If you think beautiful breasts are a thing of the past, Dr. Carlin Vickery says, think again.

When we hear “breast surgery,” most of us think of Hollywood starlets, porn stars or Pamela Anderson. But statistics show that FOFs–regular women with jobs, brains and no big-screen ambitions–are having more cosmetic breast surgeries than ever before.

Why the sudden trend? “We’re entering an era where women are going to be living a long time,” says Dr. Carlin Vickery, a board-certified plastic surgeon and one of Manhattan’s most sought after sources for breast lifts and reductions. “The quality of our lives is going to be dictated by our physicality. Being able to stay active and fit will actually extend and improve our lives.” And for many women, that means lifting and/or reducing their post-menopausal bazooms.

We spoke to Dr. Vickery about breast surgery and why FOFs are such good candidates.

• What happens to our breasts as we age?
  • As we go through childbearing, nursing and menopause, most women will lose skin elasticity. So there is a natural gravitational descent of the breast gland, which can result in droopy breasts, or, as we call them, ptotic breasts. In addition, with a loss of estrogen, the breast tissue will become more fatty, which leads to a loss of volume, especially at the top of the breast, which, in our culture, is the desirable cleavage area.
• Do breasts generally get larger, or smaller over time?
  • It depends on the woman. Some women, after having children, experience post-partum involution, meaning the breast tissue just shrinks down. That’s very common; I see it in a number of women in their 40s and 50s. Other women’s breasts get larger.
• What are the most common types of breast surgery for women over fifty?
  • Women usually come in complaining of sagginess and a loss of volume. They need breast lifts–and that can be done with or without an implant, depending on whether the patient needs more volume. Breast reductions are the other popular precedure for the over-fifty group.
• Do you think most FOFs come in with realistic expectations?
  • I think they do. A lot of younger patients come in wanting something they’ve seen on TV or wanting tons of cleavage. But women over fifty are more mature and realistic. They have a good idea of who they are and many have waited a long time for this. Often, they feel like their breasts are too big and are making them look matronly–fat and top heavy. If anything, they want their breasts to be too small.
• Is there such a thing as “too small” breasts?
  • I’m a big believer in proportionality. You never want to reduce breasts so much that your belly is leading your profile. That’s not a desirable look, and it’s going to makes clothes harder to fit.
• Let’s start with the breast lift. Does it always require an implant?
  • No–not necessarily. You can lift the breast, but without an implant, you’re not going to get that volume that most women are looking for.

    

• Do you have a preference for silicone versus saline implants?
  • I don’t. That’s a decision the patient needs to make, and my job is to give them all the advantages and disadvantages of both. I will say that the gel implant often has a slightly softer feel–but not always. For a while, silicone was under suspicion of causing autoimmune disease, so we all used saline implants, and people were very satisfied.
• What’s the biggest misconception about breast implants?
  • People don’t realize that implants require maintenance over time. The FDA has now deemed silicone implants safe, however they need to be replaced every 10 to 15 years.
• What’s the most popular procedure right now for achieving a “natural” look with an implant?
  • There’s not one. To be a good plastic surgeon, you have to be flexible, and you have to have a big bag of tricks. If you’re doing the same procedure on every patient, then you’re not achieving the best results. Two women complaining of “sagging” could have completely different anatomy: is the problem lost elasticity, or are the nipples pointing down, or do they have stretch marks, or do they have great skin with a loss of volume? If a doctor says he has one technique that he always, uses, then . . . I can’t get my mind around that.

What about fat injections into the breast? Is that possible?

• If you look on the internet, you will find doctors who are practicing these large-volume fat injections. I think the jury is still out on this procedure. I have seen some good results in photos, but there’s a lot of variation. And there’s concern about whether injecting fat into the breast can prevent effective cancer screening, or if there are biological risks to that injected fat. I think fat injection is the future–we’re just not quite there yet.

What’s the best way to judge if you’ve found a surgeon who’s going to do a good job? Are there any red flags to look out for?

• The most important thing: Is the doctor listening to what you’re saying? A good plastic surgeon really listens to the patient and attempts to understand the patient’s goal and whether or not they have a surgical technique that’s going to reach that goal.

