- What should I look for in a surgeon?
This is a personal choice. In Canada, it is important to choose a surgeon who is board certified by the Royal College of Physicians and Surgeons of Canada. Surgeons with this certification will have the FRCSC designation after their name.
It is important that you understand who your surgeon is, and what kind of surgeon they are. The term “Facial Plastic Surgeon” usually refers to ENT (Ear, Nose, and Throat) surgeons, not plastic surgeons. Similarly, a “cosmetic surgeon” is not necessarily a plastic surgeon. General surgeons can use that term. “Cosmetic physician” is a term often used by GPs and family physicians.
- I saw two surgeons, but one is much cheaper than the other. Why is this?
Don’t automatically choose the surgeon with the lowest price. Newer surgeons with less experience often charge less when they first start out. Similarly, non-plastic surgeons may charge less. The geographical area you are in may also play a role in pricing.
- Is Dr. Pirani a board certified plastic surgeon?
Yes. Dr. Pirani is a board certified plastic surgeon. In addition to being a plastic surgeon, he is one of only a few plastic surgeons in Toronto with formal fellowship training in cosmetic plastic surgery. This means that after becoming a plastic surgeon, Dr. Pirani then did further training in cosmetic plastic surgery above and beyond that taught to most plastic surgeons.
Eyelid Surgery (Blepharoplasty)
- Should I stop taking aspirin and blood thinners before my surgery?
You should only stop these medications if your physician says that it is safe to do so. Dr. Pirani prefers that patients be off of these medications for two to three weeks pre-op.
- Is fat repositioning a common part of blepharoplasty surgery?
Fat repositioning is a common and valuable tool. In the right patient, it can produce excellent results.
- How much does BOTOX® cost in Toronto?
This will vary greatly by the location and injector. Dr. Pirani performs all BOTOX® injections himself. As a board certified plastic surgeon, Dr. Pirani charges $14 per unit.
- How long will the results of my BOTOX® injections last?
In general, optimally dosed treatments will last three to four months. As you use BOTOX® more, the frequency may decrease. BOTOX® used for hyperhidrosis may last longer (six to nine months).
- I have a very wide face. Can BOTOX® help with this?
Yes, BOTOX® can be used to inject the masseter muscles (jaw muscles) to decrease facial width.
- What is a BOTOX® brow lift?
In a BOTOX® brow lift, the muscles that depress the brow are inactivated so that the frontalis muscle, which elevates the brow, is unopposed. This results in an elevated brow.
- I have a gummy smile. Can BOTOX® help with this?
Yes, BOTOX® can be used to decrease the appearance of your gums when you smile.
- How long does it take for BOTOX® to work?
It can take up to two weeks to see the complete effect of your BOTOX® injections.
- I’m only 25. Am I too young for BOTOX®?
A recent trend is for patients to come in for prophylactic BOTOX®. The idea behind this is to prevent lines and wrinkles from developing in the first place. It is a proactive approach that is increasingly popular.
- I want to get BOTOX® for my wedding. When should I get my BOTOX® treatment done?
Dr. Pirani generally recommends getting BOTOX® four to six weeks before your wedding. This will allow time for any touch-ups that may be needed.
Breast Augmentation / Breast Implants
- How long will it take to recover from my breast augmentation? How much pain will I be in afterwards?
Recovery really depends on a few factors. Adequate pain control is likely the most important. Individual pain tolerances differ greatly. In general, women who have had children experience less post-op pain, as they have a much higher pain tolerance. From a surgical point of view, there are several things the surgeon/anaesthesiologist can do to decrease your post-op pain.
Dr. Pirani generally performs breast blocks prior to making any incisions with a mix of short- and long-acting local anaesthetics, which he finds greatly reduces post-op pain. He also encourages patients to take the prescribed painkillers regularly every four hours, especially for the first 24 to 48 hours. If you don’t stay on top of the pain in the immediate post-operative period, it is extremely difficult to “catch-up.” Most of Dr. Pirani’s patients experience very little post-op pain after their breast augmentation surgery.
