By: Jennifer Hussein

Once upon a time (in 2015), none other than queen of alt-beauty Gwyneth Paltrow took to the internet to tout an “underthe-radar” cosmetic procedure known as threading, which she also dubbed “the future of face-lifts.” Fast forward five years, and she’s not the only one to praise the procedure: Beauty guru Huda Kattan did a full self-expose and video on her love for threading, Cosmopolitan labeled it a “chiller” version of a classic face-lift, and the popular Instagram account @CelebFace even dedicated an entire post trying to “expose” celebrity faces (CC: Bella Hadid, Ariana Grande, Dove Cameron) that may have secretly gotten hooked (pun intended) on the thread trend for a subtle brow lift.

But first and foremost: What exactly is threading?

“Thread lift is kind of a colloquial term for suture-suspension lifting, [which] works by introducing a surgical suture that has barbs or perpendicularly oriented rasps on it,” says Dr. Lara Devgan, New York City-based board-certified plastic surgeon and founder of Dr. Lara Devgan Scientific Beauty. “That is introduced deep into the tissue, and when it’s placed on tension, the perpendicularly oriented rasps gain purchase in the tissue, and they allow you to pull it in different directions. To put it another way, suture-suspension thread lifting allows you to, in a minimally invasive manner, create lift and directional vector changes for the tissue.” That means you get some of the lift that you’d find from a face-lift, but in a much less invasive procedure done under local anesthetic rather than general anesthesia.

While it may seem like a newer, easier spin on the classic face-lift (a surgical procedure that improves visible signs of aging in the face and neck, like sagging, fat loss, and jowls), Dr. Steven M. Levine, board-certified plastic surgeon, notes that thread lifting isn’t necessarily a new concept—actually, it dates back to the mid-’90s. “Very little is new in my field,” he explains. “Only new marketing. This is clearly one of those examples of something that has been tried and has not been successful in the past, and then companies bring it back.”

So why haven’t these suture-based lifts been successful in the past? According to both surgeons, a variety of issues arose as a result of the procedure, like asymmetry, pleating, breakage, and even extrusion or poking out through the skin (yikes). However, Dr. Devgan does note that since their inception, the varying thread options available have gotten exponentially better over time.

“So much has changed in the aesthetic in the past 20 to 30 years,” she says. “The threads themselves have been made in a different way. Instead of taking a regular surgical suture and carving little notches out of it in order to give it barbs, now the sutures are formed with custom molds. The polymer that’s poured into them is actually stronger, and this means that each thread is able to support about two and a half pounds of pressure. This allows them to be placed in deeper tissue planes of the face—that avoids many of the problems that you’ve seen in the past.”

These technological advancements, plus the desire for less invasive procedures with quicker recovery times, have driven more patients towards thread lifting—for the face, derrieres, and bosoms. Dr. Devgan cites the treatment (which results in no scars, has zero incisions, and no general anesthesia) as the leading alternative to traditional procedures like a surgical face-lift, neck lift, or brow lift. “[In that way, it’s] extremely appealing to people.”

Dr. Devgan also notes that the trending (and appropriative “fox-eye” look isn’t the only effect you can achieve with face threading. “Just like everything else in aesthetic plastic surgery, there is a whole range of possible outcomes,” she says. “So you can have an extremely subtle and natural-looking result that focuses just on symmetry, and a little bit of added optimization, right at the margin. You don’t need to look fake.”

But just because your recovery time is lessened and the procedure is minimally invasive does not mean that all surgeons will recommend it for their patients, especially if you’re looking for permanent and similar results to a traditional facelift. Dr. Levine isn’t keen on thread lifts, nor does he offer the procedure at his practice.

“The tissue can’t be suspended from just the threads,” he explains. “If this worked, I’d be out of business—nobody would want face-lifts anymore. I have never seen a long-term result from threading that I was impressed by. There might be some truly transient lifting of the tissue—meaning days to weeks—and frankly, that lift is completely reliant on the tensile strength of the barbs on that thread. The truth is there isn’t much of a result to see that isn’t swelling related. You’re not mobilizing any tissue, and you’re not separating any of the facial ligaments. It would be the equivalent of taking a piece of tape from underneath the skin and sort of taping your skin up and hoping that [it] holds for weeks to months to years.”

Even Dr. Devgan, who has performed this procedure hundreds, if not thousands, of times, admits that thread lifts aren’t a shortcut to the same results you’d see from a face-lift.

“Suture-suspension lifting has a role, but it’s very important to understand what that role is,” she says. “Thread lifting is not a replacement for a surgical face-lift and it never will be. It’s an intermediate technique that’s part way between injectables and full open surgery. In my opinion, a surgical procedure remains the gold standard for lifting the face.

As for thread lifting for your body, both experts agree that you should probably opt out of that, too. “At the present time, thread lifts for breasts and body are not robust enough to lift the tissue well because the tissues in those areas are quite heavy,” says Dr. Devgan. “I do not think thread lifts are well suited for these areas.”

However, that doesn’t mean that you need to rule out threading entirely if you’re in the market for options to lift the face. Dr. Devgan notes that there is a time and place for this procedure—you just have to figure out when with your surgeon, while also being realistic about their limitations. “Not every nail needs the same kind of hammer,” she says. “I think that it’s true, but in a way irrelevant, to say that [thread lifts] are not as good as the gold-standard technique [of a face-lift] because if you [don’t want] an invasive procedure, then maybe this is something that can still make you happy.”

So what’s the takeaway here? Although thread lifts do come with their limitations, they can be used in a variety of ways to create the result you desire—just don’t expect them to be the end-all of traditional face-lifts. Some surgeons, like Dr. Levine, will steer you towards tried-and-true procedures that are more guaranteed to adequately address your concerns.

“If you would like to reduce fine lines and wrinkles, get a neuromodulator like Botox or Xeomin or Jubo,” says Dr. Levine. “If you want to add volume to your face, have your injector put filler in your face. But if you want to reposition tissue in your face, the only procedure that has stood the test of time and will reliably give you what you want is a facelift.” But what if you’re not quite ready to explore that option? “The answer is, I say with a great deal of sincerity, if you’re not ready, then just don’t do it.” Considering that the average age of people seeking face-lifts is 50 years old, you might still have a few years to think about it, although Dr. Levine does reveal that that number is dropping. “Some seek it in their late 30s. The average age is getting younger and younger.”

However you feel about thread lifts, face-lifts, or any cosmetic procedure, make sure to consult with a trusted board-certified surgeon or dermatologist before getting any procedure done—you’ll thank yourself in the long run for it.

Photo: Shot on site at 6 Columbus. On Solveig: Pajamas, Morgan Lane; Ring, Baker & Black; Sunglasses, Dior; Hand Mirror, Tom Dixon; Carafe, Tom Dixon; Hair, Angela Soto; Makeup, Andriani.

By: Jennifer George

The past 20 years have seen the rise and fall of eye-popping breast enlargements. But does the new trend for smaller cup sizes and more subtle surgery mean we’re less bust-obsessed, or are we just expressing an age-old fixation in a different way?

‘I remember the first time I really got the concept of ‘fashion tits’.

I was at an annual industry ball my then-magazine was hosting (as a clipboard warrior, not a guest, sadly) and the CEO of the world’s biggest online fashion retailer arrived full skirt and a silk shirt unbuttoned to just about the navel. Her breasts – neat, perky but with a natural-looking, gentle slope away from the breastbone – were braless. On the show, but not showing off, giving her look the perfect balance of sexy and nonchalant; the ultimate goal when dressing for a fashion crowd. In a sea of celebrities in microscopic and outlandish designer outfits, hers (and her braless bravery) were the talk of the office the following day.

At the time – this was in 2012 – you could have been forgiven for thinking that, after a decade or two of in-yer-face fame, boobs were over. But as with most trends, our obsession with breasts never really goes away; it’s just the obsession’s form that changes.

Back when I was a teenager, they were massive: literally and figuratively (although not personally but, oh, how I longed for them). It was the early 2000s, and huge, fake breasts -and the surgeries creating them – were big news. Actresses had them, the Spice Girls had them, the most-lusted-after girl at college had them. If the Sixties were about legs, and the Eighties hair, the Noughties were all about boobs.

‘Lad mags’ – such as Zoo, FHM and Nuts – took over shelves with female cover stars who were, shall we say, ‘heavily endowed’. WornderBra and its ‘Hello boys’ campaign (featuring a bouncy Eva Herzigova with breasts hoisted up to her clavicle) caused cars to stall at traffic ligths. This was a time, remember, when it was acceptable to stuff plastic ‘chicken fillets’ into your bra to ‘enhance’ what you had. (Although I can personally attest that they did not withstand as drunken night out on the dance floor.)

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‘In 2013, more than 11,000 women went under the knife to boost their breast size in the UK’

So it’s not surprising that, even though breast augmentation has been around since the 1960s, demand for the surgeries, well, surged. Even the 2010 PIP scandal (with its stories of ‘erupting’) Poly Implant Prothese implants, made from non-medical-grade silicone) couldn’t dissuade us. At their breast size in the UK (a huge 30% jump from 2009).