What are some non-surgical ways to keep your breasts looking good over time?

• There are a lot of things–some of which you can control and some you can’t! Large-volume weight gain and weight loss stretches out the skin you’re apt to get sagging. Wear a good, supportive bra that minimizes repetitive jiggling, especially when you’re jogging and exercising. Smoking is going to hurt the elasticity of your skin–not just your face, but also on your chest wall. Spending a lot of time in the sun will also decrease elasticity and cause breasts to sag.

Non-surgical breast enhancement products–pills, creams, etc–do any of these work?

• I personally don’t know any that work. It’s not the answer people want to hear, but the fact is, anything that helps you stay more fit overall–exercise, diet–will help preserve your breasts as well.

Okay, let’s talk about breast reductions. Why is this so popular for women over fifty?

• A few reasons. After menopause, we tend to put on weight in our mid-section, so many women complain that they feel top-heavy. Also, if you have large breasts, it’s a major drag on your upper skeleton–particularly your neck shoulders and back. As women age, they can develop deep grooves their bra straps are, back pain, headaches, etc. If you’re prone to osteoporosis, it puts strain on your back and can exacerbate the problem.

So this can really be a health issue?

• Absolutely. Women who have the procedure tend to immediately feel better and lighter. Still, there are women who feel almost like they have to apologize for coming in and asking for a breast reduction. Why?! You don’t have to apologize–this makes perfect sense. You’re 55 years old, and these breasts are pulling on you 24/7 and you want to be able to go to the gym do yoga.

What’s the biggest misconception about breast reduction surgery?

• I think most women are shocked by how much younger and thinner they look after the surgery. Most of my patients who have this procedure say, “I can’t belive I waited so long!” I think people are also surprised by how well tolerated this procedure is. A breast reduction typically requires a few days of recovery and some Percocet! In plastic surgery, we often say breast reduction patients are our happiest patients.

You seem passionate about this topic.

• There is a group of patients for whom I belive their longevity and the quality of their lives would improve if they had breast reduction. Sometimes I have to sit on my hands, because I see women who would really benefit from it. But I’ve never figured out how to have the conversation with someone who’s not a patient. I just think, ‘I could really help that woman!’

Author

Dr. Carlin Vickery, MD, BCPS Plastic surgeonDr. Carlin Vickery, MD, F.A.C.S., has been practicing surgery for over 25 years. Consistently ranked as one of New York City’s top plastic surgeons by Castle Connolly Medical, Dr. Vickery has pioneered innovative approaches to breast reconstruction and augmentation. She holds an appointment as Associate Clinical Professor in Department of Surgery at Mount Sinai Medical Center, where she has taught since 1985.

The definitive guide to banishing bags, preventing puffs and smoothing circles.

Our FOF Beauty Gurus see one question more than any other: “What can I do about my undereye bags and dark circles?!” So we turned our puffy eyes to FOF Guru Dr. Sharon Giese, one of New York’s premiere plastic surgeons, and FOF Guru Dr. Cynthia Bailey, a California-based dermatologist with a penchant for finding the products that really work. Together, they gave us a truly fab blueprint for bag banishement–from potions and lotions to plastic surgery.