Of course, the type of breast augmentation you have will also determine your post-operative discomfort. Larger implants and subpectoral implant placement will also increase post-op discomfort. This doesn’t mean you shouldn’t get large implants, or place them under the muscle—you simply need to know what to expect. Many women also experience difficulty with sleeping the first few weeks after augmentation due to the weight of the implants on their chest. This is more significant in back-sleepers.
- How much time off of work will I need after my breast augmentation? When can I pick up my kids?
There is a huge variation among patients in the amount of time needed off from work. Some patients go back to work the next day (which isn’t advisable), while others take as much as two weeks off. It really depends on what you do for work and how you feel. As for taking care of your kids, if your implant is placed under the muscle, it will be a few weeks before you feel comfortable enough to pick them up.
- Will my nipple sensation be altered by having a breast augmentation?
While the literature indicates that there is a 15% chance of losing sensation to your nipple-areolar complex, in Dr. Pirani’s experience few patients have had this problem with augmentation surgery.
Although the rates of sensation loss may be as high as 15%, a significant proportion of these cases will be temporary. It all depends on the degree of injury to the nerves that provide sensation to your nipple. If the nerves are just bruised (neuropraxia), your sensation should return within six to 12 weeks. Increased sensation or hypersensitivity is also a possibility.
When Dr. Pirarni performs a breast augmentation, he is very careful when dissecting the lateral pocket. This is where the main nerves supplying your nipple are located.
- When do scars begin to fade?
It takes a year to see the absolute final result. Practically, however, by three to six months the scar will be very close to the final result. Dr. Pirani will provide you with a specific scar massage protocol and ointment to help speed your scar’s healing.
- What is the difference between a subpectoral, submuscular, and dual plane augmentation?
- Submuscular = the implant is COMPLETELY under the muscle with no release of the muscle (rarely done).
- Subpectoral = the implant is placed under the pectoralis major muscle, with the inferior edge of the muscle released so that the lower portion of the implant is covered by gland. This is what most people refer to as “submuscular”; however, they are technically incorrect. A classical subpectoral placement is the same as a Dual Plane I.
- Dual Plane = a form of subpectoral implantation with varying degrees of muscle release/separation from the gland in order to vary the amount of muscle/gland coverage ratio. Dual Plane is a form of under the muscle or subpectoral placement.
- Should I wear a surgical bra after my breast augmentation?
In general, Dr. Pirani’s post-operative surgical bra guidelines are based on the following: If he wants the implant to drop (usually after a subpectoral or under the muscle augmentation), he advises patients to go without a bra or to wear a bandeau, which pushes the implants down. This is because implants tend to ride high in the first few weeks after a subpectoral augmentation, but by following the post-operative guidelines, patients can arrive at their final cosmetic result sooner.
If the implant is inserted in either the subfascial or subglandular space, Dr. Pirani usually advises that patients wear a surgical bra, which prevents the implants from dropping or distorting the position of the IMF (inframammary fold). In cases where Dr. Pirani has altered the IMF position for symmetry purposes, patients should wear an underwire bra to help define the new IMF.
- How do I sleep after my breast augmentation?
Sleeping on your back is your best option in the early post-operative period, while sleeping on your side is your next best option. Many patients find sleeping difficult during the first few weeks after breast augmentation surgery, as you now have more weight on your chest than you did previously.
- Which incision site is best?
There are several things to consider when deciding on which incision to use. Cosmesis and the resulting scar are certainly an important consideration. Another consideration is the risk for capsular contracture. When a foreign body is placed in the body, the body reacts by forming a capsule of tissue around the foreign body. In the case of breast implants, this capsule can be soft or it can become hard and even painful. These tissues can even distort the implant and result in poor cosmesis. This is termed a capsular contracture, and the rates of these can be quite high, depending on implant choices and incision type.
Recent evidence seems to indicate that there are higher rates of capsular contracture with periareolar (nipple) incisions. Using an incision in the fold under your breasts (IMF incision or inframammary fold incision) seems to be associated with the lowest rates of capsular contracture. The cosmesis of this incision is also ideal as it is hidden under the breasts. Armpit incisions have the potential of being seen every time you lift your arms.