The goal, for most, was simple: size. ‘The obsession was about sticking volume into the breast,’ says Patrick Mallucci, one of the UK’s most well-regarded plastic surgeons. ‘Pamela Anderson, Posh Spice — they were the pin-ups of that “volumetric” era.’ Surgeons of Mallucci’s calibre (his procedures start from E9,300) have always erred on the side of caution, but it wouldn’t have been difficult to find someone willing to squeeze the largest slab of silicone into a very small space, if that’s what you desired.

‘I wanted the pushed-up look, one that would just sit completely still in a string bikini,’ Laura,* who had her first boob job at age 24, tells me. ‘I didn’t care about them looking natural. If anything, I wanted people to notice them.’ Saving up for her surgery, she forked out close to E5,OOO to ditch her AA-cup bras for DD ones. For Laura, at the time at least, they were like two globular badges of honour pinned to her petite frame. She joined an army of women— WAGs, soap stars and, in her case, financial advisors — proud to display their implanted assets. Conforming to the idea that ‘bigger means sexier’, for her it wasn’t about empowerment or owning her femininity, it was about being noticed.

But then, almost overnight, ‘boob job’ became a dirty phrase. In 2014, a year after their glory days, UK surgeries dropped by 20%. Posh Spice, who had by then successfully rebranded as a fashion mogul and mother of four Victoria Beckham, had her implants — which for years she denied, but did little to hide — removed. The interest in the fake aesthetic that had reigned for so long suddenly deflated.

The British Association of Aesthetic Plastic Surgeons (BAAPS is its apt acronym), which audits all surgery figures, put the steep decline down to two things. First, a simple blip after a ‘post-austerity boom’ in 2013. But, secondly, and more interestingly, a change in ‘aesthetic preferences’. As BAAPS President and consultant plastic surgeon Rajiv Grover explained in a report at the time: ‘2014 saw men sporting bushy beards and women bushy eyebrows; the natural look [was] definitely on the rise.’ But why did our preference suddenly shift away from ‘bigger is better’?

It is perhaps no coincidence that this trend closely followed another big shift in society: the emergence of fourth-wave feminism. With previous phases focusing on women’s rights and liberation, this one — which coincided with and took advantage of a surge in the use of social media — zeroed in on body shaming, sexual harassment and sexist imagery in the media. It included campaigns that challenged misogyny and the objectification of the female form, such as the Everyday Sexism Project, the No More Page 3 campaign and, later, the 2018 Women’s Marches.

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‘Although breast surgeries declined, Illey certainly did not disappear; they just got subtler’

But even if you weren’t picking up a banner and taking to the barricades, you couldn’t help but notice that big boobs were out of style. This cartoony version of femininity had seemed refreshing and counter-cultural when it emerged from the ashes of the angsty, gender-neutral Nineties. But, gone mainstream and stripped of the knowing irony, it became tacky and obvious to some, associated with a lack of imagination and individuality. Like it always does, the wheel of fashion turned and ‘real’ boobs, of all sizes, were in style. But when I say ‘real’, what I should really say is ‘real-looking’. Because although breast surgeries declined, they certainly did not disappear; they just got subtler, softer and smaller.

‘We learnt a lot from the era of more is more,’ says Mallucci. ‘It’s associated with many negatives — PIR ill-sitting implants —and the fact that, actually, it’s ugly.’ In 2014, alongside a fellow surgeon, Mallucci came up with the ‘perfect’ 45:55 ratio, with 45% of volume above the nipple, 55% below. ‘Naturally a breast, even in a fit 19-year-old, will have more volume below,’ he says of the subtle difference. Where surgery had once turned breasts into firm, round oranges, it was actually more of a natural pear shape that surgeons, women, men, everyone preferred. (A study of more than 1,400 people was conducted as part of this research.) What’s a good example of that ratio? ‘The Kate Moss shape is often referred to,’ says Mallucci. That modestly sized, natural-looking breast — and the one that I became familiar with working in the fashion industry in the 2010s — became the gold standard.

One surgeon famous for perfecting this aesthetic is New York’s Steven M Levine. ‘Other surgeons joke that I have the smallest business in the US,’ he tells me. ‘Because I’ve carved a particular niche for this type of breast.’ Doing three to four surgeries a week, at the eye-watering cost of E 14-23,000, depending on what is being done, he’s the go-to for the citys fashion crowd and many celebrities. He simply ‘doesn’t do large augmentations’. Of course, he can’t name names, but — when I ask about certain perky-breasted models — tells me that he’s ‘operated on a significant portion of Victoria’s Secret models’. He adds: ‘I’ve done a few of the most well-known “fashion” breasts. They just want to fill a bra. They want to look as natural as possible, but with the ability to look breasty in a push-up bra. They want to be natural, but versatile.’

This was the case for Olivia, a London-based PR, who turned to surgery two years ago — not for ‘big boobs’, but a better shape. Unhappy with her tuberous breasts (a harmless but often aesthetically displeasing condition where the shape may be elongated, droopy or with enlarged areolae), her brief was clear: ‘the smallest option possible’. Not only were there practicalities to consider— her 5ft 2in frame, clothes fitting like they did before — but she also didn’t want to be painted with the ‘fake boob’ brush. ‘People automatically knowing I’d had a boob job is something I wanted to avoid,’ she tells me. ‘Because, unfortunately, there’s a stereotype that comes with it. People can be quick to judge.’

For Olivia, aged 21 at the time, the surgery involved 265CC implants (one of the smallest options) taking her from a 32B to a 30D, ‘which sounds like a big jump, but it’s not.’ It might seem easier to create neat breasts rather than turning molehills into mountains but, in fact, the delicacies of the surgery make it harder to perfect. ‘It’s easiest to fill it up to get the lift people want,’ says Levine. ‘With smaller implants, surgeons have to be more skilled with placement.’ For Laura, the passing years made her rethink her implants; she wanted to look ‘more modern, cooler in clothes without stick-on-boobs taking over’. ‘I wanted them smaller, not as high up,’ she tells me, adding in the word ‘natural’ to her list of wants. She underwent a revision surgery, taking them a cup size smaller but ‘much more normal-looking’.

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‘With the fake look ot of fashion, patients are wanting a redo’

Every surgeon I spoke to now does more ‘revision’ work than enlargements through first-time surgeries. With the fake look out of fashion, patients are wanting a redo. Chrissy Teigen, who recently admitted to having implants fitted in her early 20s, recently documented the process of ‘getting her boobs out’. They’ve been great for many years, but I’m just over it,’ she announced on Instagram. But it’s not usually a case of just plucking out an implant. ‘When coming for downsizing or reverting to a natural shape, the redundant or excess skin requires a lift or tightening,’says Mallucci, whose ‘fixes’ have now overtaken primary jobs. ‘I think of it like dressmaking: tailoring away excess skin, tweaking and lifting where needed.’

With all of these options out thereto create the optimum natural-but-fake breast, it’s near-impossible to spot who has had ‘work’ done any more. As with all aesthetic procedures these days, we’re left puzzling over images of celebrities, wondering: Have they or haven’t they? Dr Jacqueline Lewis, a surgeon who specialises in post-cancer reconstruction, says this is a problem in itself. ‘We think we’re over the fake era, but we still aren’t being shown “normal” women’s breasts,’ she says. ‘I get so many patients, often younger than 26, who come to me with perfectly lovely breasts, but they are only used to seeing what’s in magazines.’

Hopefully, though, that tide is also turning. Online movements such as #SaggyBoobsMatter, started by writer Chidera Eggerue, celebrate normal, larger breasts — bra or no bra. Victoria Beckham says we shouldn’t ‘mess with[our] boobs; celebrate what you’ve got’. And, in typical Chrissy Teigen fashion, the model and author added to her post: ‘I’ll still have boobs, they II just be pure fat. Which is all a tit is in the first place. A dumb, miraculous bag of fat.’ And she’s got a point…

THE BEST NEW THINGS IN BREASTS

Mesh

A fairly recent innovation, the use of a biodegradable mesh is helpful in lifts and reductions. it ‘trains’ the breast to stay in place while healing, then dissolves into your own collagen.

‘Virtual reality’ consultation

State-of-the-art software allows you to take three photos of your breasts before showing you what various implants will look like using A1. ‘What you see is really what you get,’ says Levine.

Lighter implants

The latest generation of lightweight implants— called B-Lite — are 30% lighter than standard silicone, meaning the drop, over time, will be slowed down.

Skin tightening

Although there’s not a like-for-like non-invasive option to replace surgery, radio- frequency skin tightening can perk things up, helping to counteract drooping by making the chest more taut. New high-intensity ultrasound system ULTRAcel Q + has been seen to tighten skin on the décolletage enough to cause a lifting effect on smaller breasts.

By: Emily Strohm

Plastic surgeon Dr. Steven M. Levine tells PEOPLE why his phone has been ringing off the hook

Since the world entered a lockdown, nearly every aspect of life has been put on hold, but one industry that’s seen a surprising uptick in demand? Plastic surgery.

