Plastic surgeons are perhaps the most “polished” of physicians. They are typically the best dressed, have the most effervescent personalities, the perkiest nurses, and offices ripped from the pages of Architectural Digest in addition to buxom spouses.  But what lies beneath the perfect facade? Are there trade secrets these plastic surgeons don’t dare even whisper among their colleagues at plastic surgery conferences for fear of tarnishing their golden veneer even among peers? Dr. Lyle Back is a Philadelphia area board certified plastic surgeon who is not afraid to pull back the proverbial surgical curtain to give lay people the real reality of cosmetic surgery.

1. You will have  “some discomfort.”

Those might be words that will have you cursing at your surgeon under your breath post-surgery.

There’s a general perception in society that cosmetic surgery is somehow less physically taxing than regular surgery, since it’s elective and aesthetic in nature. Some patients might be surprised that work during a tummy tuck extends from the rib cage all the way down to the pubic bone, for example. Dr. Back explains that some surgeons not only minimize the level of pain, but the length of time needed for recovery as well. This leads to patients not being adequately prepared for child care and work issues which is not fair to patients or the important people/responsibilities in their lives. Since pain and recovery time do vary Dr. Back suggests talking to several people who have had the exact procedure to get an average.

2. Bad scarring.

When it comes to scars from big procedures like tummy tucks and breast lifts, many believe it’s a surgeon’s skill that determines how badly you’ll scar post-surgery. However, Dr. Back says it really comes down to a patient’s genetic factors. A skilled plastic surgeon, “can do the same exact closure on two different people, and one heals with imperceptible scars and one doesn’t,” he says. This is important to keep in mind before going under the knife, especially if you’ve got a darker complexion and high skin pigmentation, which Back says put you in the high risk category for scarring.

3. We have a secret weapon we can use when things go wrong: Leeches.

By restoring blood flow and secreting a chemical that prevents blood clots, leeches can help salvage complex reconstructive procedures (e.g., a reconstruction flap for breast cancer or a reattached finger) that are struggling to heal properly. It sounds a bit scary, but reconstructive plastic surgeons will use them when needed.

4. Sorry, there’s no good surgical fix for cellulite.

There are a wealth of options available today, each claiming to treat cellulite effectively. Cellulaze, a highly promoted treatment, is an actual surgical procedure using an invasive laser that must be threaded under the skin. Scarring, infection, and other healing problems are real risks, even with small incision, minimally invasive procedures. “The risks are very low, says Dr. Back, “but they’re still there—and you have to weigh the price, too.  The treatment is invasive, costly and the results are so-so; I’m not a fan.” The Verju’ green laser is a completely nonsurgical noninvasive office treatment for cellulite that patients are raving about. To date, the Verju’ green laser is still the only non-surgical treatment for cellulite cleared by the FDA!

5. You look amazing… for now.

Even the most skilled surgeon cannot produce a facelift with “permanent” results unless the patient being operated on has figured out how to stop aging! The average “shelf life” of a facelift is about 10 years and that depends on a patient’s skin elasticity, if they maintain a stable weight, how much time they spend in the sun and if they smoke. The lower quadrant of the face will always age faster because the skin is fleshier and has less bone. “People should usually expect that the jowls will be the first to return.” says Dr. Back.  This is not to say that men and women should not get facelifts!  “You will still look better after a few years than you would have looked if the facelift weren’t done. But a facelift at 60 is not going to block the aging process. Don’t expect that facelift to look the same 35 years later!”

6. Trade a brow lift for a brow wax or Botox.

As we age, our eyebrows droop, causing us to look tired.  Years ago, this might have been  improved with an expensive surgical brow lift. While effective, many people who consider this costly surgery could look almost as good with a $30 or less brow wax. The key is to instruct your aesthetician to remove the hairs on the undersurface of the eyebrow. This opens up the space above your eyelids, making you look more alert and refreshed. Just make sure she doesn’t remove too much. Sometimes eyebrows don’t grow back! And a single 5 minute special Botox treatment by an experienced plastic surgeon can get your eyebrows lifted, restore a nice feminine arch to them and make your eyes look rested and refreshed for 4 or 5 months. According to Dr. Back, with “no incisions, no scars, no downtime, and minimal cost – Botox is the clear winner for lifting eyebrows!”

7. It’s better to have an elective surgery early in the week.

Many doctors go away for the weekend. If you have a complication over the weekend, or even if you are just concerned that an incision is oozing, you don’t necessarily want to get someone covering for your surgeon.

8. It’s the anesthesia you need to worry about.

With so much focus placed on the surgeon performing your procedure, the person performing the really dangerous part — administering anesthesia — is often overlooked. Ask your surgeon directly about the anesthesia – will it be a nurse-anesthetist or a board-certified anesthesiologist? “An anesthesiologist is a fully trained physician professional who is dedicated to the anesthetic needs of the patient and doesn’t have to be supervised,” Dr. Back says. But in most states, nurse-anesthetists do require supervision. Consider this – your plastic surgeon may be the one doing the supervising! That’s not to say nurse-anesthetists aren’t competent, but it does mean you should ask additional questions — like what the anesthetist’s experience is with outpatient aesthetic surgery. If your physician uses nurse-anesthetists and you would prefer a board-certified anesthesiologist, ask if it’s possible to have one.

9. If you aren’t honest about previous surgery, your current surgery might not turn out right.

Plastic surgeons have seen and heard it all. “But If a patient does not tell me about a previous nose job, breast implant, liposuction etc. then I could literally be ‘‘operating in the dark”, says Dr. Back.

He adds, “For example, previous liposuction can mean there’s hidden scar tissue and toughened fat that can’t be detected from the outside. This all makes the next round of lipo much more difficult and the fat harder to remove.  Patients always need to be honest so that their surgeons can properly determine what can be realistically expected – risks, recovery, results –  when a procedure is being performed on an area for the 2nd or 3rd time.”

10. Ask About Their Complication Rate.

“If a plastic surgeon tells you that they’ve never had any complications, they’re either lying or haven’t operated enough to have seen any.”  The more experience a surgeon has the better. Complications happen – it’s a fact of life. “But that’s one of the ways a surgeon gains experience and can then build upon to hone his skills to an even higher level” says Dr. Back.