the outcome.

Generally speaking, the “ideal” patient for tummy tuck surgery is one who has completed pregnancies, is psycho socially/emotionally/financially stable, has an excellent social support system surrounding him/her, is capable of arranging enough recovery time, does not smoke and who has reached a long-term stable weight. Q: Are there different types of tummy tucks? A: Mini Tummy Tuck, Full Tummy Tuck and Extended Tummy Tuck. The mini tummy tuck is an operation that produces very limited results and is very rarely indicated. It involves a shorter incision but does not address the majority of the abdominal wall issues present for most patients who present consultation. For example, the area of skin excised is quite small. The abdominal wall musculature is addressed below the umbilicus leaving the upper number wall potentially lax. The appearance of the umbilicus is not necessarily addressed sufficiently.

For the vast majority of patients who have had pregnancies and/or weight loss a full abdominoplasty is necessary to achieve the desired results. If the patient has issues with her back area, the extended tummy tuck is discussed.
Q: Can Tummy Tuck surgery be used as a weight loss method? A: No, this surgery is for removal of excess skin and adipose tissue after weight loss/ pregnancy, this is NOT a weight loss treatment. Q: Who prescribes the painkillers and can we collect them prior to surgery? A: All necessary prescriptions will be prescribed by the doctor several weeks prior to surgery (at the pre-op appointment) and so you will be able to pick them up prior to surgery.
LIPOSUCTION Q: Are there different types of liposuction? A: Some offices use different names which mean the same thing. You may hear words such as “lipoplasty” “liposuction” or “suctioning lipectomy” — they all mean the same thing. Q: Can liposuction be used as a weight loss method? A: No, liposuction is used to get rid of isolated areas of fat which are diet and/or exercise resistant NOT for weight loss. Q: Who is a good candidate for liposuction? A: The best candidates for liposuction are people at their normal weight who have isolated areas of fat. Firm, elastic skin allows for a better outcome. The patient’s age is not a factor, however, older patients have less skin elasticity and may not achieve the same results as younger patients. Q: How long do I need to be off of work? A: It is suggested that you take off of work for 3-5 days after surgery but continue to avoid strenuous activity for one month after surgery. Q: When can I get back to my normal routine? A: Each San Diego Cosmetic Surgery patient differs with recovery times. Also, the recovery time will vary depending on how much liposuction was performed. Most patients are able to return to work 2-7 days after surgery depending on the areas treated. Q: When can I start exercising? A: Dr. Pousti will assess each patient and discuss returning to their exercise regimen. We highly recommend walking within the first couple of days – this helps with the swelling, constipation, etc. Depending on the areas treated, most patients are able to resume exercise 2-4 weeks after the procedure. Q: Anything I can do to decrease the swelling? A: Most of our San Diego Cosmetic Surgery patients find that walking helps decrease the swelling after liposuction surgery. Q: Will the fat return to the area that was treated? A: If after liposuction surgery one does not eat healthy and exercise regularly, the fat cells that remain in the treated area will grow. The fat cells that have been removed are gone forever. Liposuction is not meant to be used as a weight loss program. Q: Can I do multiple areas at the same time? A: Yes. Dr. Pousti will discuss what procedures may be performed at the same time while still being safe. Many patients will opt to have liposuction and breast augmentation surgery OR liposuction and tummy tuck surgery at the same time. Combination surgeries can give dramatic results. Q: Will I be wearing any special garments after the surgery? A: Yes. When you wake up after the procedure, a garment will be on the treated areas. This compressive garment is there to assist in the healing process and to decrease the amount of swelling. Dr. Pousti will discuss the amount of time you will need to wear the garment – depending on what areas are treated. DSC08025 23
BREAST AUGMENTATION Q: Should implants be placed under the muscle or over the muscle? A: The decision to do a sub-muscular (under the muscle) or sub-glandular (under the breast tissue) breast augmentation is based on several factors. Some of these factors include the patient’s preference and the patient’s anatomy. Each type of augmentation has its pro’s and con’s. In general, however, all things being equal, I prefer to do sub-muscular breast augmentations. This type of augmentation is associated with less chance of seeing or feeling the breast implant. This operation is also associated with a decreased risk of breast implant hardening (encapsulation or scar tissue formation). Sub-muscular breast augmentation interferes with the performance of mammography less so than does sub-glandular breast augmentation. shot1 On the other hand, sub-muscular breast augmentation is generally associated with more patient discomfort and a longer period of time to achieve the final cosmetic results compared to the sub-glandular breast augmentation. Weighing the pro’s and con’s of each type of augmentation, whenever possible, I prefer to perform a sub-muscular augmentation to achieve an end result with fewer complications and a better aesthetic result.
