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Cosmetic Surgery

Cosmetic Surgery

Dr. Hugh Hetherington at Bozeman Health Cosmetic Surgery + Medical Spa uses the newest, least invasive methods and cutting-edge technologies to achieve long term results. Procedures are done outpatient under local anesthesia and/or conscious sedation, although general anesthesia in the hospital is also possible.


Sculpt away genetically stubborn, unwanted fat deposits that exercise and healthy eating just can't. *Liposuction removes fat and fat cells, sculpting the body to a leaner version of itself. It is one of the most common cosmetic procedures performed in the U.S. today.*

Injecting tumescent fluid - a dilution of local anesthetic and a capillary constrictor - into subcutaneous fat, causes the targeted tissues to swell and get firm. This technique provides long-lasting local anesthesia requiring less pain relieving drugs post-surgery. Associated vasoconstriction (blood vessel shrinkage) also prevents significant blood loss.

After tumescent fluid is injected, surgeons make small incisions. A cannula, a stainless steel tube, is inserted to remove unwanted fat cells. Using canulas allow for gradual and controlled fat removal achieving smooth results.

Frequently asked questions about liposuction:

  • Who is a candidate for liposuction?
    Liposuction is not a weight-loss solution. It is best used on individuals who are active and of normal body weight to remove localized fat deposits that are diet- and exercise-resistant.
  • "I'm thinking of having a liposuction procedure done on my abdomen, is liposuction safe?"
    When liposuction is performed using the tumescent technique, it is very safe.
  • Will liposuction hurt?
    We use conscious sedation and a local anesthetic in the tumescent fluid. This helps makes the procedure almost completely pain free.
  • How long is the recovery?
    Most patients are back to work in a day or two *. Some patients take a little longer. The sites will remain tender and bruised for several weeks.
  • What areas respond to liposuction?
    Liposuction is the most versatile fat reduction method available. It may be used to reduce fat deposits of the abdomen and waist, hips and buttocks, thighs, upper arms, back, inner knee, chest area, cheeks, chin and neck, calves and ankles.

Breast Augmentation

Create larger, fuller and often more lifted breasts with fluid-filled implants. Our surgeons use the newest surgical method leaving virtually no scars.

Trans-Umbilical Breast Augmentation (TUBA) v. underarm insertion

Trans-Umbilical Breast Augmentation (TUBA) implants are placed under the breasts through the navel using an endoscope leaving an essentially invisible scar hidden in the navel and no scarring on or around the breasts.

This endoscopic procedure involves a small incision in the belly button. A tunnel is made through subcutaneous abdominal fat and a pocket is created either on top of or under the pectoralis major muscle. The implant is placed through the tunnel and inflated. Final adjustments are made to the implant pocket and the incision is then closed. The procedure is commonly performed using local anesthesia and with intravenous sedation.

Advantages of the TUBA procedure include:

  • A single inconspicuous scar deep within the navel
  • Less invasive and, therefore, less breast trauma
  • Minimal bleeding
  • Faster recovery
  • Less risk of injury to the sensory nerves of the nipple and breast
  • Shorter operative time
  • Less anesthesia

Implant types

    Saline vs.

  • Lower rate of capsular contraction (see under silicone).
  • Can be used with TUBA method.
  • Can be filled once placed in body.
  • Can be adjusted after placement.
  • Considered safer because saline is essentially water, so there are few concerns if an implant leaks or ruptures.
  • Usually slightly overfilled to minimize ripples along implant edges and to prevent folding. This makes the implant feel a bit firmer.
  • Can have mammograms for breast cancer screening rather than more expensive MRI.


  • More natural feel and appearance.
  • Slightly higher rate of capsular contraction causing distortion, hardness and sometimes chronic pain.
  • Pre-filled requiring larger skin incision and cannot be used with TUBA method.
  • Requires biannual MRIs to screen for implant ruptures (more pricey than mammograms).

Implant placement

Implants may be placed between the gland and the chest muscles or underneath the pectoralis muscles. Location choice is determined based on the need for adequate soft tissue necessary to minimize visibility of implant edges.

    Subglandular vs.

  • Placed under the gland and on top of the pectoralis major muscle.
  • For those patients who have sufficient breast and subcutaneous tissue, results are more natural.
  • Requires less dissection, is less traumatic and, therefore, results in quicker recovery.


  • Provides slightly more soft-tissue for implants placed underneath the pectoralis major muscle. Typically, the muscle is detached from the lower ribs and does not cover the lower portion of the implant.
  • Because some muscle attachments are disrupted, this placement is more traumatic and may increase recovery time.
  • Because the implant is partially placed beneath a powerful muscle, it will temporarily change shape with vigorous contraction of the pectoralis. This deformation is minimal but may be noticeable to the patient during vigorous exercise.

Implant size

Generally, the larger the implant, the more obvious it will be and the more it will sag over time.