PEOPLE spoke with Dr. Steven M. Levine, a New York City-based plastic surgeon whose subtle improvements grace some of the most famous faces and figures in the world — his patient list includes A-list actors, supermodels and more.

While the highly sought-after doc is naturally tight-lipped about his client list, he spoke to us about the reason behind a surge in plastic surgery requests in the age of coronavirus (COVID-19), why he’s turning away his high-profile clients right now, and when he thinks he can get back to business.

“Since our office closed in early March, we expected a decrease in phone volume,” says Levine whose price for a breast augmentation is $15,000, while face procedures can run $45,000 and up. But instead, Levine only saw a boost in his already booming business.”We had to hire new staff just to keep up with the number of calls.”

How quickly into lockdown did the requests for Botox and plastic surgery begin?

Dr. Levine: Requests actually began about five days before the formal barring of elective surgery. I stopped operating prior to the governor’s order in step alongside many of my colleagues in N.Y.C. who felt that something was coming and until we had a better handle on the situation, we shouldn’t be doing cosmetic surgery. Once we started telling people “No” and canceling already scheduled procedures, people were understandably bothered. People who choose to have plastic surgery usually plan for it several weeks or months in advance, so [having their appointments] canceled or rescheduled was anxiety-provoking for them. As the quarantine continued, requests continued for procedures. Patients started to realize that most of their social commitments would be postponed and the upside was an unprecedented amount of recovery time. At the very beginning of this, no one knew how bad this would get, so a number of patients felt like we were over-reacting. That said, in general, most were very understanding.

What was the wildest reaction you received?

Dr. Levine: Initially, I think people threw out bribes in a playful, almost joking idea. And then depending on our reaction would follow it with a statement demonstrating their seriousness. Like, “I know you said Dr. Levine isn’t able to perform surgery now, but what if I paid him double?” My patient coordinator would laugh it off, and then she would hear, “Seriously, though would he?” Someone offered me a month in their home in the Hamptons recently (in addition to payment), if I performed a procedure for them during lockdown. The answer is just no. I may be focused on beauty, but I’m still a doctor.

What was your typical day at your practice like pre-pandemic?

Dr. Levine: I have a very boutique practice which means if someone makes a request, we try to honor it. I have flown overseas for a 20-minute consultation. But the for most part, I am lucky to be in my office in the Upper East Side that is home to my private operating room and recovery facilities. Most days, I start surgery by 7 a.m. and do one to three surgeries depending on the procedure. After surgery, I start seeing patients. This is a mix of post-op visits and new patient consults.

What’s your working from home situation look like?

Dr. Levine: Video consultations have always been a part of my practice, but maybe I would have one or two a month. Now, everything is virtual. To use the phrase of the day, it’s the “new normal.” At first, I found it very confining, but I’ve learned to embrace it. ftn fascinated that since my practice has been closed, I’m putting in long hours, despite not operating. I have no idea where the time goes. For someone who is used to having a real product to show for their work, this has been extremely frustrating. I’m a results-driven kind of person. And now I just talk all day. I can’t wait to be back in the operating room. Until that day comes, I spend my time in front of a computer connecting with old and new patients over video chat. It’s not the same, but we make it work.

How busy do you expect to be when you’re back up and running?

Dr. Levine: We have been eagerly awaiting the governor’s 0K to resume our practices. We expected he would allow us to operate again in mid-May so we booked surgeries every day, including weekends. When that didn’t happen we moved everyone’s surgery. We were sure he would allow us to operate by June 1, then that didn’t happen either. Elective surgery isn’t a switch you can just turn on. We need time to plan. The patients need time to plan, the staff needs time to plan. so we canceled Cases again and have everyone rescheduled for later in June. Usually, we operate three to four days per week, but we have surgery scheduled six days per week for when we reopen. We hope that’s on June 8, but we’re awaiting final guidance from the governor and the Department of Health. It’s not just the new patients who are eager to get in the office — there are dozens of people who expected surgery in March, April, and May and they are still waiting. We have a morning and evening shift Of nurses set up for when we return so that we can work expanded days and meet the demand.

What ways will COVID-19 forever impact the practice of plastic surgery?

Dr. Levine: COVID-19 will change the way Our practices run. We are forced to be more efficient with our patient schedules to minimize or completely eliminate use Of the waiting room. But as far as demand goes, the pandemic won’t change things. All of us care about how we look. And now that more of us are faced to stare at ourselves on Our computer screens while on video conference, I expect people who otherwise may not have been interested in surgery to consider a consultation. I tell everyone — if you’re thinking about it, make a consultation. You owe it to yourself. It doesn’t mean you have to have surgery, it’s called a consultation for a reason.

By: Steven Levine as told to Alyssa Shelasky

Dr. Steven Levine is one of New York’s top plastic surgeons. He’s best known for his “natural” face-lifts and breast augmentations. His clients include some of the mostfamous actresses, supermodels, and socialites in the world. Below, he talks to the Cut about the kinds of requests he’s been getting in lockdown.

Though I’m isolated with my wife and kids outside of the city, I’m shockingly busy. I’m only doing virtual consults all day. The demand from wealthy and celebrity clients to get work done — face- lifts, tummy tuck, breast augmentation — while no one is looking, while they have nowhere to be, is extremely high. Sadly, my answer is either no or not just yet.

I was raised by two New York City schoolteachers so I can tell you, even in my own eyes, my profession can be absurd. On some days, it’s caring for wonderful, “regular” people who have entrusted me with something important to them. On other days, it’s this intersection of unlimited money and crazy wish lists. Most days, it’s a little of both.

So I’m used to unimaginable requests even before all of this. Pre-pandemic, I’d get things like someone asking to be the only patient that day — so that they have my complete focus — and they’ll offer to pay double for this, to compensate for the other surgeries that I can’t take. There’s a lot of people saying, “I want your staff to sign nondisclosure agreements.” Some people want me to personally spend the night at their house after surgery to make sure they’re okay. For the most famous celebrities, they want me to come to their homes for all their “post-op” appointments so they never have to be seen in the office. It’s a huge amount of extra time and attention on my end, but I try to accommodate requests when I can. I recently spent 20 extra hours visiting a celebrity at home for her post-op visits. I have an hourly rate, which she knew I would bill her for, and she was happy to pay.

With that said, the volume of calls, and level of intensity, is probably higher during COVID than not COVID. Almost every virtual consult ends with “How quickly can you do this?” They want to take advantage of this perceived downtime. It seems like the perfect time to recover from a procedure like a face-lift, where you need at least two weeks to lay low (whereas for breast augmentation, you only need a few days to rest at home).

I think the requests for face, neck, eyes, and nose are constant at the moment because people are looking at themselves on Zoom all day, analyzing their angles. We all have bad angles. We will all take bad photos. They don’t want to hear that. I don’t judge any of them. When you look good, you feel good.

Extremely successful people are used to getting what they want, when they want it. That is the reality of their life. One very well-known entrepreneur wanted to come to my office on the Upper East Side and get her face done, like, yesterday. She offered me more than four times my usual fee, all cash, and told me she’d have her lawyer draft a nondisclosure that she wouldn’t tell anyone we did it. I told her, “I love you to death, but no.”

Will she go to someone else? Maybe. But people who can afford to make those kinds of demands only work with the best surgeons. No good surgeon would do that right now.

I’ve gotten a lot of this: “I live alone, pose no risk, and need Botox now. I don’t care what you charge me for it.” I say no.

I had a patient last month who offered to send me a plane to her country in the Middle East (I do operate there a few times a year normally) for a face- lift. She guaranteed it would be a completely private plane, all the precautions, etc. That one, I admit, I considered because I wasn’t sure what law I was breaking. I have a medical license in that country and that country didn’t have a ban. It was a tough one. While elective surgeries are now allowed at most hospitals — including New York and certainly where she is from — it ultimately felt wrong to leave my family and go.

A lot of my clients have cornered themselves off in their mansions around the world, and they want to get things done while they’re there. I’ve had people be flirty or playful to convince me to come over with injectables or open up the office for surgery. There’s a lot of, “Hypothetically speaking would you come over and treat me in my house if I let you leave with my car?

I was taught in medical school that you get in the most trouble when you try to do a favor for a patient. You should always be acting above reproach. Like, doctors who call someone’s rhinoplasty a “necessary functional operation” — as a favor, because why not? — and then the patient wants more from you for free, and soon there’s a blackmail letter from their lawyer that you committed insurance fraud. Bottom line: You don’t lie, and you don’t do things that are unethical.

The pent up demand for plastic surgery is off-the-charts crazy-high right
now, and everyone wants to be first in line when I do open. All we can do is
stay in touch with them. Over-the-top exceptions aside, most patients
handle that response with grace. This virus doesn’t care how wealthy you
are. So for the most part, when it comes to staying home until the
government says it’s okay, all our interests are aligned.

