I’ve spent my career, as a board-certified plastic surgeon in Beverly Hills, performing aesthetic surgery of the face, breast and body. My experience has taught me that just because we can perform a procedure doesn’t mean it is the best option for a patient.
When considering surgical interventions, I weigh the predictability and reversibility of the results, potential complications, the longevity of the outcomes and, finally, whether I would recommend the procedure to someone in my own family.
Here are the six procedures I rarely, or never, recommend, ranked from the ones I may consider in select patients to the one I would avoid entirely.
1. Cheek implants
In this procedure, solid implants are placed over the cheekbones to permanently increase projection and contour. These can create beautiful results in the right patients, so I don’t consider this a ‘bad’ procedure. I do worry about the aftereffects.
Facial aging will continue to take its course while the implant remains a fixed size and shape, for many years. This can result in a very unnatural appearance. Implants can also shift, become visible or even infected, demanding revision or removal.
Today, we have other ways to restore facial volume that allows more nuance and individualized treatment. I generally prefer an approach that allows the surgeon to sculpt the face rather than committing every patient to a permanent implant.
2. Chin implants
For properly selected patients with a recessed, under projected or ‘weak’ chin, implants can be a great solution. However, they are not the answer to every case.
The surgeon must determine why the chin appears deficient. Is it purely aesthetic or is there a medical issue that needs to be addressed?
Some patients have a skeletal or bite issue that an implant cannot correct because an implant rests on the outer surface of the lower jaw. Depending on the anatomy and desired degree of correction, the patient may require invasive surgery that cuts and repositions the actual jawbone.
Potential chin implant issues include malposition, asymmetry, infection, numbness and, over time, pressure-related changes to the underlying bone, if the implant settles in the wrong spot.
3. Lip implants
Lip implants are permanent synthetic implants inserted through the lip to create lasting volume. The word ‘permanent’ may sound attractive, but lips are dynamic structures that move constantly when we speak, smile, eat and kiss.
A permanent implant can sometimes feel too firm, become palpable, migrate, become infected or simply look unnatural as the face changes with age.
If the patient dislikes the size or shape of their lips, correction requires another procedure. I much prefer creating subtle lip enhancement with temporary hyaluronic acid filler because it can be adjusted over time and, importantly, can often be dissolved if necessary.
I much prefer creating subtle lip enhancement with temporary hyaluronic acid filler
4. Buttock implants
Unlike breast implants, solid silicone buttock implants are positioned in an area subjected to significant pressure and muscular forces from sitting, walking and exercising.
Recovery can be very difficult because patients cannot simply stop using their gluteal region during everyday life. Complications can include wound separation (the reopening of stitched incisions), infection, fluid collection, implant malposition and the need for revision surgery.
In patients seeking gluteal enhancement, I would rather evaluate whether there is a safer, anatomically appropriate alternative rather than placing a large permanent implant in an area exposed to so much mechanical stress, including surgical fat transfer and good old-fashioned exercise.
5. Transumbilical breast augmentation
Transumbilical breast augmentation (TUBA) places breast implants through an incision hidden inside the belly button and advances them through a tunnel up to the breasts.
Typically, empty saline implants are inserted into the body empty and then filled, as opposed to silicone gel implants which arrive from the manufacturer filled to a fixed volume.
The obvious selling point is no incision on the breast, but I don’t believe hiding a small scar justifies sacrificing surgical control. The technique limits a surgeon’s ability to visualize placement of the implant.
For me, breast augmentation is about precision: controlling the pocket, position, symmetry and implant relationship to the patient’s anatomy.
I prefer an incision that gives me direct access and maximum control rather than choosing a technique primarily because the incision sounds more appealing.
6. The procedure I would NEVER recommend
Injectable silicone is in a completely different category from an FDA-approved silicone breast implant.
For me, breast augmentation is about precision: controlling the pocket, position, symmetry and implant relationship to the patient’s anatomy
In this procedure, silicone is injected directly into tissues to enlarge areas such as the buttocks, breasts, face or lips. I would never recommend cosmetic free-silicone injections.
Silicone can migrate from where it was injected and trigger chronic inflammation, granulomas, tissue destruction, infection and other serious complications that may appear years later.
Once injected, it can be extraordinarily difficult, or impossible, to remove completely because it becomes incorporated throughout the tissues. Some complications require multiple operations and can cause permanent deformity. For me, the risk-benefit equation simply does not make sense.
The common thread is that aesthetic medicine should never be about doing a procedure simply because it exists or because it is trending. My job as a plastic surgeon is as much to operate as it is to know when to say ‘no.’
The best procedure is the one that gives the individual patient the safest, most predictable, most natural-looking result, with risks that are justified by the potential benefit.
