COSMETIC SURGERY TRENDS, NEWS, & INSIGHTS FROM DR. ZUCKERMAN


“What will my scar look like?” This is one of the most common questions Dr. Zuckerman receives from prospective patients before their cosmetic plastic surgery. After surgery, very few patients even mention their scars: they are very happy with the dramatic change in the aspect of their bodies that bothered them. There are several types of factors that affect scar formation, and among them is the skill of your plastic surgeon.

Scarring after surgery is quite different than scarring due to accidental injury. An incision made in a controlled manner and closed properly will heal to thin – in many cases almost imperceptible – line in the majority of patients. The scar will never “go away entirely”, but mature surgical scars are often very difficult to spot! In addition, if you take care of your scar, as demonstrated below, its ultimate appearance can be improved significantly.

Healing and scar maturation are different, but connected, processes. Any time an incision is made, the body heals with a scar. The incision becomes water-tight in 24 hours, and there is an associated inflammatory process that occurs with healing. An incision is “healed” at 2 to 3 weeks after surgery, and only then becomes a scar.

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Scar maturation of a C-section scar: this patient came to Dr. Zuckerman for his customized scar care regimen. Surgical scars such as those due to abdominoplasty (tummy tuck) will mature similarly, but results vary by patient.

Scars are made of collagen fibers – though all skin is as well – and contain varying degrees of organization and thickness of the fibers. Scar maturation is a process that takes a full year or longer to reach completion. Until that time, collagen fibers are actively remodeling. Scars may be pink or purple up to nine months, and that signals active inflammation and active scar remodeling. That’s normal and to be expected.

There are several factors that affect the quality of a surgical scar. Some of them are technical, in that they result from the skill of the surgeon at the time of surgery. Some are factors intrinsic to the patient, including genetics. The third group of factors are due to the patient’s care of the scar after surgery.

Technical Factors (Surgical Skill): As with the surgical result itself, the quality of the scar depends on the skill of the plastic surgeon. The surgeon must put together the skin under minimal tension, matching the edges of the incision precisely (especially the dermis – which is the strength layer of the skin), and use a multilayered closure to distribute tension evenly.

Intrinsic Patient Factors: As noted above, a significant factor in the formation of scar tissue is out of one’s immediate control and depends on intrinsic patient factors such as genetics, ethnicity, skin pigmentation (pigmented skin has a tendency to form a pigmented scar), and the tendency of the patient to form a thick or raised scar. A hypertrophic scar is a scar that is thick or elevated but stays within the confines of the original scar; a true keloid scar grows beyond the boundaries of the original wound or incision. Both of these are relatively rare. Age is not really a factor in scar formation: older people actually tend to form a more favorable scar. Another important factor is skin elasticity, and weight loss patients can often have unfavorable scars.

Patient Scar Care: There are three things Dr. Zuckerman does to help patients influence scar maturation favorably after surgery:

  1. Prevent sun exposure: This is an important factor that patients can control. Protecting the scar from the sun primarily helps to avoid scar pigmentation, or darkening.
  2. Silicone: The patient applies a silicone gel or a sheet topically to the scar. This has been scientifically demonstrated to flatten and smooth the scar.
  3. Scar massage: Massaging the scar regularly helps break up collagen fibers as they are forming. This can improve scar texture and prevent thickening.

These care instructions are the most important for the first three months after surgery, but Dr. Zuckerman has patients protect the scar for about a year using SPF 50+.

Scarring after Breast and Body Cosmetic Surgery: Tummy Tuck, Breast Lift, etc

Abdominoplasty (tummy tuck) and mastopexy (breast lift) patients especially are interested in their ultimate scar appearance given the significant incisions involved in these procedures. Dr. Zuckerman takes extreme care to place incision lines where they are rarely visible: beneath the lines of underwear, in the existing folds or creases of skin, etc. There can be significant differences in where a plastic surgeon will place their scars, especially in the case of abdominoplasty. A well-performed tummy tuck will place the surgical scar as low as possible on the abdomen, so that it is well-hidden under underwear. As always, choose your surgeon carefully!

What can you do for an older scar?

If you have a scar whose appearance you dislike which is older than one year, unfortunately, much of the scar is likely permanent. However, laser resurfacing has been shown to lighten and decrease the thickness of scars in some patients. There is an additional risk factor though for patients of certain skin types for skin around the scar to also lighten.


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In 2011, the FDA identified an association of ALCL (anaplastic large cell lymphoma), a type of non-Hodgkin’s lymphoma and a cancer of the immune system, with breast implants. This cancer is known formally as BIA-ALCL and in the majority of cases, has been found in the scar tissue surrounding breast implants or the fluid nearby. The risk of this cancer is very low at approximately 1:30,000 of breast implant placements, although research is ongoing. It is generally assumed to be associated with only textured implants. (However, recently the FDA stated that there have been known cases in women with smooth breast implants.) There have been cases reported with other types of implants as well including those used in orthopedic knee replacement. Generally speaking, current research suggests that some kind of irritation due to the surface of the implant and possible bacterial contamination are contributing factors.