• FOF: First of all, what causes undereye bags and puffiness?
  • Dr. Sharon Giese: Bags are caused by fat herniation. That doesn’t sound pretty, but it’s just a weakening of the membranes beneath your eyeball. Your eyeball sits on a sling and some fat for cushioning. As you age, the membranes that hold the fat loosen, and the fat can sag and pooch forward.
  • Dr. Cynthia Bailey: Eye puffiness can also be caused by congestion of your blood vessels, which can occur because of genetics, lack of sleep, illness or just generally being ‘run down.’
• FOF: Some women appear to actually have dark skin under their eyes.
  • Dr. Bailey: That could be either excess pigment or shadowing. Excessive skin pigment can cause a brown discoloration of the undereye area and is often genetic.
  • Dr. Giese: Shadowing is literally a casted shadow caused when overhead light hits a physical indentation between the eye and the cheek. It happens when the fat starts to sag, as I described above, or when the cheek starts to drop with age, leaving a hollow indentation between the eyeball and the bone beneath it. It’s a shadow, so no matter how much concealer you use, you can’t cover it up.
• FOF: Okay, so now we know the main causes–can we talk about how to fix them? Let’s start with congestion of the blood vessels…
  • Dr. Bailey: Your undereye circles are a great barometer of your body’s vitality. If you eat well, exercise and get adequate rest, your circles will fade. Also, cut down on salt and MSG to reduce fluid build up in this area.
  • Dr. Giese: And stay hydrated. Your eyes and skin always look better when you’re hydrated.
• FOF: Are there any products that improve vascular congestion?
  • Dr. Bailey: Replenix Eye Repair Cream is my absolute favorite undereye product–bar none! It has ingredients to improve circulatory issues including arnica, Vitamin K and peptides.
• FOF: Okay, what do you do about hyperpigmentation?
  • Dr. Giese: That can be covered by a concealer.
  • Dr. Bailey: Yes, and you also want to protect this area from the sun to prevent further darkening. Use a broad spectrum UVA/UVB mineral sunscreen every day. Products with 5% or more of zinc oxide give the most complete protection. My favorite undereye sunscreen is Glycolix Elite Sunscreen which has a whopping 17% zinc oxide and is gentle on the eyes.
• FOF: Can you actually lighten the skin under your eyes once hyperpigmentation has already occurred?
  • Dr. Bailey: Skin lighteners such as hydroquinone cream, Retin A, AHAs or retinol can help decrease pigment, but they can be harsh and should be used with care around the eye area. My favorite is Replenix Eye Repair Cream because it has just the right amount of retinol for this delicate area. I’ve also seen some people get great results with light treatments (Intense Pulsed Light) which can lighten pigment.
• FOF: What can you do about shadowing?
  • Dr. Bailey: If your main problem is shadowing, there are cosmetic procedures and plastic surgery that can actually change the coutour of your eye.
• FOF: Dr. Giese, as a plastic surgeon, this is your area of expertise . . .
  • Dr. Giese: Yes, the general goal when you’re dealing with the lower eyelid is you want to blend the lower eyelid to the cheek. The smoother that transition is, the younger you look. That’s why models are often airbrushed to look like their lower lid blends seemlessly into their cheeks. Plastic surgeons used to treat the lower eyelids by taking out the fat–they’d remove the undereye “pouch” to smooth things out. But now we see that this can make you look very hollow, and you can even end up with a dent between your eye and your ocular bone which causes more shadowing.
• FOF: What’s the most current procedure?
  • Dr. Giese: More often now I’ll use injectable filler to smooth the area between the lower lid and the cheek. I use hyaluronic acid–typical brands are Restylene and Juvederm–and do several minute injections, directly onto the eye bone. That smooths the transition and the dark circles are gone.

FOF: And that’s less invasive that fat-removal surgery?

• Dr. Giese: Yes. And it allows you to camouflage a little bit of fat herniation or a little bit of cheek descent. If someone has severe fat herniation, I would still take the fat out. Or if someone has really a lot of cheek drop then they’re a candidate for a facelift.

FOF: How expensive is the filler procedure?

• Dr. Giese: I charge $1200 for both eyes.

FOF: How long does it last?

• Dr. Giese: Three to four years.

FOF: How do you know if you’re a candidate for fat removal vs. injections?

• Dr. Giese: You need to discuss that with a good doctor. The undereye injection is a very particular injection and not everyone does it. I would ask to see a number of that doctor’s before-and-after photos to see what result you can expect. Personally, I think it’s best to consult with a plastic surgeon who does injections. If you go to someone who just does surgery, you’re gonna get surgery. If you go to someone who just does injections, you’re gonna get injections.

FOF: What is someone like that called?

• Dr. Giese: Either a plastic surgeon, facial plastic surgeon, or ocular plastic surgeon. “Cosmetic surgeon” is not a medical speciality according to the American Board of Medicical Specialities. You want a Board Certified Plastic Surgeon. Any doctor can say he or she specializes in “cosmetic surgery,” but that’s a real buyer beware.

FOF: Are their topical creams that can also get rid of shadowing?