breast before augmentation
Breast before augmentation
breast before augmentation
Breast after subglandular augmentation
breast before augmentation
Breast after submuscular augmentation
Q: How long do I need to be off of work? A: It is recommended that you take one week off of work after breast augmentation surgery and continue to avoid strenuous activity and heavy lifting for 4 weeks after the surgery. I also ask the patients to not drive for 2 weeks after the surgery. Q: Who is too old to get a breast augmentation? A: Breast augmentation can be performed from an age of 18 years old on up. You are NEVER too old to improve the appearance of your breasts. Q: Is it necessary to wait until after having children before having breast augmentation surgery? A: No, it is a matter of choice for each woman. More than half of patients perform the surgery before having children and the majority of them have no problems breast feeding afterwards. The incisions used are small and the surgeon attempts to minimize the amount of disruption of the glands to the nipple/areola. The underlying breast implant does not harm the breast fed baby in any way. Q: How do I decided what size to go? A: The size that a patient decides to achieve is a very personal decision. Often time the patient wishes to achieve a “natural look” to simply improve the proportionality of the upper and lower body. Some patients, however, want a “round” look. For these patients a “natural look” is not a priority and they are not concerned if other people know that they have had a breast augmentation. In making this decision, it helps to discuss your goals with your surgeon. Pictures are often helpful as a form of communication between the patient and the surgeon. Often times, discussing “cup size” is useful but one must be careful since “cup size” depends on the manufacturer of the bra. Q: Do breast implants interfere with mammography? A: Yes. Breast implants, regardless of their location in the sub-muscular or sub-glandular location, can interfere with mammography. Generally, the breast implants placed in the sub-muscular position tend to interfere with mammography less than those placed below breast tissue. Mammography centers are well accustomed to performing mammography on patients who have had breast implants (using displacement techniques). Q: Can sensation of the nipple/areola be lost after breast augmentation surgery? A: Yes, a small percentage (<5%) of patients have permanent nipple/areola sensation loss after breast augmentation surgery. Many patients have temporary loss or hyper-sensitivity of the nipple/areola complex. The surgeon takes great care during the operation to avoid injury to the nerve supply to the nipple/areola complex. Q: How do I decide on the incision (approach) to be used during breast augmentation? A: Several approaches are available to perform the breast augmentation. These include the following: an incision under the areola, under the breast (just above the infra-mammary fold), and in the axilla (arm pit). The choice of incision is a decision made by the patient and the surgeon. In general, we try to use the incision which is best hidden and therefore less visible. Often times, this decision is made based on the patient’s anatomy. For example, if the patient has some amount of excess skin under the breast, an incision can be well hidden in this area (just above the infra-mammary fold) otherwise an incision around the areola tends to heal very nicely and becomes barely visible with time. Q: How do I decide to go over or under the muscle with the breast implant? A: The decision to do a sub-muscular (under the muscle) or sub-glandular (under the breast tissue) breast augmentation is based on several factors. Some of these factors include the patient’s preference and the patient’s anatomy. Each type of augmentation has its pro’s and con’s. In general, however, all things being equal, I prefer to do sub-muscular breast augmentations. This type of augmentation is associated with less chance of seeing or feeling the breast implant. This operation is also associated with a decreased risk of breast implant hardening (encapsulation or scar tissue formation). Sub-muscular breast augmentation interferes with the performance of mammography less so than does