By: Jolene Edgar

Seeing an aesthetic procedure all over social media can breed a strange sort of FOMO. (Hey, we’re not immune.) Yet it may be difficult to distinguish for-the-’Gram fads from truly “Worth It” tweaks. Which is why we’re launching a new series on RealSelf: Everybody’s Doing It. Each month, we’ll explore all sides of an of-the-moment cosmetic procedure, to bring you the uncensored truth about its efficacy and safety, so you can decide if it’s right for you. Here, in our first installment, we’re dissecting the buccal fat removal debate.

While I’ve never quite understood society’s gross fascination with pimple-popping content—stomach of steel, that Dr. Sandra Lee—I have found myself recently spellbound by extraction videos of a different variety: buccal fat removal. Anyone who’s witnessed the face-slimming surgery—that moment when glistening yellow fat erupts from the inner cheek—can no doubt relate. And I’m guessing that’s more than a few of you, given the sudden prevalence of these videos on social media. “There’s definitely been an uptick in requests for buccal fat removal,” says Beverly Hills, California, facial plastic surgeon Dr. Sarmela Sunder, who fields upwards of 10 inquires a week about the surgery, primarily from women in their 20s and 30s. The procedure’s popularity has soared in response to a collective quest for a specific face shape, she adds—one with cheekbones strong and wide, a tapered chin and a chiseled jaw.

“The whole purpose of the operation is to highlight the bony architecture, giving more definition and angularity to the face,” says New York City plastic surgeon Dr. Alan Matarasso, who was among the first to describe the intraoral buccal fat excision technique in scientific literature. As with contouring makeup, the goal of surgery is to cast a shadow across the mid-cheek hollow, thereby highlighting the cheekbone above and jawline below—only, in this case, to permanent effect. “It simulates the look one has when sucking gently on a straw,” he explains. “When done right, it’s always a subtle change.” 

Dr. Matarasso performs the surgery across demographics, he says—“in teenagers who are also having their noses done [slenderizing the cheek can help bring balance], twentysomethings after the model look, and older patients with very full, round faces.” Even men are getting wise to the perks of the procedure. “Fifty percent of my buccal fat consults are guys,” says Dr. Sagar Patel, a facial plastic surgeon in Beverly Hills, California. “The majority are wanting to look more mature and masculine so [that] people at work will take them seriously.” Imagine that—getting plastic surgery because you want to look older.

The buccal fat removal movement is not without dissenters, however—plastic surgeons who deride the rise of such “fad procedures” and fear the long-term consequences of plucking fat from cherubic twentysomethings. But before we weigh the treatment’s reputed benefits against its potential pitfalls, let’s take a closer look at this particular fat pad.

What is buccal fat, and what happens to it with age? 

When old ladies pinch babies’ cheeks, they’re usually grabbing hold of buccal fat—that pudgy part by the corners of the mouth. But the buccal fat pad isn’t limited to the lower cheek—it extends back toward the jaw and up into the temples, with some segments embedded deeper than others. It’s sandwiched between two masticatory muscles, where it serves as a sort of gliding pad. In infancy, it facilitates suckling; later in life, it assists in chewing. It also shares space with the parotid duct, which funnels saliva into the mouth, and the facial nerve.

“The buccal branches of the facial nerve, in particular, are intimately associated with the buccal fat pad, so it is in a bit of a danger zone in terms of operating,” notes Dr. Steven Levine, a plastic surgeon in New York City. (Tweaking those nerves could affect your smile and the ability to puff out or suck in your cheeks. “But such injuries are rare, and when they do occur, they usually resolve on their own within three to four months, if not sooner,” he adds.)

While all facial fat shrinks to some extent over time, “the buccal fat, in my experience, tends to maintain relatively well throughout life,” says Dr. Levine, who commonly finds a fair amount even in his 70-year-old facelift patients.

And here’s where things get controversial. The persistence of buccal fat—how much it degrades, how swiftly and how its absence may influence your future face—is a point of debate among experts. According to Dr. Matarasso, “the volume of the buccal fat pad is fairly consistent among all adults, regardless of gender, age and body type, and it doesn’t change much over time.” Several published reports support his position (here and here). One study involving the dissections of six cadavers—all older than 60—found buccal fat pads of “normal weight and volume” even in emaciated specimens.

Dallas plastic surgeon Dr. Rod Rohrich, who has written extensively about the fat compartments of the face, insists that buccal fat does, indeed, diminish with age and that “in most cases, you should not remove it—except in the person with a really full face—because doing so can cause premature aging and midface distortion in the long term.” In his estimation, buccal fat ages faster in men and in folks with genetically thin faces. 

While there are many deep and superficial fat compartments contributing to youthful plumpness, “it’s the malar fat pads, or apples of the cheeks, that are the most pleasing and important,” contends Dr. Lara Devgan, a plastic surgeon in New York City and RealSelf’s chief medical editor. As they flatten and fall, many choose to restore them with filler injections or fat grafting. On the contrary, she notes, “it would be rare and exceptional to want added fullness in the buccal sulcus [cheek hollow].”

A 2018 retrospective analysis of buccal fat removal data entitled Buccal Fat Pad Excision: Proceed with Caution makes the point that “buccal fat pad growth is dynamic and drastically increases between the ages of 10–20 … to then decrease over the following 30 years.” The authors also repeatedly acknowledge the lack of “published data regarding the long-term patient follow-up and complications of this procedure”—which makes it impossible to predict how such fat-subtracted faces will fare in the future. 

This fact has some surgeons concerned: “If you’re talking about doing this surgery on a 25-year-old looking for that whistle look—I’d advise against that in almost all cases,” says Dr. Levine, who worries about the predictability of the outcome, both now and later. “When you’re taking out buccal fat, it can be hard to judge exactly how much to remove to create enough of a difference without making someone too gaunt.” Regarding the few young patients he’s made exceptions for over the years, he says: “If you were to ask me if I’m worried about [how] those patients [will look] in 20 years… yeah, I guess I am.”

So where does that leave us? Dr. Sunder offers this indisputable takeaway: “There’s definite clinical evidence that the face, on the whole, does become more gaunt over time. To what degree depends on the individual and their ethnicity. But regardless, if you’re removing any fat from the face—whether it’s fat that’s thought to atrophy with age or not—then you’re adding to that phenomenon of facial thinning.” 

Related: The Surprising Reason I Tried Cheek Fillers for the First Time

Is buccal fat removal right for you?

If your lower-cheek fullness (aka chipmunk cheeks) bugs you enough to land you in a surgeon’s office, then buccal extraction is certainly worth discussing. Be aware though, it is feasible for a face to be too plump for this procedure: “In about 10% of cases, I have to tell someone their face is too full—usually they’re significantly overweight—and that buccal fat removal is unlikely to show results,” says Dr. Patel. “That’s a pro and a con of this surgery—it gives only a subtle change in almost everyone.”

Doctors will also turn you away if they determine your fullness to be caused by something other than buccal fat. “One of the most common things people mistake for buccal fat is masseter hypertrophy,” says Philadelphia facial plastic surgeon Dr. Jason Bloom, referring to bulky jaw muscles that can result from teeth clenching and grinding. “Those big masseter muscles are further back on the face and can be slimmed down with neuromodulator injections,” he explains. “If someone has both problems, I can Botox the back and take out the buccal fat up front, to sculpt the lower face more completely.” But rashly removing the fat alone could accentuate the heft of the jaw, so make sure your surgeon accurately pinpoints the true source of your discontent.

Age is perhaps the biggest—and most contentious—of disqualifying factors. Certain doctors will hesitate to remove buccal fat on patients in their 20s, or even early 30s, who haven’t naturally leaned out yet. Referring to the aforementioned study showing that buccal fat continues to grow throughout the teens and 20s, Dr. Sunder says, “If we remove it during this period, when it’s expanding, you could look doubly hollowed-out in your 30s or 40s.”

When consulting with young people, she’ll ask to see photos of family members they resemble. If said relatives are gaunt at 40, 50 or 60, she’ll caution patients about removing fat at such an early stage. If they decide to move ahead, she explains, “I’ll take a more conservative approach than I would with someone who’s already reached the potential of her leaning out.” But if they’re obviously chasing a more dramatic effect than the procedure can procure, she’ll refuse to operate, knowing “they’ll likely be displeased with the subtlety of the immediate result—and then they may be unhappy with the long-term outcome, because even a conservative approach can lead to significant hollowing down the line.” 

Still, plenty of doctors will acquiesce when it’s clear that someone understands and accepts their uncertain fate. “Patients will say, ‘I don’t care—this is for my career. I need to look my best right now, and if I’m gaunt in the future, I’ll worry about it then,’” says Beverly Hills, California, plastic surgeon Dr. Sheila Nazarian.

And should they later regret that decision? “A little bit of [collagen-building] Sculptra can usually take care of the problem,” says Dr. Nazarian, who also finds that “fat transfer back into the buccal fat pad works really well.” Other surgeons argue that correcting buccal hollowing can actually be quite challenging. “I have patients come in, saying, ‘I had my cheek fat removed years ago, and now I look hollow,’ so we’ll do filler or fat grafting to replace it,” says Dr. Sunder. But because this is a highly dynamic zone and “pretty much the only area of the face where there’s no firm foundation or bone, one can look really done and obvious, if treated poorly.” 