The FDA recently conducted a review of textured breast implants in March 2019. In May 2019 after performing a thorough review of existing scientific data, the agency concluded that the risk of this cancer involving textured breast implants did not meet the standard to ban them as medical devices. While a few other countries internationally have initiated a ban on textured breast implants, these markets typically use a much larger proportion of textured implants than the United States – up to 80% market share versus the United States at 10%. These countries also allow a kind of textured breast implant not approved for use in the United States. In addition, the FDA has announced further measures to help track cases of the BIA-ALCL and to educate the public on the risks associated. The agency will partner with patient registries, such as PROFILE, to collect accurate BIA-ALCL data on patient outcomes. Manufacturers will also be required to file individual adverse event reports, which will be made available to the public. Previously, these companies were permitted to submit summary reports of such events. The FDA is also taking steps to make other women’s healthcare professionals outside of the plastic surgery community such as gynecologists, dermatologists, and internists aware of this rare cancer and to work with pathologists about testing.
While plastic surgery research in this area is ongoing, Dr. Zuckerman feels that all patients should be fully informed about the risks of BIA-ALCL before undergoing breast augmentation surgery with breast implants. He discusses this issue with all prospective breast augmentation patients but encourages patients to weigh the relative risk of this disease given its rarity.

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1. Undergo treatment from a board-certified physician.

While Botox is the most popular cosmetic injectable treatment by a significant margin with over seven million treatments reported by the American Society of Plastic Surgeons last year, it is a medical treatment that should be performed by a board-certified physician. Surprisingly, in the United States, regulations currently allow non-physicians to perform Botox injections. In theory, non-physician injectors should be supervised by physicians, but the extent of the supervision varies widely: patients may find themselves in an office where there is little to none. Botox is a safe and quick treatment in the right hands, but there are areas of the face – especially around the eyes – where it may be possible to cause complications. Dr. Zuckerman has been asked to treat partial eyelid paralysis and problematic facial expressions due to prior improper Botox injections, but most Botox complications must simply be “waited out” for three to four months when the product wears off.

2. Ideally, a Botox injector should be a plastic surgeon or facial plastic surgeon: a physician with surgical expertise.

Botox injections target specific muscles in the face, and plastic surgeons are the most familiar with the underlying facial anatomy. For example, Dr. Zuckerman uses slightly different injection sites to address crow’s feet versus to perform a Botox non-surgical brow lift around the eyes. These require careful treatment, because injection into the upper eyelid could impact an incorrect muscle and drop the eyelid. Plastic surgeons typically have hundreds or thousands of hours of experience with Botox and other fillers starting during their training. Visit plasticsurgery.org to find a board-certified plastic surgeon.

3. Visit an injector who performs frequent treatments.

Practice does make perfect! (Or at least very good!) As mentioned above, most plastic surgeons have a multitude of hours of experience injecting Botox starting early on in their training. As a result, patients can be confident that a plastic surgeon performing Botox knows the injection techniques and locations to a high level of precision. Ask your Botox injector how many years of experience they have with the product.

4. How much does the injector dilute the product?

Those with less experience or less steady hands often dilute Botox more when reconstituting it, which involves adding saline to the raw product received from the company. The more dilute the product, the more potential exists for the effects to spread further than desired from injection sites. Especially around the eyes, this is undesirable for obvious reasons. Dr. Zuckerman dilutes Botox very little, as do many plastic surgeons.

5. Ask your injector if they are actually giving you Botox.

Several competitor products to Botox have come to market in recent years, and patients should ask their physician which neuromodulator they actually administer. Some physicians use the term “Botox” as a catch-all term that can mean any of BotoxDysport or Xeomin. Patients may have different reactions to different injectable products, and the effects of treatment may vary in duration. Injectors may also be able to acquire Botox competitor products at less cost than actual Botox, which potentially creates an adverse incentive to use other products. In general, Dr. Zuckerman discusses with patients which actual neuromodulator he is going to administer and always starts with actual Botox unless the patient asks for a competing product.

6. How does your injector titrate the number of units for your personal Botox treatment? Do you come back for a follow-up?

Botox is a relatively simple injectable treatment, but its effects do vary across patients depending on age, facial muscle strength and other factors. Dr. Zuckerman feels that it is important for first-time Botox patients to visit his office for a follow-up approximately one week after treatment. At this subsequent appointment, the effects of treatment have set in, and Dr. Zuckerman can evaluate if further Botox injection is required. If you feel that your Botox injector is a “factory” churning out treatments with little time spent on each, Dr. Zuckerman recommends visiting a practice with a more personalized medical treatment approach.

