Plastic Surgery: Advances, Alternatives, Before, After


Dr. Gregg (left) and Dr. Wu. “One of the most important pre-op procedures,” says Dr. Gregg, “is to work with patients to ensure that there are clear expectations about what is possible and what is not. For this purpose, computer imaging is one of our most important surgical tools.”

For plastic surgeons Cynthia Gregg and Cindy Wu of Cynthia Gregg Face and Body Specialists in Cary, the transformational work they do has been affected in countless ways by changing tools and technologies. “However,” observes Dr. Gregg, “beyond the advancements in surgical techniques, it is the growing understanding of and development of the things supporting plastic surgery that is so important. Improved anesthetics, medicines, nutritional supplements, even computer imaging—all contribute to better outcomes and faster recovery.”

Dr. Gregg, for many years one of the area’s preeminent facial plastic surgeons, and Dr. Cindy Wu, who performs body surgery—including breast reduction and augmentation—share their thoughts about the remarkable advances in 21st century plastic surgery.

Managing Expectations

DR. GREGG: There are many pre-op considerations—including diet and medication—that contribute to successful outcomes and quick recovery. However, one of the most important tasks in preparing for plastic surgery is managing expectations. It’s an absolutely critical part of what we do.

First, there’s simply the educational process: getting past the myths presented by Dr. Google and helping patients to know their realistic options. These conversations are so important. I need to know their goals and concerns; they need to understand what’s possible. Sometimes a patient will come in wanting a specific procedure, but when we explore their concerns, we find that the best option might be a non-surgical one. Or there may be anatomical factors that will influence and sometimes limit their options.

One of the wonderful tools we have in our office is the Vectra system. It provides a 3D visualization that allows patients to see their bodies “before” and “after” the surgical changes. This computer imaging is an invaluable tool, especially for my rhinoplasty patients as it can show them pretty accurately how the surgery will alter their face. The process helps me understand what they’re visualizing, and it helps them see what I think looks normal for their face. The goal is to come together and agree that: “We like this and this is realistically achievable.” Then we can move forward.

DR. WU: I absolutely agree, and consider 3D imaging one of my most important surgical tools. This is particularly true for breast augmentation, because patients will often come in wanting to go to a specific breast size. When that happens, I’ll simulate a few different sizes—with her body—and can show her how what she is envisioning would actually appear. Based on these simulations, she can see what’s realistic and what isn’t.

It’s equally important for a breast reduction patient. If, for example, their breasts are really large, and they want to go really small, my message is: “I can guarantee you that I’ll take off enough tissue to make your breast much lighter, and I can also make your breast aesthetically more pleasing. But I cannot guarantee a cup size.” But because I can image that—so they can see exactly what is possible—they are happy with the final results. 

With this kind of surgery, we absolutely need patient and surgeon to be on the same page, and to visualize the same results. So, this is a critically important part of surgical process.

Reducing and Managing Pain

DR WU: Unquestionably, among the most important advancements we have seen are improvements in pain management. Not only are there better ways to control pain, but we can now do so with less reliance on opioids, reducing the risk of addiction. I use just such an opioid-sparing protocol, which combines non-opioid medications in timed sequence to start managing pain even before surgery begins. The result: my patients need fewer opioids post-operatively to control pain at home.

During a breast procedure, I also use an intercostal nerve block in addition to traditional anesthesia, permitting us to use less systemic medication, which reduces the likelihood of a post-anesthesia “hangover.”

New local anesthetics can last for up to 72 hours, and for many of my patients, this is long enough to get them through the days that would typically bring the most discomfort. By the time the medication wears off, the body is already well on the way to recovery.

New Tools, New Medications

DR. GREGG: There have been some remarkable advances in the realm of anesthesia in recent years—changes that have a tremendous impact on the patient’s recovery. We are now able to do many cases under what might be called “twilight” sedation rather than general anesthetic. This means that the anesthesia is administered intravenously, without anesthesia gases and intubation. We support the patient’s airway, but they don’t need a breathing tube. That is especially helpful for the facial plastic surgery that I do. And the benefit for patients is significant, since they will wake up a little easier and are less likely to have postoperative nausea.

DR. WU: Fat grafting, or fat transfer, is an innovative surgical technique that I use more frequently now in breast augmentation. It is a process of removing fat from one part of the body through liposuction, purifying it, and then using it rather than silicone or saline implants. It provides a softer, more natural shape and poses less risk than traditional implants, so many of my patients prefer this more natural approach. For the right patient—because there are limits to the size of the increase that can be accomplished with fat transfers—it’s an ideal approach. And it has the added benefit of removing stubborn fat from other areas of the body. 