Of course, in 15 or 20 years, when buccal-depleted millennials and Gen-Zers are mourning their lost fat, volume-replacement techniques will surely have evolved exponentially. “It’s going to be a totally different game,” says Dr. Patel, “so I really don’t think [long-term hollowing] is an issue.”

What to expect during buccal fat removal surgery and after

Buccal fat extraction is, by all accounts, relatively quick and low-risk in the hands of an experienced board-certified plastic surgeon or facial plastic surgeon. That being said, “if you don’t know what you’re doing, you could be mucking around in a rough area,” notes Dr. Levine. Bleeding and infection are possible complications; nerve injury, as mentioned, is rare and usually temporary. 

The procedure can be done in your surgeon’s office or operating room (OR), under all manner of anesthesia, depending on doctor and patient preferences. Some find numbing shots to be sufficient; others combine local with oral or IV sedation; and in the OR, many use general anesthesia.

Once you’re anesthetized, your surgeon will mark a one- to two-centimeter incision line on the inside of your cheek and use a scalpel to slice through the superficial tissue. “The muscle underlying it, I don’t cut, because that can cause too much bleeding,” says Dr. Bloom. Instead, he uses a blunt instrument to vertically dissect through the muscle fibers until he’s met by buccal fat. At this point, your surgeon may have an assistant press on the outside of your cheek while he slowly teases free the fat from inside. “I only take what your body gives me,” says Dr. Patel. “If I tug gently and nothing more comes out, that’s it—I don’t go digging for more.” (Doing so can cause scarring and nerve damage.) Doctors commonly compare the size of the extracted fat wad to that of a walnut or large grape. One or two dissolvable stitches is generally all that’s needed to close the wounds.

The procedure takes 15 to 30 minutes, causing soreness and swelling akin to that of wisdom-tooth extraction. Occasional icing and sleeping with your head elevated should help minimize side effects. Your doctor may limit you to soft foods for the first few days and advise against exercising for up to a week. You’ll have to swish with a prescription mouthwash after meals, to keep your incisions clean. 

“It usually takes about two weeks for the majority of the swelling to go down,” says Dr. Nazarian, at which point, your results should gradually start to show. But doctors say it’s highly variable, with some people not noticing complete payoff until three or six months post-op. “There’s a little bit of a shrink-wrap effect at work—you have this empty space after surgery, and it takes a while for the tissues to come back together,” Dr. Sunder explains. “I’ve had patients who are thrilled at three months and then come back at six months, looking even better.”

Buccal-plus: other procedures commonly done with buccal fat removal

While buccal fat removal can certainly be a solo act, in some instances, accompanying procedures can make for a more harmonious outcome. “I don’t think I’ve ever taken out buccal fat as an isolated surgery in young patients—it’s usually done with neck liposuction and/or a chin implant for an overall slimming effect,” Dr. Levine says. In Dr. Matarasso’s office, nose jobs and neck lipo are popular complements to buccal removal, since they work together to “enhance the contour of the face,” he says.

In about half of Dr. Patel’s female buccal patients, he’ll recycle the culled fat once it’s been properly sterilized and filtered. “I usually remove about 4 cc from each side, and I’ll reinject it to give people higher cheekbones, for a more impressive result that lasts,” he says. Likewise, doctors routinely add temporary hyaluronic acid fillers to the tops of the cheeks following buccal extraction, to give the whole of the cheekbones more pop.

In older patients whose skin lacks spring, removing fat in isolation can lead to lower-face sagging. Facelifts and minimally invasive tightening procedures, like FaceTite, can help pick up the slack. Liposuction of the neck and jawline is another sometimes necessary supporting procedure. Without it, an aging jowl may suddenly steal the show: “It’s a compare/contrast issue,” says Dr. Sunder. “The jowl may appear to protrude more, once the area above it thins out.”

Related: Off-Label Is the New Black: The Weird New Ways Doctors Are Using Filler

One final note

For those of you wondering, as I was, if fat-dissolving Kybella might be a worthy competitor to buccal surgery: Nope. Doctors don’t recommend using the injectable in this nerve-rich region. As Dr. Nazarian explains, “Our nerves are all surrounded by a [protective sheath of] fat called myelin. And Kybella doesn’t differentiate between fat we don’t like and the myelin around our nerves. So if we hit a nerve, your smile might be off for six weeks or so, until the myelin regenerates.” Plus Kybella has become synonymous with major swelling and repeat treatments. With buccal surgery, patients swell just the once, she adds, “and then they’re happy and move on with their lives.”

Dr. Levine gives us some insight into cosmetic surgery, misconceptions of the industry and what he hopes for the future.

New York City based plastic surgeon, Dr. Steven Levine, sat down with V to discuss his practice. He is one of the most accredited and accomplished plastic surgeons in the city and has worked with some of the world’s top models and actresses, making his main goal to increase the self-esteem of his patients.  Read below to get his professional opinion and insight into the world of cosmetic surgery.

I know so little about what you do in general. I’m curious about what makes you different than your peers. Like, what makes someone go to one doctor as opposed to another?

Dr. Levine: Absolutely. The biggest difference between surgeons, without a doubt, is not technical ability. I would like to think that my hands are better than the next guys or girls, and I don’t know, maybe they are, maybe they’re not. Certainly if you ask my mother, she would say they are. But I think the biggest difference between surgeons is aesthetic judgement – [meaning] knowing how much to lift, what direction to lift in, how much skin to remove. The cutting and sewing – the technical part – is not the challenging part. What [patients] pay for is aesthetic judgement. The most common things people do in the aesthetic world deal with some of these minimally invasive things like neuromodulator’s like Botox, Xeomin, Eysport and fillers. [Patients are] not here for the product, [they are] here for the person using the product. I think there are, like the rest of healthcare in the United States,  2 tiers of this. You can think of what I do as a commodity, or think of surgery or injectables as commodities, and if that’s the case [you would choose the] least expensive price, that makes total sense. But, it is not necessarily true for aesthetic procedures. To me, it is reasonable that some people think this that “I get my Botox wherever is cheapest.” That’s fine. I have no knock against that. I don’t think they are doing themselves a disservice. They may even be getting a great deal that way [and] may have found this great provider who is really inexpensive. That’s a win! In general, what you are paying more for is the judgement and expertise of who is doing it. Listen, do your due diligence. What you shouldn’t do is think [that] just because someone is licensed to hold a needle or syringe, or just because someone is licensed to hold a scalpel, that they are as good as anybody else. There is a bell curve in everything. You either – depending on the procedure you are having done, maybe you are having a mole removed from your leg – maybe you don’t give a crap [and] go to the person who takes your insurance or is cheap. I get that, I totally get that because who cares. But maybe if it’s on your cheek, you think differently.

Yeah. What do most people come to you for?

Dr. Levine: Two-thirds of my practice is face. That means typically face lifts [and] eye surgery. By the way, when I say face lifts, it always means face and neck. They go together. The truth is, some of the best looking people on this planet have figured out that the funniest people have gotten too much Botox and filler… way too much. It’s common to say, like, “look at her, I wonder who does her filler. I wonder who did her surgery, it looks terrible!” But honestly, the patient probably never had surgery, the patient has just had a shit ton of filler that is completely gone. We are doctors so there should be a diagnosis and treatment. You don’t walk into your doctor’s office and the doctor looks at you and just goes “yeah, you could use some antibiotics today” or even “you don’t feel well, we’ll give you some antibiotics.” Like, no. You’ve got to be diagnosed with a bacterial infection and then you get antibiotics. Filler is a great tool, just like chemotherapy and just like antibiotics. What’s it a tool for? The symptom it treats is volume loss. It’s filler, it fills. So if I look at you and we are talking about your aging pattern and we say, well, listen, you’ve lost volume here, here and here, then I have no problem, filler is great. In general, for people who are coming here for aging concerns [and] if you haven’t lost volume, then filler is not a good tool. Most of the time, people mistake laxity, looseness of tissue, and descent of tissue for volume loss. And really, what they need is that tissue brought back up. I open everything up and I’m looking at it and I say “I’m not Michelangelo. If you don’t like the way you looked 10 years ago then you’re not gonna like the way you look after you get the surgery. I’m not beautifying you I am literally just putting things back where they were. If you are vacuuming your house and you move your coffee table away, you know where the coffee table needs to go back every time because you can see the little disks on the floor where the coffee table was. I think the same is true when I do face surgery. When I lift everything up and I’m looking at the deeper structures I think it is very obvious where they used to be. I literally pick them up and then sew it in place and that’s it. It doesn’t really feel like surgery. It feels like, oh I’m just doing some chores and I’m just like oh, this clearly used to be here, this used to be here, this used to be here, and when I’m done I’m not even thinking about it. It’s just putting things back. So, the reason I would care to educate an 18 to 34 year old about that is I’m not trying to sell them a face lift, that’s not my goal, although you would be surprised how young I do this surgery. I mean, I can certainly do this surgery for late 30’s for …

Well, I was going to ask, do you feel like your clientele, in general, for these things is getting younger and younger? I’m 28 now [and] I don’t think people in their 20’s were getting a ton of fillers. I think the Kardashian effect  has made it so normal so, are you seeing that?