7. Don’t price shop for cheap medical injectable treatments!

As mentioned in the first item, technically speaking one does not have to be a plastic surgeon, or even a board-certified physician, to perform Botox injections in the United States. While that may change in the future, searching for the lowest price option now may put a patient at risk of undergoing treatment from an unqualified provider. Botox is still medical treatment! Groupon is not the answer!

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As a specialist in body cosmetic surgery, one of the most common questions Dr. Zuckerman is asked by prospective patients during consultation is if an abdominoplasty (tummy tuck) is necessary to achieve desired surgical goals or if liposuction alone will suffice. The answer varies by patient, but this is an important question given a resulting abdominoplasty scar is significantly larger than the 2-3 millimeter pokehole incisions left by liposuction.

Tummy Tuck Indication #1: Previous Pregnancy

Although pregnancy affects every woman’s body differently, the majority of patients seeking contouring of their abdominal region after a pregnancy require a tummy tuck. This is for a couple of reasons: 1) liposuction cannot address excess skin or stretch marks whereas abdominoplasty can and 2) pregnancy often leaves diastasis recti, a separation of the abdominal muscles, which is only addressable via tummy tuck. However, pregnancy may also cause the body to redistribute fat to some degree, and even for those lucky moms without excess skin or stretch marks postpartum, they may be left with excess pads of fat in the abdomen. These can be quite stubborn and difficult to address via diet and exercise. For this reason, Dr. Zuckerman combines liposuction with virtually every tummy tuck he performs for patients after a previous pregnancy.

Tummy Tuck Indication #2: Massive Weight Loss

The body’s fat volume decreases upon weight loss, but the skin may not fully contract back to its original contour. Skin has a certain elasticity, and it cannot fully contract when stretched beyond its limit. Dr. Zuckerman’s weight loss patients most often have lost in excess of 100lbs and may undergo a variety of body contouring procedures including abdominoplasty, breast lift surgery (mastopexy)thigh lift surgeryarm lift surgery, and others. For a weight loss abdominoplasty in particular, Dr. Zuckerman removes excess skin surgically before pulling abdominal tissues taut. For those who have lost lesser amounts of weight and may suffer from more minor amounts of excess skin, there are some new medical technologies that use energy from a laser or radio frequency to achieve some skin tightening without full surgical intervention.

Liposuction Indication #1: Targeted Pockets of Fat Alone

Dr. Zuckerman can perform liposuction on many areas of the body as demonstrated on the Liposuction guide page under the “Am I candidate for Liposuction”. Even large volumes of liposuction up to five liters from multiple areas can be performed in a single procedure. However, Dr. Zuckerman examines each prospective patient to ensure that he feels the skin elasticity is sufficient to create a taut, smooth contour after liposuction, because multiple liters of liposuction aspirate means removing significant volume from a targeted area. Patients are not well served by liposuction if their skin then lacks the ability to fully skin contract postoperatively. Dr. Zuckerman has treated patients who underwent prior liposuction procedures with other surgeons and were left with excess skin; those patients would have been better served by undergoing abdominoplasty in the first place.

Contraindication for both Liposuction and Tummy Tuck: BMI Above 30

It is a misconception among patients that both abdominoplasty and (especially) liposuction are weight loss tools. While Dr. Zuckerman can create a dramatic change in contour using either surgical tool, neither actually helps patients lose weight beyond a few pounds of fat or tissue removed. Dr. Zuckerman counsels patients with a BMI well above 30 to lose weight through traditional diet and exercise before undergoing surgery for best results. He is happy to recommend a nutritionist to help with these efforts if requested. Patients who can maintain a stable weight are the best candidates for these procedures as significant weight gain or loss postoperatively can compromise the surgical result.

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Many patients want to minimize their downtime or days taken off from work when undergoing cosmetic surgery with Dr. Zuckerman. For liposuction especially, Dr. Zuckerman has devised methods to minimize downtime and quicken recovery. While this rapid recovery does depend on the extent of liposuction performed and will vary by patient, Dr. Zuckerman can often offer the procedure on a Thursday or even a Friday and have the patient back to work by Monday.


About Us

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Zuckerman Plastic Surgery is the cosmetic surgery practice of board-certified plastic surgeon Dr. Joshua D. Zuckerman, MD, FACS located in New York City. Dr. Zuckerman specializes in tummy tuck surgery, liposuction, buttock augmentation, and cosmetic breast surgery. Zuckerman Plastic Surgery also offers an array of non-surgical treatments including musculoparalytics such as Botox, lip augmentation, tear trough rejuvenation for dark eye circles, laser resurfacing, microneedling, medical grade skincare and more. Zuckerman Plastic Surgery is a d.b.a. name for Joshua D. Zuckerman, MD, FACS, P.C., a Professional Corporation registered in the state of New York (DOS ID #: 5192265)
800A Fifth Avenue Suite 101
New York, NY 10065
Phone: 212-231-9897
Specialty: Plastic Surgery
Joshua D. Zuckerman, MD, FACS, P.C.
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