How to look younger- without looking “plastic”

Dr. McKee talks about what makes a more youthful appearance, avoiding an “overdone” face, and whether TV commercial promises can live up to the hype.

What specific problems do facelifts address?

Its power is the neck and the jaw; you get some of the wrinkling out of the cheeks and pull a little of the nasal-labial fold up, but mainly its strength is the neck and the jawline. And it can rejuvenate that back to a– well, in some patients, to a look they’ve never had. There are a lot of patients that have had an area of fat under their chin that has always been there at every age, and they’ve never had a very nice flat platform. So what we do is we remove that fat and then we tighten the skin, so a lot of people end up having a neckline that they never had when they were 20. It makes a flat platform under the chin, back to a sharp drop.

We’re trying to achieve a refreshed, and certainly a younger look, but we’re not after an age-specific look. We’re not saying we’re going to take 30 years off of you, specifically, but a refreshed, rejuvenated, but still natural look. You will still look like you and not unnatural.

The “Over-done” look

I don’t think there’s any other cosmetic operations that we do that are so culturally determined as to what people think is a good result.

What that means is, patients that I see in my office complain about the celebrities they see on TV: they look over-operated on; they do not look natural.  At the same time, those people you see on TV that I and my patients would call over-operated, would be disappointed if they didn’t get that dramatic operation.

So what is off-putting for many people in our section of the country about facial rejuvenation, is they think that everybody who gets a face lift, brow lift, eyelids, are going to end up with something that is very unnatural and off-putting. That’s not the case. I don’t do the same operation that the FL and NY and CA plastic surgeons do when I do facelift and facial rejuvenation surgery. I am after a very natural result.

Now what does that mean in very specific terms? That means that I make a tight, tight neck and jawline. My opinion is that you can’t tighten the neck or the jawline too tight. It is a nice look, at every age. And if you’re 75 and have a very tight, flat platform under your chin that goes to a sharp drop, nobody complains about that, it is a very nice look at every age.

On the right: “a flat platform back to a sharp drop”

It is the cheeks that are the problem, and the eyes and the brow that are the problem when they’re over-operated. If you try to use the facelift to rejuvenate the mouth, you will get a very unnatural, wind-swept look. That’s what the celebrities have that people do not like. Their mid-face is way too tight. They try to do things, in my opinion, with the facelift that you cannot do, which is rejuvenate the nasal-labial creases a lot (those grooves just above  the mouth and the upper lip), and the area around the lips.  You cannot really rejuvenate those with a facelift. And when you try to do that, it’s not a nice look, as far as I’m concerned. It’s an over-operated, unnatural look. So we don’t do that operation. We do a face lift, which is really a neck- and jawline lift, and some cheeks, and we tighten the neck and jawline up tight, but don’t tighten the cheeks up very tight.

Healing from a facelift

A facelift is about a 3-hour operation, it’s done in the Operating Room of the hospital, you can do it under local anesthesia with sedation, or you can do it under general anesthesia, probably as safely. The patients go home the same day, or if they live out of Nashville, we have them stay in town in a hotel overnight, they return to the office the next day, get the dressing out that was put on in the operating room, and any drains that might have been used, those are removed the morning after surgery.

The patients are allowed to go home, they are allowed to shower the day after surgery, shampoo their hair, then they return to the office 5-6 days after surgery for suture removal and, the day following suture removal, they are allowed to use make up.

In terms of the amount of bruising and swelling people get, is very variable. Some people get very little, some people get a lot, pretty unpredictable. Almost everybody gets some, particularly in the neck and low neck and it settles by gravity over time.

What I tell my patients is that in 3 weeks, they are going to look good. They may look good before then, but if they have a major social engagement, like a wedding or something like that, they really need to allow three weeks.

There is very little pain associated with a facelift. If you have a lot of pain, you need to call your doctor. It is uncomfortable and your neck is certainly tight, and you may have a sore throat (it may hurt to swallow from both the tightness and if you had a general anesthetic, from the tube that was in your throat during the surgery), but other than that, very little pain.

The only scars I’ve ever had to revise are occasionally the scars in back of the ears, where you move into the hairline in back, I’ve had to revise a couple of those. Otherwise, the scars are almost imperceptible, even those that lie in front of the ears- they make thin, white lines, very hard to see.

Franchised “Thread-Lift” Procedures

We’re talking about those advertised, franchised procedures you see on TV: most of the patients who go there will end up getting a facelift, of varying qualities, but they will get a facelift. And if you look at the captions underneath the pictures they show on TV, it will always say the patient had additional neck-tightening procedure. The procedure they are advertising is some kind of thread lifting, it’s supposed to be quick and easy, with long-lasting results. That is not true. It has a high complication rate. But most of the pictures they show, whether they had threads or not, they basically had a face-lift. Now they may have had it by a surgeon who had a 2-week training course instead of being a board-certified plastic surgeon trained in face lifts, but they had a face lift of varying qualities.