• Dr. Giese: There’s no magic cream that’s going to do what filler or surgery can do, but the lower lid skin tends to be very delicate and crepy, so you have to have very good skincare. I can use filler, take out the fat, do Botox–everything–but if a woman has dry, dead skin under her eyes, she’s not going to look good. I recommend regular exfoliation, hydration and vitamins for the skin. By vitamins, I mean anti-oxidants–typically some vitamin A, C and E and then a great hydrator to plump it up.
• Dr. Bailey: Eye creams like Replenix Eye Repair Cream contain ingredients that layer on the skin in a way that fills in wrinkles and crinkles to brighten the appearance of skin so that it throws more light.

FOF: Dr. Giese – do you have a specific eye cream you recommend?

• Dr. Giese: I don’t have a specific cream, but I do recommend dermaplaning around the eye—it’s a very gentle form of skin exfolation so there’s no downtime. I also use a machine called Biophysique to do a preocedure every four week that stimulates collagen production and oxygenates the skin.

FOF: What’s on the horizon for treating underye bags and circles?

• Dr. Giese: The most promising thing I’ve heard of is a new procedure that takes your own blood and concentrates the growth and nutrient factors. Then they nick the surface of the skin under your eye and rub that concentrated factor right in it. It actually stimulates your own collagen and rejuvenates the skin. It’s great for the delicate undereye skin because it’s non-invasive.

FOF: How far away is that?

• Dr. Giese: It’s kind of here. I had it done myself and I’m going to start clinical trials on it within the next few months. There’s not a lot of clinical data to show exaclty how much it’s going to impact the aging, but the science is very good that this is something that will be a trend in the future.

If you’ve gone through menopause, it’s time to go through your bathroom vanity. Dr. Dina Anderson, a New York dermatologist in private practice, explains how your skin type changes after fifty, and what you can do about it.

• How does a woman’s skin type change after fifty?
  • When you start going through menopause, hormonal fluctuations and hot flashes can really effect the skin. Typically, your skin becomes drier and more sensitive. So it you were oily, you may now be “normal.” If you were normal to dry, you’ll get even drier, and you may start develop sensitivities. If you had sensitive skin, you may develop rosacea-type eruptions due to the hot flashes, or pigmentation problems from the hormone changes.
• How do you know if your skin type has changed?
  • You’ll start to notice that your products aren’t working as well. Your cleanser might start to irritate your skin or your moisturizer leaves it feeling dry. You may have to re-assess everything from your sunblock to you moisturizer to your cleanser. The products you use and make all the difference in the world.
• So if you’re reassessing your routine, and you’ve been using products for oily skin, what should you switch to?
  • Ones that say “normal” or “normal to oily.” You want to move one step towards dry.
• And if you had dry, sensitive skin, then during menopause, what can you do?
  • You want to protect and soothe your skin. Use a very gentle, non–foaming, milky cleanser. La Roche Posay makes an over-the-counter cleanser called Lipikar that I like a lot. A lot of doctors recommend Cetaphil but it has propylene glycol which I’ve noticed can be irritating to my sensitive FOF patients. Choose a moisturizer with antioxidants to protect the skin during the day. I like Active C, also OTC from La Roche POsay.
• What if you want to fight aging, but the anti-aging ingredients are now irritating your newly sensitive, dry skin?
  • I like the cream-based moisturizers that contain growth factors–proteins that help promote the cell growth that decreases as we age. I recommend Citrix–made by Topix–which contains a growth factor called TGF Beta. It’s especially good if you have skin that’s still a little oily but also sensitive. Neocutis makes Biocream with a growth factor called PSP that was originally developed for wound healing. It’s a great anti-inflammatory that really calms sensitive skin down.
• You mentioned that women can start developing rosacea-type reactions during this period. What products do you recommend for women struggling with FOF rosacea?
  • If you tend to be ruddy and get really flushy and blush, I like a cream called Revale, which contains Coffeeberry extract–a powerful antioxidant–as well as a sunblock.
• Should you use a special sunblock if you’re FOF?
  • UVA rays are the ones that cause a lot more damage as far as aging. You have to have a UVA sunblock every day, all through the year. The best blockers for FOF skin are the physical blocks–zinc and titanium–because they don’t have any chemicals so you can’t be reactive. But they’re hard to formulate so they’re elegant. Luckily, a few companies have made really good ones. Tizo has 9% zinc and 4% titanium, and they’re micronized so it doesn’t leave any white residue at all. Plus, it’s tinted, so I have patients who use it as a light foundation. Elta MD is another company that has a whole gamut of inexpensive, quality physical blocks.
• What the biggest mistake you see women making after fifty?
  • Using a lot of exfoliating scrubs.When you exfoliate, you disrupt the skin barrier and you’re more likely to be irritated by whatever product you’re using. This is especially true for women using Retinoids. They can cause your skin to peel, so some gentle exfoliation is okay, but never more than twice a week. You’re almost putting holes in the top layers of your skin and then if you use a product with glycolic acid or retinol it’s going to become even more irritating.
• Every doctor says to use retinoids, but if you have this newly sensitive skin, can they be irritating?
  • Yes, absolutely. And if that happens, I’d switch to the more antioxidant-based products. Not everyone can tolerate retinoids. I’ll often switch patients Replenix, a cream with retinol, which is less irritating than retinoids, and with antioxidants and hyaluronic acid to seal that barrier better. Or, if they’re using traditional retinoids like retin A, I’ll switch them to twice a week rather than every night.