Dr. Levine: Absolutely. However, what I’m sort of focusing on is more on the surgical side. I’m seeing it as a backlash to the Kardashian effect. Meaning, I’m seeing younger people coming for surgery whereas their mother and grandmothers may have done it at 50 [and] they are coming in and doing it at 40 because they don’t want to turn out looking like –

 …Because they don’t want to eventually have to get fillers, or think that they want fillers.

 Dr. Levine: Right, or they had fillers once or twice and they’re like “every time I go to the dermatologist, they tell me I need more filler, and I feel like I am going to look like one of those freaky duck ladies, and I don’t want to do that.” So, I’d rather just do this. Whereas, what you here a few years ago was, “Oh my god, I’m not getting surgery. I never want surgery, I’ll just get some filler..” Here’s my thoughts on that sentence. I don’t want surgery, perfectly valid. There are so many good reasons to not want surgery, great. Don’t get surgery. I’ll be fine.  I am plenty busy. I don’t need every person to get surgery. But, don’t say I don’t want surgery so [instead] I’ll get fillers. Just don’t have surgery. It’s all good, nobody is forcing you. Don’t think that somehow adding more and more volume is a way around getting surgery. Just recognize, at a certain point, volume loss may be there [and] it’s good to replace that volume with a little filler. But, when you go beyond the natural dimensions, you’re lost.  So, you started asking what I do. So, ⅔ of what I do is face and eyes. Here is a young girl. She’s sort of well known and is 46-47, something like that. Very pretty model. See how her upper eyelids are getting close to her lash line? So, this is her 2 days after surgery. Her eyes are more open. Right, you can just see the whole lid. It’s not a whole-sale change, right.

It’s subtle.

Dr. Levine: And that’s the point. You can’t do that without surgery. I think getting people to realize that most of the funny looking disasters they see on the street are from too much filler and too much Botox, will help them realize. Well done surgery, and by the way there are fewer people, surgeons, doing good surgery now, and that’s sort of a positive. There are probably 3 or 4 guys in the city that do the majority of facework. There are more guys doing breast and body and that’s about ⅓ of my practice. I do a fair amount stillof breast augmentation and breast lifts, liposuction, and I actually love doing that stuff but most of my stuff is face, eyes, neck, nose. It is a heavily concentrated procedure. It’s an] 80/20 rule. 80% of facelifts are done by 20% of the surgeons. So, that’s the answer for most of what I do is invasive – surgical. . But I’m not anti-filler, I’m just anti too much filler. In fact, I think– I do very few brow lifts in my practice, right. I don’t do this operation because I think it looks weird most of the time. Whereas, I think Botox or neuromodulator, if we want to be brand agnostic, [is a] great way to kind of give somebody a one or 2 millimeter brightening, opening of the brows. So, I am fully willing to admit that I think that is a better solution than surgery for certain things. I can surgically enhance your lips by putting a little bit of fascia in there or some fat, but I’m all for filler – a little filler to give you some lip volume, yes, you don’t need to go under the knife for that…that’s a no brainer. But certain things just need surgery. They just do.

Do you have a lot of people who come in and, I’m curious about this because I know somebody who I think had an issue with this, where they got a surgery pretty young, maybe like 21, and I think now they are 28, and they have just had so much work done. I just kind of wonder, when they go to a doctor – I’m almost like pissed at the doctor that they would do something. I look at him and I think, you are clearly someone who has done too much. Essentially, he has body dysmorphia and has no idea and I’m sure you deal with that all the time. Also, maybe knowing that if you say no to someone, they are probably going to go to someone else who says yes, like it’s a really tough...

Dr. Levine: So, everything you said I completely agree with. I am lucky, I don’t operate on anyone I don’t want to, and I tell people no all the time. All my patients come from word of mouth so, I’m lucky. Most people [who] come here want surgery. They didn’t find me on the internet, they come here like “you operated on my friend Jen, and “I love the breasts, that’s what I want.” And I’d say a third and a half [of patients[I say no to. Sometimes I get weird vibes, sometimes I don’t think I can make them happy, sometimes I don’t think they’re ready, um, or it might be it just won’t look good on them. Uh, so the answer is yeah, I think this of that doctor too. I think if you have a friend who has done too much, that doctor should be held accountable. Um, but you brought up a good point, now what are you going to do with this person who is sitting in your chair, and you’re like, I know if I say no, they are going to go somewhere else. So, the things I do are, I say things to them like “I am telling you no which means I am turning down a fee. Right, you are offering me money and I am saying no. Please understand that that means that I think this is a bad idea for you.  There is a 100% chance that you can find someone else to do this. I know that. I am telling you for free, –donate your money to charity, save it do something else with it – this is not a good idea, please stop. So, I’ll say something like that  We are talking like honest people here, this is how I make my living and you are begging me for surgery and I am saying no so that’s got to ring true to you. I’d be lying if I said that there haven’t been times where I have done sort of placation things for people. Someone I really like or someone I have known for a long time, and who I think is someone who sort of just wants something. I’m afraid that someone else is going to do too much…I think they basically don’t need anything but I know if I do nothing that they’ll end up hurting themselves so I’ll do something minor. That may not be the thing I am most proud of, but that exists, these sort of placation operations. Again, I don’t think that’s the greatest thing to be advertising, but if I’m being totally honest…it’s [a] rare [thing for me to do.] One or two times a year  I’ll do something that is like – by the way, take it on the low level. The person who is dying for more filler, and they already have [a lot in] and you put in a tiny little squirt, it’s not going to hurt them. I’m not doing that for the money, you’re doing it [because] they’re not leaving here without it and you don’t want…

Well, I dont think that anyone would buy it if someone said they never ever do that. Somebody that’s honest, but it’s like of course. If you told me never ever…

Dr. Levine: Right, I almost feel bad. It’s not the fee. I literally just don’t want you getting screwed up.

Is that something you do a lot though, where someone is coming in and saying “I’m so this, I’m so that” and you’re like no.

Dr. Levine: No I’m really lucky. I have a really awesome patient population. It is rare I get the crazies. People ask this all the time, like, “Park avenue plastic surgeon”… You know, most of my ladies who lunch thing [is] over. The only thing stopping [my patients] from getting surgery –because they almost always want it – t is how long is this going to take to recover. “When can I get back to work?” “When can I get back to…?” Maybe they don’t have a job, maybe they do charity work. They want to know when they can get back to the gym, when they can get back to work, when they can get back to their lives. They don’t have 6 weeks. They want to know *snaps*.  I take care of a lot of women who need to be back at work in a week…they aren’t hiding it at this point. Go back! They are a little bruised, a little swollen still and if someone asks they are like, yeah, my neck was bothering me and I had to get it done before I turn into my mom. Done! That’s it. Those are the best patients. It’s so much nicer when you can own something that you’re doing. You know, I think something the press could probably do to help people in general would be the reaction that people have when you tell them that you are doing cosmetic surgery or even Botox, fillers, or something small. Most of the time, think about it in your own life, you’re a young guy, you’re friends like “I’m thinking about getting a filler.” You say to her, “you know, but your lips are beautiful!” Imagine if you said, “that’s so exciting!” “Who are you going to go see?” Or “That’s so exciting, what made you want to do that?” Imagine if she told you that she was taking this incredible vacation.  Typically, the response is “you look incredible, you look so much younger, what do you need that for?” They obviously…its something that bothers them and they are trying to open up to you and they are not–you think that you’re giving them a compliment, you’re not. There is some sort of jealousy, maybe, of like you don’t want them to do it because you’re missing out or maybe you genuinely don’t think they should. But I think a nice thing for people in general would be to react to people’s desire to have an aesthetic procedure with like, uh, this, “wow! This is so exciting! Tell me about it.”

Yeah. For someone like myself who knows nothing about the world [of cosmetics], what would you say are the most common misconceptions you get?

Dr. Levine: Well, I think one misconception goes back to the original question of what makes one different from the other. It’s the misconception that it’s a commodity. You know, that it’s a Chinese menu of things. Like ah, I maybe want a breast lift, I want a face lift. That’s a doctor, she must be good at it! It’s just not true. I think this is something that truly blends art and science and the fact that you are a doctor and you went to medical school  means that you probably have the science down. But the art, who knows. Plastic surgery is a wide field and there are people with various amounts of certain talent and artistry and I think that it is really important to make sure that you check them out in some way.