Almost every plastic surgeon in the Nashville area has a patient who has come to them because they’re unhappy with the results they had at one of these franchised sites. There are no shortcuts. There is no exercise you can do to remove fat or skin. You can do all the neck and facial exercises you want, you can tighten the muscles, but it does not increase the tightness of the skin, nor does it remove fat from that site. If you burn more calories than you eat, you’ll burn fat, but your body will decide where that fat comes from, so there are no shortcuts.

If you have a lot of hanging skin in your neck, the only good way to remove that skin is through surgical incision, and the only good place to remove it is in front of the ears, and that is a facelift.

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Dr. McKee has over 30 years’ experience in cosmetic surgery, including facelifts. Please call us at 615-868-4091 or send us a confidential email to schedule your consultation.


The Big (and Small) Picture – Part 3

If you’re unhappy with your breast size, breast augmentation could be the answer to achieving the shape you want. In the final segment of our Breast Augmentation interview, Dr. McKee talks in-depth about the potential complications associated with the surgery. Plus, what you’ll need to do after your surgery to help protect your investment.

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What else can you tell me about complications associated with the surgery?

David E. McKee: Yes. First of all, you have to have an anesthetic. There are people who do this operation under local anesthesia, but the truth is, there is no anesthetic that’s 100% safe. And the amount of sedation that’s required to do this operation under local anesthesia probably makes it more unsafe to do it that way than just to put somebody to sleep. General anesthetic is incredibly safe today, but there’s always some risk. No matter what kind of anesthesia it is, you can get a medicine that can cause you some reaction that you could even die from, but that is incredibly rare. So that’s the first complication I always tell people about.
You could have a pulmonary embolism from a blood clot that forms in your leg- again incredibly rare, especially in an operation, like breast augmentation, that is so short (I do it in about an hour and fifteen minutes) that the chances of you having any blood clot problems is almost zero, but nothing is zero in medicine.
Then you get to the operation itself: you could get a wound infection. Wound infections in breast implants are very, very rare because we’re careful in every operation to keep things sterile, but we’re incredibly careful about any time we’re putting foreign bodies in because it doesn’t take many bacteria to cause an infection in the face of a foreign body. So if you get an infected implant, it’s very possible and even probable that we’re going to need to remove the implant to get the infection clear. So we are very careful about infection, but infected implants occur in the United States with some frequency. Not as high in breast augmentation as in breast reconstruction, but still.
Malposition: we work very hard to make the pockets exactly the same, perfectly smooth, how big they are on the sides, how tall they are at the top, but sometimes after you’ve fixed the pockets and they’re perfect, implants can move.
Implant failure is not a complication: it’s guaranteed, if you live long enough, because all implants fail. All implant manufacturers guarantee their implants for life and will provide you with a replacement implant, no matter when it occurs, whether it’s 20, 30, or 40 years later, they will supply you with a free implant to replace the one. But, they only give you money to help pay for the replacement of your implant in the first 10 years. Beyond 10 years you can buy an extended warranty from the company and, if you do that, they will provide you with money to help replace the implant no matter when the implant has to be replaced.
The single biggest complication in terms of frequency is capsular contraction. Every implant gets a scar around it because your body recognizes the implant as a foreign body. That is not a complication, but in some patients, that scar thickens and tightens down around the implant and it can make look and feel different and it can be uncomfortable. Probably the frequency of capsular contraction, either in one or both breasts, is as high across the board in the U.S. currently as about 35%. Most of those patients do not require surgery because it’s not severe enough that it bothers them that much. It doesn’t change the way the breasts look or feel and it’s not painful, but if you check the breasts for symmetry by feel, you’ll find that one is encapsulated and the other is not. That patient doesn’t have to have anything done, but she has a complication called capsular contraction. They are graded from 1-4, many of the complications of capsular contraction are mild and do not require surgery, but about 5% of patients who have breast implants will require treatment, surgery, for capsular contractions.

After Your Operation

DEM:  Let me talk about post-operative care a minute. There’s a thousand ways to take care of breast enlargement patients after surgery. Anything that’s been proven beneficial, everybody does, but the rest is magic, and every doctor has their own magic. Some doctors wrap patients up in Ace bandages, some use special surgical bras, some doctors make patients buy this or that special device. All of that is “magic”. My personal approach is, I use gauze dressings on the incisions only, let the patients take those off a day after surgery. I let patients shower after 24 hours, put a little vaseline on the incision and wear a t-shirt as a dressing. I do not wrap and I do not want patients in a bra at all, at least until they come back for their first visit. That’s my personal magic, and I’ve had good results with it.
Whether your implant is above or beneath the muscle, there are certainly activities you want to avoid: stooping, bending, straining, lots of things with vigorous arm motion, certainly lifting heavy weight, running, jumping, jogging. All of those things should be avoided for 3 weeks in my practice and with some doctors, even longer.

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If you think Breast Augmentation might be for you, schedule a consultation with Dr. McKee.  E-mail us using the form below or call us at 615-868-4091. All information is kept confidential.