The IMF incision also provides the surgeon with the best approach to perfect your implant pocket, alter the IMF if needed, and obtain hemostasis. Much of the armpit approach involves blind and blunt dissection.
- How much does a breast augmentation cost in Toronto?
Silicone/cohesive gel implants will run somewhere between $9000-$10,000 in most cases. Saline implants are usually a few hundred dollars less. The size of your implants rarely impacts the price.
- Is there a natural way to increase my breast size and avoid surgery?
Be careful of any products promising natural breast enhancement. All proven methods involve surgery.
- What cup size will I be after my breast augmentation?
There is no way to guarantee a particular bra size. Bra sizing varies greatly between bra manufacturers and a C in one bra will be a D in another. What matters more than the assigned bra size is the way the implants look on you. The best option for your body and aesthetic goals can be determined in a thorough implant sizing session.
Implant sizing depends on several factors. One of the most important factors is your breast width. Generally, your surgeon will measure your breast width, and then provide you with a range of implant sizes appropriate for your native breast size. While there are more nuances involved, this general approach works for most women.
Dr. Pirani usually has patients bring in a large bra and a tight t-shirt to do sizing. He then chooses three to four implants he feels are appropriate and has patients place them in the bra under the tight t-shirt. Patients can then look in the mirror and get a good sense of what they will look like with the provided implant sizes. By using this technique, Dr. Pirani can outline a range of appropriate implant sizes that will be aesthetically pleasing, and you make the final decision.
- What exactly does the phrase “the pocket” refer to in breast augmentation?
The pocket refers to the space that is created for the implant to be inserted into.
- Can I be awake for my breast augmentation surgery?
There are surgeons that will do awake surgery for breast augmentations, but Dr. Pirani does not. Most surgeons in North America do not offer awake breast augmentation surgery. There may be a cost advantage to being awake; however, the safety and comfort of patients is paramount. Accordingly, Dr. Pirani prefers to have patients asleep for breast augmentation surgery.
- What implant size should I choose?
This is often a difficult decision; however, a thorough sizing session can help patients better understand their options. Dr. Pirani provides patients with a range of about three to four implants that are appropriate for their specific measurements. He then has patients try the implants on while wearing a special sizing bra. With this process, patients can choose their own implants. Your surgeon should be willing to spend the time with you doing this.
Breast Fat Grafting
- Can I use fat to augment my breasts?
Yes, fat grafting the breasts is an accepted method of augmentation. Several sessions of fat grafting are often required to obtain substantial volume increases, with the number of sessions depending on the amount of augmentation required.
- Can I use someone else’s fat to augment my breasts?
Unfortunately, no. You cannot use someone else’s fat to augment your breasts as your body will reject it.
- How much does it cost to transfer fat to my breasts to augment them?
It really depends on how much fat you have available to transfer, the elasticity of your skin, and how big you want to go. More than one surgery may be needed. The best way to get specific answers for your body and your goals is to see a board certified plastic surgeon in your area for a customized and personal consultation.
- How much fat will survive?
Every case is unique, but in general 30-80% of the transferred or grafted fat will survive.
Breast Lift (Mastopexy)
- Can I get a breast lift without implants?
Yes, you can get a breast lift (mastopexy) without implants. You should only receive an implant if you want larger breasts. Some surgeons will use implants to fill out the upper pole of the breast at the same time as a mastopexy. This, however, can sometimes be accomplished without an implant by rearranging the breast tissue if you have enough tissue (auto-augmentation).
- How long will it take to recover?
Recovery varies greatly from patient to patient, but in most cases swelling and bruising will resolve within 10 days. Some residual bruising and swelling can last longer, even up to four to six weeks post surgery.
- How much does a facelift cost in Toronto?
The price can vary greatly depending on your geographical location and the skill/credentials of your surgeon. In Toronto, it can easily cost anywhere from $9500 to $30,000, which is a large range.
- Are skin lift-only facelifts not performed anymore?
They are still performed, but if you want a long-lasting improvement, then Dr. Pirani recommends tightening the underlying muscle layer (SMAS). The traditional skin-only facelift is rarely used today.