Author
	Dr. Dina Nicole Anderson Dr. Dina Nicole Anderson is a board certified dermatologist in private practice in New York City. She was the Director of Cosmetic Dermatology at SUNY Downstate in Brooklyn, New York from 2001-2005. Dr Anderson has lectured internationally on aging skin, acne and facial rejuvenation techniques. She is on the editorial board of Skin and Aging and Practical Dermatology.

Two Cleveland Clinic dermatologists–Dr. Wilma Bergfeld and Dr. Melissa Piliang– weigh in on what to do when your locks are lacking. (Hint: There’s a lot you can do.)

• FOF: How common is hair loss for women over 50?
  • Dr. B: Extremely common. 100 percent of women go through hair loss to some degree during menopause.
• FOF: What happens during menopause that triggers hair loss?
  • Dr. P: Estrogen levels start to drop. All hormone levels drop over time, but sometimes estrogen drops a little faster and you get an imbalance with too much of the male hormones like progesterone and testosterone. Most hair loss in women over fifty has to do with these hormone changes.
•  FOF: Are there other causes?
  • Dr. B: Genetics play a factor as well as nutrition. Endocrine and metabolic diseases such as diabetes and thyroid disease can also be factors.
•  FOF: Are these diseases more prevalent in women over 50?
  • Dr. P: Diabetes tends to increase with age and weight. Many people gain weight over time and at menopause. Thyroid disease is fairly common at all ages but the incidence is cumulative. So as people age, more people are developing thyroid disease. Any time someone has hair loss we check the thyroid.
•  FOF: What can you do to prevent hair loss?
  • Dr. B: No one knows for sure. A healthy lifestyle can really help. Hair cells turn over quickly, which means that external and internal factors such as diet and exercise have a large effect. Some women think a healthy diet means eliminating carbs and red meat but in fact those foods can provide nutrients that are helpful for hair loss.
  •  I believe in vitamin supplements. When you are low on zinc, iron, antioxidants and Vitamin D your hair doesn’t do as well. Most people are Vitamin D deficient so we need to supplement it with vitamins.
•  FOF: What about shampoos?
  • Dr. B: Choose shampoos that contain zinc. They inhibit testosterone, which clogs the hair follicles, preventing growth.
•  FOF: Are there psychological effects of hair loss?
  • Dr. B: Studies on acne and psoriasis have found that if your body is altered and unlike other people’s you are more likely to be depressed and anxious. Also, those people are hired less and are less likely to have good interpersonal relationships.
•  FOF: Once you’ve already lost a significant amount of hair, is there anything you can do to grow it back?
  • Dr. P: It’s important to correct any problems you have that are causing the hair loss. So if you have a lot of stress, it’s important to get your stress under control through exercise, yoga–those kinds of things.
•  FOF: What about hormone replacement pills or birth control?
  • Dr. P: Hormone replacement and birth control pills provide estrogen to rebalance the hormone levels. For many women they have helped significantly. That became abundantly clear to me in the early 2000s when everyone went off of hormone replacement because of data linking it with breast cancer and heart disease. We suddenly saw a lot of women with shedding. Spironolactone, an off-label drug, has anti-androgen effects and can block that male-type hormone effect in the hair follicle, so it can counteract some of the age-related, hormone-induced hair loss.
•  FOF: Explain “off label.”
  • Dr. B: These drugs are not specifically approved for hair loss, but they are safe and effective in treating it. FDA approval takes a lot of money – millions. If the drug is already on the market for one thing, the drug company doesn’t go back and ask for approval for another use.