What’s the best way to check someone out? Just by looking at their work online? Like, how do you…

Dr. Levine: No. For me, I don’t even put my work online. I mean, I literally won’t do it. The reason I don’t put it online [is] because I want people to understand that there is a privacy here and by the way, it’s so easy to see before and after. Just come and I’ll show them to you. I’m not trying to get your 300 bucks. That’s not the goal. I’m about to show you the most sacred thing I have in my professional life. Right, it’s the reason I don’t post pictures of my kids either and that’s the most sacred thing I have in my personal life. That’s mine. My before and after’s are the most sacred thing I have and my patients who have given me permission to share with other patients understand that they are giving permission to do so here, inside the office. And by–I’m sure I could ask them. My patients are awesome. I think you’ve got to make the effort at least to come in.  If someone is being referred to by another doctor, that’s another good way to know who is good. Then from another patient. Right, especially from a patient who either knows someone who’s had the procedure, has had the procedure themselves, hairdressers, makeup artists. Those are some of my best referral sources, believe it or not.   

So, it is most word of mouth then. 

Dr. Levine: Yeah, yeah. That’s all word of mouth.  It’s kind of impossible to find me on the internet. I mean, if you search for my name, you’ll find me. But,  if you type in “who do I go to for a face lift in New York City”, I don’t think you’ll find me. I know who you’ll find if you do that but I bet it’s not one of the 2 or three busiest guys in the city. You just don’t tend to do that.   The industry determines the closure rate. Right, it’s sort of a dirty thing to talk about, but it’s like what percentage of people sit in this chair and then have surgery. My percentage is very, very, very high and, I think by industry standard it would be 40-50%  and mine is double that or close to it I’d say. And, that doesn’t mean I’m great. That isn’t the point, it’s just a different demo. If I advertise more, I’d probably be busier and my closure rate would go down. All that means is that I don’t have a lot of shoppers. All it means is that “you did my friend Jannis’s so and so, and I want that.” Literally we like, talk about our kids and our families, we get to know each other for a minute, and then, like, I walk out and Courtney comes in and gives them the fees, and they figure out the dates, and that’s the end of it. That’s lovely because there is nothing worse than feeling like a shoes salesman as a doctor.  I’m not going to analyze you and tell you what I think. I just don’t have the stomach for that. If you leave this office feeling worse about yourself than you did when you walked in  then I have done myself a disservice. I have done you a disservice, I have done my practice [a disservice].I want you to leave here feeling awesome. I don’t care if you decide not to have surgery. I’d rather you leave here saying like, “that guy was awesome. He told me I didn’t need anything.” I’m happy to give them more surgery to do if I think it’s good for them but, my fear is somehow that I now give them a complex. I really try to make people feel good about themselves.  I did a facelift [for a patient] 2 years ago and she told me [that] this is the prettiest she has felt in her entire life. I gave her a hug and I said, “that’s so awesome”. You know, it’s not the famous person who I see on TV, and yeah, that’s kinda cool. That’s like a feather to the cap. But this is like, she’s happy every day. I have moved offices recently. I am building a new office that should be ready in September, and I’m renting here for the year and-and my wife is helping me move. My bottom right desk drawer had all these letter from patients. and she opened them up and she’s like, what is this? She sees a few hundred letters from patients that are not like one liners. Like, three page letters from people talking about how they never felt pretty before, they look in the mirror and they feel happy every day, and these incredible things. . I’m just saying, it turns out that making people feel good about themselves is really, really important. It’s not shallow. It’s not some silly exercising fad. When you look good, you feel good. 

You really have covered everything.

Dr. Levine: My goal, in becoming more forward facing, is I want to be seen as someone who is approachable and easy to talk to and I do think­–I happen to think I am very good at what I do. But, I think that there are a lot of myths out there. One of the things you asked on your sheet, remember you asked about do you think Botox is preventive and is that what most people are doing it for? The fact is, Botox weakens muscle. So sure, technically, my scientific answer is that if I put a bunch of Botox in your forehead then you won’t wrinkle as much, so you won’t get the wrinkles. So, there is some truth to that. It’s a little disheartening to me. That is, I don’t want young people worried about wrinkles.  But it’s nice to know that it’s sort of the whole feel. But, I want people to understand – here, how’s this for a public service announcement, and I like this as an idea. I think people should have plastic surgeons the same as they have OBGYN’s and internists. Like, I think you should have a plastic surgeon in your life who is your touchstone for cosmetic things. You are going to read stupid magazines and you are going to read about this new facial energy-based ultra facial – whatever, and  you see these celebrities are doing it. You want to have someone in your life that you can go to and be like “what’s the deal with this.” Don’t get your [medical]  information from a magazine. Go talk to your plastic surgeon. I don’t think you need to get plastic surgery, I think you should think of your plastic surgeon as, like, someone you hire. In my world, I charge people a consult fee because I don’t want just anyone walking in. So, I make you pay a consult fee but I would only make you pay it once. So once you are my patient you can come in as many times as you want, and I’ll talk to you, I’ll sit with you, and I’ll make sure you are well educated. I run my consultations as if you are going to someone else. I talk to you like I am trying to educate you and if you end up choosing me, great. If you [end up] choosing someone else, I stand by everything I say. [What] I say, I promise it’s true, whether you come to me or go to someone else.  I just want people to know more.

Yeah. Well, hopefully this helps. I really appreciate it.

By: Beth Sternbaum

TO FILL OR NOT TO FILL?

One of the most common procedures is also the most complicated. Tatiana Boncompaqni weighs /the pros and cons of plumping your pout.

“WHO DID YOUR LIPS?” is not a compliment. Because If someone can tell you’ve plumped your that’s a sure sign it wasn’t done well “If lips aren’t Injected perfectly, it’s obvious,” says Marina Peredo, M_D., a New York dermatologist. Nevertheless, it’s a risk that more women are willing to take, especially since the procedure is temporary (hyaluronic acid injections last between SIX months and a year, at about per treatment). Thinking about going bigger? Here’s what you need to know

WHY PEOPLE FILL “As we age, lips naturally lose volume,” says Oren Tepper, M.D., a plastic surgeon and director of aesthetic surgery at Montefiore Health System in New York. If that’s a concern, the time to schedule a doctor’s appointment is “when you’ve essentially lost the definition between your lip and the skin above or below it,” says Steven Levine, M.D., a plastic surgeon in New York. In these situations, fillers are most doctors’ go-to as they can quickly restore lips to their original size and shape. As for which filler to choose, there’s a plethora of FDA-approved hyaluronic acids that can provide either structural support (like Juvéderm Ultra XC) or a subtle hydrated effect,“like you have lip gloss on” (such as Restylane Silk), says Peredo. Discuss which one is right for you with your doctor, based on your ultimate lip goals. The beauty of hyaluronic acid? It’s biocompatible, dissolves over the course of a year, and has been shown to stimulate the production of your own natural collagen. Also, it’s easily erased with hyaluronidase, an enzyme that quickly degrades filler if things go awry. To keep that from happening and achieve the most believable outcome, Peredo has patients book two or three appointments over two weeks so that she can build volume gradually and ensure symmetry.

WHY PEOPLE HESITATE Fear of lips looking fake, bruising, and safety concerns are all reasons patients are nervous about getting lip filler, says Tina Alster, a Washington, D.C.,–based dermatologist. To avoid an unnatural look, ask for a consultation to make sure your aesthetic goals are aligned with your doctor’s work (patient beforeand-afters are great for this). You want to see balance: “The upper lip should be one-third and the bottom lip two-thirds of the total size of the mouth,” Peredo says. “Also, your top lip should never project over the bottom.” After the injections, your lips will likely swell by up to 25 percent, so schedule your appointment at least three days before a big event (ideally longer). Bruising is common, even if you stay away from blood thinners (such as ibuprofen and aspirin) and alcohol the week before the treatment. While rare, practitioners can accidentally inject filler into a blood vessel, leading to serious injury, notes Alster. “It’s important that your practitioner understands anatomy so he or she can recognize and treat potential complications,” she says.

A NEW ALTERNATIVE While injections can add volume, they can’t shorten the length between your nose and upper lip, which becomes more drawn with age. For that, there is a more permanent solution. Enter the surgical lip-lift. In this procedure, a surgeon reduces the distance between the nose and top lip by removing a sliver of skin and tissue directly underneath the nose. The 30-minute procedure, which costs $3,000–$4,000, can slightly “flip” the lip upward, so more of the pink part is visible. The results should last for more than 15 years. As you ponder your options, consider this: Research shows that smiling can make you look younger too.

Dr. Steven Levine gives us the boob-job 411.

By: Hannah Baxter

In the world of plastic surgery, breast augmentation—otherwise known as a “boob job”—is consistently the leading procedure year after year. According to an annual report from the American Society of Plastic Surgeons, of the 1,811,740 cosmetic surgeries in 2018, over 17 percent (or 313,735) were breast augmentations. That number increased 4 percent from 2017 to 2018, and a whopping 48 percent from 2000.

Clearly, there is no lack of interest in increasing, refining, and perfecting the shape of one’s breasts (we were surprised by the amount of interest just in our office), but it is important to remember that this surgery, like all surgeries, is not to be taken lightly. Being an informed patient is crucial for safely achieving your desired outcome, in whatever form that takes. To help guide you through the process, from pre- to post-op and everything in between, we spoke with one of New York’s top plastic surgeons, Dr. Steven Levine. Keep reading for everything he had to say about breast augmentation.