Another innovation that I’ve been using for the past year or two to minimize scarring is a little device called a Brijjit. This is a plastic bridge that spans the incision and helps prevent the skin edges from forming a thick, hypertrophic scar. By taking the tension off the incision early on, it sets up the skin to heal in a thin, fine line. This is especially important for people with darker skin color, where thicker scars are more visible.

Alternatives to Surgery: A Continuum of Care

DR. GREGG: You can’t talk about advancements in facial plastic surgery without considering the remarkable development of non-surgical options to address the effects of aging. We offer what I like to call a “buffet” of options including skin care products, injectables that reshape contours and stimulate collagen, lasers to resurface skin, and ultrasound treatments that basically offer a “non-surgical face lift.”

And these new non-surgical treatments aren’t merely “alternatives” to surgery. In fact, in many ways they are complements and often prepare patients—short- and long-term for surgery. We look at this as a continuum of care.

Take, for example, what we call “prejuvenation.” That’s the term we use for things people can do to prevent or reduce the problems of aging—starting when young. It includes good skin care, sunscreen, good nutrition, and exercise. And the next steps on the anti-aging path might include medically directed skin care, or Botox to minimize wrinkles. Then maybe fillers will be used for volumization or to stimulate collagen.

All of these measures contribute to healthier skin. So, years down the road, they may come to me for surgery—and they will come to me with healthier, thicker skin. If your skin is healthier and thicker, you’re absolutely going to have a better result from the surgery.

Skin Care: Before and After

DR. GREGG: Preparation for facial surgery often includes focused skin care over a period of time, to optimize results. And for certain procedures I recommend a skin care protocol for six months or more pre-surgery. And this is true even for some non-surgical procedures. Before we do any type of CO2 laser resurfacing of the skin, for example, they have to pre-treat their skin for a minimum of four to eight weeks.

And for all of our surgical patients, we strongly recommend postoperative skin care, and we get them started on that right away. The exact protocol will vary, depending on the person; it’s not one-size-fits-all. They may need Retin-A; they may need antioxidants such as vitamin C; they may need more hydration. It really depends on their skin.

Recovery Begins Before Surgery

DR. GREGG: The surgery we do is traumatic; and the best outcomes result when we succeed in managing post-operative pain and providing maximum support for the healing process. And that is why many of the choices we make as surgeons and the protocols we follow—before, during, and after surgery—are focused on optimizing the recovery process.

In fact, the ERAS (Enhanced Recovery After Surgery) protocol we use, actually starts before surgery. Especially for long or complex cases, we provide patients with a pre-operative carbohydrate-heavy drink. It keeps their blood sugar more stable during the procedure, and they’ll wake up feeling better. It’s like carbohydrate loading the night before you run a marathon.

And we are also doing something new intraoperatively that has proven of great benefit. We give our patients tranexamic acid intravenously, which helps to minimize bleeding and thus bruising. We have used arnica and bromelain supplements for years to help with this, but the tranexamic acid treatment has been even more effective in minimizing bruising and bleeding.

Post-operatively, recovery has been significantly enhanced because of newer, longer-lasting numbing medicines. Thanks to these medications, numbness lasts six to eight hours, and in some cases up to a few days. It gives patients a chance to go home and start their recovery process more quickly.

DR. WU: For the more complex cases I do—such as breast reductions and tummy tucks—the ERAS protocol is especially important. For example, both the opioid-sparing medications for pain management and the pre-op carbohydrate drink contribute significantly to an easier and speedier recovery.

I encourage patients to hydrate and to have a high-protein diet, which will support their recovery. And there are special nutritional considerations for fat grafting patients. With fat grafting, you want all the fat that has been used for breast tissue to survive. So, I encourage patients to have a high-carbohydrate as well as a high-protein diet. I want there to be enough glucose in their system—which their body needs to heal—so that the body will not use the newly transferred fat as a fuel source.

The Patient’s Role

DR. WU: For the surgeries I do—especially the bigger combination procedures that involve a tummy tuck and breast surgery—the most important factor in the recovery process is the patient herself. We can do a lot to make the recovery easier and to manage pain effectively, but as I tell my patients: “You need to take care of yourself to optimize healing.” I encourage patients to take two weeks. Usually, people are off pain meds by the first week, but they’ll still be sore and tired, and all their energy needs to go into healing. And the other advice I offer is “you need to get your house in order.” Literally. Don’t plan on doing a lot of chores; in the first few days you’ll need help just getting in and out of bed. So, before surgery: find a caregiver; clean your house; stock your fridge; give yourself the gift of self-nurturing; and allow yourself to heal. The rewards are immense.