This is provided for informational purposes only and is not intended to take the place of a personal consultation. Every patient has different needs.  As always, Dr. McKee would prefer to speak with you in person to discuss your specific situation.

The Big (and Small) Picture – Part 1 of 3

An Interview with Dr. McKee about Breast Augmentation Surgery

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If you are one of the increasing number of women who are considering getting breast implants, then you probably have many questions about the procedure. Am I a good candidate for the procedure? Will it look natural? What are the risks of complications? In Part 1 of this 3-part series, Dr. McKee speaks openly about implants, incisions, the problem of “going too big”.

David E. McKee:The first decision you have to make about breast augmentation is where are you going to put the incision? Where am I going to have permanent scars? It’s not a question of whether or not you’re going to have scars, it’s a question of where you’re going to have scars. There’s the belly button, very few people in the country are doing that operation. Nobody in Nashville as far as I’m aware is doing a belly button. So, if you eliminate the belly button, then you’re left with 3 basic places for a scar: the crease under the breast, around the areola on the front of the breast, or scars in the armpits. The armpit scar is a very nice scar, it’s off the breast, so it’s not very noticeable, but it requires you to do the operation as a blind surgeon, you can’t really see what you’re doing. So I reject that approach. I either use the incision under the breast or the incision around the areola, but the incision around the areola, to me, is just in a more noticeable place than the incision in the crease under the breast.

Will there always be a scar?

DEM: There’s always a scar. You cannot do any surgical procedure without a scar.

What kind of scar could I expect to have?

DEM: My standard approach, I use a 4-5 cm-long incision in the crease under the breast, which ends up about a centimeter or a centimeter and a half up on the bottom of the breast after the implants have settled just a little. 5 centimeters is 2 inches, so it’s just under 2 inches long. It heals as a thin white line scar. It can heal as a wider scar- if it does, we can always do a little revision in the office and see if we can’t get a thinner scar. I’ve never had a keloid scar on the breast, but I have had a few scars that I’ve revised in the office under local anesthesia.

After deciding where to make the incision, the next decision is where’s the implant going to be? Is it going to be under the breast or under the muscle and there are specific indications in my mind and advantages and disadvantages to each of those locations.

The third decision is what kind of implant are we going to use? Not only do we have to decide between gel and saline, but we also have to decide between textured and smooth, round and shaped, or tear-drop implant, so it’s a very complex choice. I will use pretty much any implant that a patient wants, but I have my own prejudices based on 30 years of doing augmentations.  My standard implant is a gel, round, smooth implant. That’s the implant I think will give the most consistently good result. But there are complications associated with all the implants.

What’s the difference between silicone and saline implants?

DEM: A saline implant is empty when you get it and you just fill it up with IV saline, which is just salt water. You have some flexibilty in terms of adjusting the volume on the operating table. The gel comes pre-filled, you cannot adjust the volume, but there are plenty of sizes of gel to accommodate different needs. The biggest difference for me, and the reason I prefer gel, is because it’s more natural to the hand. The gel is made with a consistency that is very much like natural breast. The saline is much firmer.

How long do implants last?

DEM: The average lifespan on the new generation of gel implants, I think, is going to be greater than 15 years. It’s probably going to be closer to 20 years. Probably on the latest generation of saline implants, it’s going to remain about 15 years. But there are no guarantees. I certainly have patients with 30-year old implants in, but I also have patients where I’ve put implants in who have had implant failure within the first year. So these numbers are averages of length of survival of implant, so for an individual all bets are off. But the average lifespan, I think, is going to be over 15 years for both types.

How do I decide what size is best for me?

DEM: There is no right or wrong answer about size, but I always tell people, ‘The harder you push, the bigger you go, particularly the smaller you are to start with, the higher the complication rate. Of all complications: implant displacement, getting the implants uneven in terms of their position on the chest, capsular contraction, infection, bleeding, nerve injury- injury to the nerve that goes to the nipple and gives you permanent feeling in your nipple. All of those complications go up the harder you push,the bigger the implant you try to put in. So I try to encourage pts to be realistic about their size, particularly the young women who have never been pregnant, who have A or AA breasts. We can certainly go to a C, C+ a little bit, but beyond that I think you are risking complications and I try to discourage that. Ultimately, it’s up to the patient, but if a patient asked for me to do something I wasn’t comfortable doing, I’d just suggest that they probably ought to go see somebody else.

We size patients in the office with a bra and different implants that are placed in the bra just to give an idea, a starting place. The office manager helps them work through that process. It’s not perfect, but it gives us a range, it gives them some idea.

(Click here to see what Dr. McKee has to say about the visibility of breast implants)

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In part 2 of our interview, Dr. McKee will discuss payment options, recovery times, and what you can do NOW to become a better candidate for the procedure. Stay tuned!

This is provided for informational purposes only and is not intended to take the place of a personal consultation. Every patient has different needs.  As always, Dr. McKee would prefer to speak with you in person to discuss your specific situation.

To schedule a consultation with Dr. McKee, e-mail us using the form below or call us at 615-868-4091. All information is kept confidential.