sub-glandular breast augmentation. On the other hand, sub-muscular breast augmentation is generally associated with more patient discomfort and a longer period of time to achieve the final cosmetic results compared to the sub-glandular breast augmentation. Weighing the pro’s and con’s of each type of augmentation, whenever possible, I prefer to perform a sub-muscular augmentation to achieve an end result with fewer complications and a better aesthetic result. Q: What is capsular contracture? A: This is scar tissue that forms around the breast implants causing the breasts to harden. This hardening may be associated with tenderness and pain. This is the most common complication with breast augmentation. Sub-muscular breast augmentation helps to deter capsular contracture. Massage may be useful, especially for implants placed above the muscle. If severe capsular contracture occurs, it may be necessary to remove the scar tissue and replace the implant (preferably in a sub-muscular position). Q: Who should perform my breast augmentation surgery? A: The physicians most qualified to perform breast augmentation surgeries are board certified plastic surgeons. It is important to get information regarding the surgeon’s training. Can the surgeon perform this procedure in a major hospital in your city? What do other patients say about the surgeon’ s ability to communicate and his level of care post-operatively? Q: What do the implants feel like? A: In general, implants feel firmer than your own breast tissue. Also, the appearance and feel of augmented breasts depends on how much breast tissue the patient had pre-operatively. In general, the more tissue the patient the patient has pre-operatively, the more natural the look and feel post-operatively. Q: What medications should I stop before surgery? A: It is recommended not to take any aspirin containing medication, ibuprofen containing medication or any herbs or weight loss medications for at least 2 weeks before surgery. Q: How do I reduce nausea post-operatively? A: Unfortunately, nausea is a common problem after many surgical procedures. Many medications can be used intra-operatively in an attempt to reduce this problem. Post-operatively, nausea can be reduced by minimizing the use of narcotics and taking the medication with a small amount of food in the stomach. If nausea is not relieved by these measures, anti-nausea medication may be prescribed. Q: How do I know if I need a breast lift? A: A breast lift (mastopexy) is an operation used to treat ptotic (sagging) breasts. A consultation with a well qualified plastic surgeon can help answer this question for you. In general, evaluating the position of the nipple/areola complex in relation to the fold under the breast (infra-mammary fold) will help determine the need for lifting. Different types of breast lifting operations are available depending on the severity of the sagging. Reviewing pictures of patients with similar situations may be helpful in deciding how to proceed. Q: What can I expect post-operatively? A: Unfortunately, most patients experience a moderate to significant discomfort post-operatively. This seems to be increased with sub-muscular breast augmentation compared to sub-glandular breast augmentation. Many patients are unable to sleep because they are not used to sleeping on their backs. Soreness of the back and neck may be related to this difficulty finding a comfortable position. Some patients choose to use 2 pillows and sleep in a reclined position. Q: What is symmastia? A: This is when the two breasts communicate in the mid line (cleavage area). This may be done to “increase cleavage” by dividing the soft tissue or muscle fibers at the medial edges of the breast. This can be seen with implants placed over or under the muscle. It is a correctable problem — it is challenging and requires surgical intervention. Q: What is the difference between textured and smooth implants? A: Texturing refers to the surface of the breast implant. Textured implants have a rough surface in an attempt to prevent contracture formation (especially when the implants are placed above the muscle). This does not appear to be relevant in the sub-muscular position. Textured implants may be associated with rippling more than smooth implants.