BREAST AUGMENTATION BASICS

Whatever you want to call it—boob job, augmentation, mammaplasty, etc.—the procedure involves the careful placement of implants within the patient’s breasts. And while you might assume that most breast augmentations involve a significantly larger implant than the patient’s natural size, Dr. Levine assures us that that is very much the opposite of his aesthetic. “Most people I see want small augmentations.”

Breast implant size is measured in cubic centimeters, or CCs. He explains that the majority of sizes he uses are in the 140 CC to 250 CC range (for context, a 5 CC difference is roughly a teaspoon in volume). The correct size, which is altogether objective, is determined during your initial consultation.

“It’s all about implant selection and implant size,” he says. “I’m sure you’ve seen implants where people have sort of circular-looking breasts. What’s happening there is that the implant is overriding the actual breast tissue and giving you that circular shape. If I put in an implant that is smaller than the base width of the person’s breast, that means that they get to keep their natural breast shape for the most part, and all we’re doing is pushing things forward.” When done well, your breasts will retain their natural teardrop shape after the augmentation, regardless of size.

WHAT TO ASK AT YOUR INITIAL CONSULTATION

The primary focus is to discuss exactly how you want your breasts to look after the procedure, as well as what makes you unhappy about your natural size or shape. And while you may find it helpful to bring in a photo of your favorite celebrity to a haircut, Dr. Levine does not recommend doing so for an augmentation. “Frequently what they see in photos is either photoshopped or somebody is wearing a bra, so it’s not particularly helpful. But most women who come in have fantasized, at least somewhat, about what they’re going to look like after surgery. Whether it’s how you look when you get out of the shower or how you look in a certain type of dress or bathing suit, those are the things that are really helpful to convey.”

To help inform a patient who is considering various implant sizes, many doctors, including Levine, use 3-D imaging to provide a sample “after” image. “It’s a quick 3-D scan—it takes [about] a minute, and you can show someone a catalogue of implants. It’s really helpful to be able to show somebody how they’re going to look without clothes.”

3 DECISIONS TO MAKE PRE-SURGERY

Aside from the implant size, there are three other major decisions to make ahead of your breast augmentation: a silicone versus saline implant, the location of the incision, and placement of the implant above or below the muscle. The patient can weigh in on the type of implant, but the latter two will be primarily determined by your doctor.

1. SILICONE VS. SALINE

Do you want a silicone-filled implant, or a saline-filled implant? Both contain an outer silicone shell, but saline is filled with sterile salt water. Saline implants are inserted into the breast empty and filled once they’re in place. Silicone implants are pre-filled with silicone gel, which closely resembles the feel of human breast tissue and fat.

Says Dr. Levine, “I tell all my patients, silicone is just a better product; it’s a better device, and it feels more natural. They’re better built than they used to be, so in general I put silicone implants in almost everyone.” They also come in three different shapes and textures: smooth round, textured round, and textured anatomical teardrop. Textured implants have recently been linked to a very rare non-small-cell lymphoma, ALCL, which is why many surgeons, including Levine, no longer work with them. Silicone implants are also not FDA-approved for patients under the age of 22.

In terms of additional risks for each type, if a saline implant ruptures, you will know right away because the implant will deflate almost immediately. With silicone, you likely won’t know if they rupture unless you get a mammogram or an MRI. It won’t deflate as quickly, if at all.

2. INCISION LOCATION

There are four possible places for the incision. The two most common are the inframammary fold (the crease beneath the breast) or the periareolar, which is around the height of the areola. The third, which Dr. Levine says is the least common of modern accepted techniques, is the transaxillary—an incision in the armpit. The fourth is a belly-button incision—a procedure called a tuba—which can only be done with a saline implant (because it is empty and filled once in place).

“Ninety-five percent of my augmentations are done with a small, 3 cm incision in the inframammary fold,” says Dr. Levine. “It gives me the best visibility to put the implant in under the breast tissue, and nothing is more important than your surgeon’s visibility. You’re creating a space that didn’t exist, so the better visibility I have, the better results you get. It heals incredibly well, with all types of skin tones. It basically blends into the natural skinline.”

3. OVER OR UNDER THE MUSCLE

The majority of Dr. Levine’s patients have their implants placed below the muscle, especially if they don’t have a lot of breast tissue to begin with. “If you choose the position over the muscle, which is a perfectly acceptable thing to do, your chances of seeing and feeling that implant are very high.” Your percentage of body fat and breast tissue will help inform your doctor of the proper placement for your implants.

BREAST IMPLANT RISKS

As crazy as it may seem, there is a chance that your implant could migrate through the body due to a technical error during surgery. If they do so, it’s often downwards (thanks to gravity). The decision of where to dissect the tissue and create a pocket either above or below the muscle is the single greatest indicator of whether or not this complication will arise. As Dr. Levine explains, it’s not as simple as “making a big pocket and throwing an implant in there. There is finesse to this surgery.”

AFTER THE IMPLANTS ARE IN PLACE

Says Dr. Levine, “Whenever you put a foreign body in someone—this is true for a hip replacement, knee replacement, etc.—the body forms scar tissue around it. That scar tissue is called a capsule.” He explains that, for many people, “capsule” is a dreaded word and something to be avoided, but what you actually need to be wary of is a capsular contracture. This is when the capsule becomes thick and can displace or misform the implant, thereby causing pain and disruption of the normal contoured implant.

Luckily, given 21st-century advances in the procedure, these are now quite rare, although every patient will inevitably still create a thin capsule around their implant (like a shell). If you’re still wary, consider this: If you have a rupture of your implant, it will most likely be contained by the capsule, thereby preventing the silicone or saline from migrating elsewhere in the body.

DAY OF THE PROCEDURE

Dr. Levine works out of a private operating room at his Manhattan practice, which functions similarly to a hospital. After his patients change into a robe, he marks them standing up so he knows where to make the incisions and where the perimeter of the breasts naturally fall. A nurse will take your blood pressure, and you’ll meet with the anesthesiologist to go over your medical history. Once you’re in the OR, you’ll get an IV and be placed under a deep sedation, or general anesthesia, if you prefer. The procedure takes about an hour and a half, and then you’ll wake up in the recovery area.

POST-OP BASICS

“You feel like someone is sitting on your chest, and then it’s usually three to five hours after surgery that 50 percent of my patients tell me that they have almost no discomfort at all. The half that do have discomfort say it’s really rough for about 24 hours. [Instead] of narcotics, I usually tell people to take Valium, because it’s a muscle relaxant, and what you’re not liking is the fact that your muscle feels stretched. And just try not to use your arms.” That means giving yourself plenty of time to rest, so plan your work and social life accordingly. He also advises his patients to avoid the gym for three weeks.

FOLLOW-UP APPOINTMENT

Every surgeon has different after-care protocol, but Dr. Levine requires his patients to return one or two days after their procedure. “I’d have you come in another four times over the next six weeks or so to make sure that the implants are dropping the way I want.” Why so frequently? Because young, healthy women have well-developed pectoral muscles, and when the muscles are engaged, they will push the implant up. “Almost everybody has an implant that rides a little high to begin with. So frequently, I will give you what’s called a breast band—a piece of elastic that you put over top of your breast that applies a bit of counterpressure to your pec muscles.”

RECOVERY TIMELINE

Everything will fully settle in about a year, says Dr. Levine. Three months is typically when the implants have migrated downward to the ideal location—the changes that happen during the remaining time can usually only be detected by a professional, if at all.

NO NEED FOR REPLACEMENTS

The old lore was that breast implants needed to be replaced every 10 years, but Dr. Levine explains that that is no longer true. “There is data that supports up to 30 percent of women get a second surgery within 10 years.” However, there is no additional research into why those women seek out another surgery. Some of them may have had children and just wanted a breast lift or decided they wanted bigger implants. “The health answer to ‘Doc, I’m 50 years old, I had these implants placed when I was 25, do I need to change them?’ I say, ‘Are they bothering you? No? Then you don’t have to change them.’”

AVERAGE COST

Like other cosmetic procedures such as rhinoplasty or liposuction, the cost can vary greatly depending on where you live. For major cities like New York, Miami, and Los Angeles, the price can top $16,000 (although that also includes your initial consultation, pre- and post-op care, as well as follow-up appointments). For breast augmentation, like all cosmetic surgery, price should not be the deciding factor in choosing your physician. Quality of care, similar aesthetics, and safety are all priorities to consider, in addition to cost.

BREAST AUGMENTATION MYTHS

“I think the biggest misconception is that breast augmentation has to look fake, and that’s just not true. I think it can look augmented, if that’s the look that you’re going for, or it can look very natural. The second would be that you really do have a big say [in your augmentation]. The size that you choose is a huge factor in how you look afterwards. So if you don’t get good guidance in helping you choose [your] size, then you’re kind of stuck. It’s your body, and you should do whatever you want with it, but you want to make sure that you have the same aesthetic as whoever is operating on you.”

[Editor’s Note: As ever, we are not doctors or medical know-it-alls. And everybody is different, so make sure to check with a doctor before trying anything new.]