- How soon after my facelift can I dye my hair?
Dr. Pirani allows patients to dye their hair six weeks after all the incisions have healed. If done earlier, you run the risk of tattooing your incision lines.
- Can men get facelifts? What’s different?
The surgical techniques for facelifts are very similar for men and women. Men often bleed more and their skin/soft tissues are thicker, but otherwise the actual techniques are the same. Sideburn management is also slightly different in regards to incision placement in men, but that’s a minor part of the surgery.
- How can I avoid bruising and hematomas after my facelift?
A certain amount of bruising is to be expected. Bruising is called ecchymosis. A hematoma is different—it’s an actual collection of blood that forms. In the case of a facelift, hematomas are less likely than ecchymosis. There are several factors that can affect whether you develop a hematoma after a facelift:
- Surgical technique – Your surgeon must be meticulous about obtaining hemostasis intra-operatively.
- Your biology – if you have coagulopathy, are taking blood thinners, or are naturally predisposed to bleed more (red-heads), you have a higher chance of developing a hematoma.
- Hypertension – an elevated blood pressure in the peri-operative period can cause a previously occluded vessel to dislodge a clot and bleed, thus, resulting in a hematoma. Medications such as clonidine can be given in the peri-operative period to keep your blood pressure low. Dr. Pirani usually admits facelift patients overnight and has a nurse monitor their blood pressure.
- Dressings/Drains – although there isn’t any good evidence for this, many surgeons will use drains at least overnight to prevent any pooling of blood. Some surgeons will also apply a compressive dressing around your head to prevent bleeding.
- Can I get a facelift if I’m a smoker?
Smokers should not get facelifts as the risk of skin necrosis is too high. At the very least, you should be able to stop smoking six weeks before and after a facelift.
- How long does a facelift last?
The answer depends on the type of facelift performed. In Dr. Pirani’s opinion, longevity is achieved with facelifts that address not only the skin but more importantly the muscular layer of tissue beneath the skin (SMAS layer). SMAS stands for superficial musculoaponeurotic system. This layer of tissue is responsible for the age-related changes we see in the midface/neck/jaw.
Raising and repositioning this layer can result in a long-lasting facelift that lasts as long as eight to 10 years. Of course, everyone is different. Sun-loving smokers may not experience such lasting effects.
- How do I avoid the “wind-swept” look?
The best way is to choose a surgeon that has shown you pictures of their facelifts and to judge the appearance of these results. The “wind-swept” appearance occurs from placing too much tension on the skin. We now know that the skin on the face is not the main cause of jowls and the descent of youthful facial features. The problem is with the underlying layer of tissue known as the SMAS (superficial musculoaponeurotic system).
Most of the lift obtained in a modern facelift is achieved by raising the SMAS. This can be done by either creating a flap in this layer of tissue and re-draping it, or by using sutures to tighten this layer. Regardless of the specific technique used, addressing the SMAS is the key factor in achieving ideal cosmesis in a modern facelift. Once the SMAS has been addressed, the facial skin can then be re-draped, and a minimal amount of skin can be removed. The skin should be inset with very little to no tension. This avoids the “wind-swept” appearance and improves scar healing.
JUVÉDERM® and Restylane® (Fillers)
- Do you use special needles to avoid injuring a vessel?
We can use something called a microcannula. It looks like a needle but is blunt-tipped. We believe this decreases the chance of hitting a vessel, thus reducing the risk of bruising.
- Can I get filler while breastfeeding or while pregnant?
The use of fillers has not been approved during pregnancy. It’s not worth the risk.
- How much does liposuction cost in Toronto?
Most common liposuction procedures cost at least $6500+, but it depends on how much fat needs to be suctioned. The only way to know for sure is to see a plastic surgeon in person for a consultation.
- What is the limit to how much fat can be removed in one session?
Safety limits the volume removed to at most 4-5L in any one session. Dr. Pirani rarely removes more than 2-3L in most cases as liposuction is not a substitute for weight loss. Removing larger volumes of fat in patients with high BMIs poses significant risks.