Q: What is a “Tuberous Breast”? A: Tuberous Breasts, otherwise known as constricted breasts, are associated with some breast tissue deficiency especially medially (around the cleavage area). The appearance of the breasts can vary greatly from a very severe deficiency of breast tissue to mild deficiency. Often times, the patient will have different size and shape between the right and left breast. This is a correctable condition. Of ten, implants can be used to improve the size, shape and symmetry of the breasts. Q: How long will I have to wear this special bra? A: Normally, the bra will need to be worn for 2-4 weeks. There are reasons why the bra is important and following San Diego Cosmetic Surgeon’s, Dr. Pousti, directions will give you the best possible results. Each patient is different and so the recovery will also be different. Q: How long do I have to wear the bandeau? A: The amount of time that the bandeau needs to be worn depends on your specific situation. On average, the bandeau will be worn for 2-4 weeks after the procedure by our cosmetic surgery patients. Q: When can I start to exercise? A: Dr. Pousti does not recommend heavy weight lifting or strenuous exercise until 6 weeks after the procedure. Patients may walk and do leg exercises soon after the procedure. Q: How long is the recovery? A: Every San Diego Cosmetic Surgery Patient is different in their recovery. Most patient’s are able to resume the majority of their normal activities 4-6 weeks after the procedure. Q: Do I have to do any special exercises to massage the implants? A: There will be exercises that Dr. Pousti and his office staff will review with you. Generally, we perform downward massage for first time breast augmentation patients to help with the settling of the breast implants into the pocket that was created.  Follow your surgeon’s advice as to how long and how forcefully to perform the breast massage. Massage Video
Q: Anything I can do to decrease the possibility of getting capsular contractures? A: No. Our San Diego Cosmetic Surgeon, Dr. Pousti, will do all that he can during and after the procedure to decrease the chance of capsular contracture. By placing the breast implant under the muscle, the risk of getting capsular contracture will be decreased. Dr. Pousti follows his patients long term to diagnose encapsulation and there are now medications that may be used to combat this problem. Q: Do these implants have warranties? A: Yes, these breast implants have life time warranties. The breast implant companies will cover the cost of the breast implants for life and will also supply a stipend to cover some of the cost associated with returning to surgery (anesthesia, surgery center, etc.) for 10 years after your primary procedure. Q: Can I get silicone implants? A: The FDA has approved silicone gel breast implants for all patients (cosmetic and reconstructive) over the age of 22. Q: I have friends from out of town/state who have gone to see Dr. Pousti, how can I schedule a surgery without coming in for a consultation if I live out of state? A: Our San Diego Plastic Surgery office has many patients coming from out of town/state to have Dr. Pousti perform their breast augmentation surgery. We can discuss the majority of what we need to via e-mail. Our office tries to work with your schedule so that the inconvenience is minimized. Q: When do the stitches come out? A: Depending on what was performed on the patient, will determine how soon the stitches will come out. Q: When can one shower after this procedure? A:Follow your surgeon’s instructions as to when it’s appropriate to shower. Q: If I have to have the surgery redone later in life, will the incision be made in the same place as the original? A: Usually, yes, the incision would be made in the same area. Q: Will I need expanders to achieve the size I want? A: Usually expanders are not necessary. Q: Do you use sizers during surgery to best determine size? A: Yes, I always use sizers. Q: How many different sizes of implants do you take into the OR? A: I always have all breast implant sizes available in the OR. Q: Do you make over-sized pockets? A: Pockets are slightly larger than the implants used. This will allow for some movement of the implants so as to resemble natural breasts as much as possible. Q: If I develope a capsule and the implants have to be removed, will I be able to have them put back again? A: Most of the time, patients wish to have implants replaced after removal of capsules (capsulotomy). Q: What guarantees are offered with the implants? A: Currently, the implants are warrantied for life by the implant manufactorer. They also provide a stipend to return to the OR if an implant leak occurs within the first 10 years. Q: What is the best way for me to determine the size implant I will need to go from where I am to where I want to be? A: Often, by looking at pictures, we can ascertain your goals of size and shape of breast desired. Q: Will I be able to sleep on my stomach? A: In general, approximately 2-3 months after surgery, one is able to sleep on their stomach. Q: Who prescribes the painkillers and can we collect them prior to surgery? A: All necessary prescriptions will be prescribed by the doctor several weeks prior to surgery (at the pre-op appointment). 2 CARD-7

Medically reviewed by Tom Pousti, MD, FACS, and written by The Pousti Plastic Surgery Team.

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Pousti Plastic Surgery of San Diego
8851 Center Drive, Suite 300
La Mesa, California 91942
Phone: (619) 466-8851 or Email
Dr. Tom Pousti is a San Diego and La Jolla Plastic Surgery specialist. He has provided plastic surgery treatments to many San Diego and La Jolla facelift, tummy tuck, liposuction, breast augmentation, and rhinoplasty patients. His office is located in San Diego, serving the La Jolla, Riverside, Inland Empire and Temecula areas. Disclaimer

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