• FOF: There are many non-prescription hair loss treatments advertised, from lasers and creams to supplements. What works and what’s hype?
  • Dr. P: That’s very difficult to determine. The only thing FDA-approved for hair re-growth in women is Minoxidil, so many patients we see with hair loss of all types we start with Minoxidil because that’s always a safe and reasonable thing to try.
• FOF: Menoxidil? Is that Rogaine?
  • Dr. P: Generic Rogaine, yes. There’s a formulation for women and a formulation for men.
• FOF: We spoke with Tiffany Masielle-Helt of Precision Laser Therapy who said that they have a 90 percent success rate re-growing hair on women they treat with laser therapy. Could this be true?
  • Dr. P: I have not seen results like that in my experience. I don’t know what lasers they were using or what therapy exactly they were using. I would be skeptical of anything that claims a 90 percent success rate. Without seeing that data, I can’t comment for sure.
• FOF: What about hair transplants–do they work?
  • Dr. B: They’re excellent if done by the right surgeon. I have many patients who have had them and love them. The trick is to pick a surgeon who is known for doing females. It’s a little more difficult to do hair transplants on women than men.
• FOF: How do you find a reputable hair replacement surgeon?
  • Dr. P: Ask your dermatologist for recommendations. You want someone who primarily does hair transplantations–a large volume. Sit and get consultations. Spend some time with at least three hair transplant surgeons and look at their results.
• FOF: If someone doesn’t qualify for hair transplants or laser therapy, what do you think of wigs or hairpieces?
  • Dr. P: Certainly those are options. They can be emotionally life altering for patients. If a woman’s hair is very thin and she feels self conscious going out, a hairpiece can make her feel much better. And they’re not going to damage your hair or make your hair loss worse.
• FOF: Even those that use adhesive or glue?
  • Dr. P: If you go to someone who is very good, they’re not going to damage what hair you have left. Sometimes if patients have medical problems, they can get a prescription for “hair prosthesis” (technical term for a wig) and insurance will cover it or it can be written off your taxes as a medical expense.
• FOF: What kind of doctor should you consult if you notice hair loss? A Dermatologist? An Endocrinologist?
  • Dr. B: Not to many doctors pay attention to hair loss. I’d say a dermatologist who is interested in hair loss. There are only a few people across the country like this. If I were a patient, I would call a dermatologist and say ‘Do you take care of hair loss?’”
• FOF: What’s the most important thing FOFs can take away from this conversation?
  • Dr. B: When it comes to hair loss, most doctors will say ‘you are getting older so you should expect it.’ Do not accept that statement. Hair follicles are one of the bodies’ fastest cells to turn over so there might be something you can do about it.

Author

Dr. Melissa Piliang and Dr. Wilma Bergfeld Melissa Piliang, M.D. Cleveland Clinic, Anatomic Pathology Melissa Piliang, M.D., is a Dermatologist who practices at the Cleveland Clinic Center. Dr. Piliang has joint appointments in the Departments of Dermatology and Anatomic Pathology. She is board-certified in both dermatology and dermatopathology. Her many interests include acne, androgen disorders, hair disorders, nail disorders, dermatitis and tumors of the skin. Wilma Bergfeld, M.D. Cleveland Clinic Center, Anatomic Pathology Wilma Bergfeld, M.D. is a Senior Dermatologist and Professor of Dermatology at the Cleveland Clinic. She is also the Director of the Cleveland Clinic’s Dermatopathology Fellowship. Dr Bergfeld’s specialty interests include clinical dermatology, dermatopathology, hair disorders, androgen excess, photoaging and cosmetic dermatology.