Breast implant size is a personal decision determined by patient desire and what the patient’s tissues can accommodate. The amount of soft tissue coverage is key to determining how large an implant is reasonable.

We use a system of objective measurements to determine a reasonably sized implant for each patient. We ask patients to participate in this process by padding a sports bra to determine the approximate size the patient wants.

Anesthetic Technique

We have a great deal of experience performing surgery using local anesthesia with intravenous sedation in our hospital procedure room. Most patients tolerate it well, have little, if any, memory of the procedure and recover is relatively quickly.

Common misconceptions about transumbilical breast augmentation (TUBA)?

The most common myths concerning transumbilical breast augmentation were summarized and dispelled in an article published in the official journal of the American Society of Plastic Surgery* as paraphrased below:

It is too difficult to dissect all the way up there.
The pocket is created not by dissection, but by expansion. There is no cutting behind or in the breast. Pocket creation is actually easier than using any other method.

There are too many complications.

The original study showed a lower complication rate than with other methods. There is also less bleeding compared to other methods.

The surgeon cannot control bleeding.
There is a remarkable absence of bleeding with TUBA and rarely any bleeding at all to control. However, doing so presents no problem by visualizing the implant pocket through an endoscope.

The surgeon cannot position the implants properly.
Because the surgeon sees the exact shape of the breast and position of the implant during the expansion phase, there is no guesswork in implant positioning.

Pushing implants through the tube damages them.
Implants are not pushed through a tube. The implant is seated on the end of a tube used to push implants into position.

The technique leads to visible track deformities on the abdomen.
The author saw no visible track deformity in seven years performing TUBA.

Using the implant as an expander damages it.
This is the most understandable of the misconceptions. Originally, the implant itself was used as an expander, putting it under excessive stress. This has not been done since 1992. Instead, a separate expander step has been incorporated into the technique.

Using the transumbilical technique will void the warranty on the implant.
This is patently untrue. We have verified with implant manufacturers that this technique does not void the warranty.

It is a blind technique.
This has no significance in actual practice. Tissue expansion, rhinoplasty and liposuction are all "blind" techniques that are well-accepted, performed frequently and have low complication rates. Moreover, the transumbilical technique is the only one of these "blind" approaches in which the operative site is inspected with an endoscope, so is not truly blind.

The technique increases the risk of implant failure.
This is untrue in both practice and theory.

The technique Is only suitable for prepectoral placement.
This was initially true. However, instrumentation and techniques for subpectoral placement have been available for some time.

Removal of the implant cannot be done through a transumbilical incision."
The saline implants are easily removed through the navel.

"Disrupting the abdominal muscles causes excessive pain.
Abdominal muscles are not disrupted in any way. The entire procedure is performed above the anterior rectus fascia in the subcutaneous plane. One noteworthy feature of the transumbilical procedure is that it is less painful than other methods and results in quicker recovery.

The technique cannot be performed if the patient has an umbilical hernia.
The original article cited "abdominal hernia" as a possible contraindication to transumbilical augmentation. In fact, an umbilical hernia can be repaired at the same time.

The implant must pass between the abdominal organs.
The transumbilical procedure is entirely subcutaneous and does not involve abdominal organs or muscles.

The technique cannot be performed if the patient has a navel ring.
Navel rings have proven no obstacle. Some surgeons prefer the ring to be removed during the procedure and reinserted afterward; others prefer to leave them in place or even use them to aid in elevation.

Going through the navel will cause infections.
No surgical procedure can be free of the possibility of infection. The author has seen no infections with the transumbilical procedure; but has seen them with other methods of augmentation. Infection is very unlikely. With the incision so remote from the implant, even a wound infection would be unlikely to reach the implant.

The surgeon cannot control the plane of the implants.
The endoscope is used to verify that the implant is in the proper plane relative to the pectoralis muscle.

Using a drain would require a breast incision anyway.
Most surgeons performing transumbilical augmentations have not used drains. Thin, round drains may be used through the navel and so no breast scarring. At Big Sky Cosmetic Surgery, we have rarely found drains to be necessary.

*Dowden, R. V. Dispelling the Myths and Misconceptions about Transumbilical Breast Augmentation. Plastic & Reconstructive Surgery. Volume 106(1), July 2000, pp 190-194

Rhinoplasty (Nose Surgery)

Boost your self-confidence with this outpatient nose surgery that corrects deformities. Advanced imaging software enables you to preview a computer-generated image of your new nose before surgery.

Questions about Rhinoplasty

What is rhinoplasty?
Rhinoplasty is a cosmetic surgery performed to reshape the nose by reducing or increasing its size, removing a hump, changing the shape of the tip or bridge or narrowing nostril span.

Am I a good candidate for rhinoplasty?
Rhinoplasty is ideal for healthy, psychologically stable men and women who are seeking improvement, but not perfection in their facial appearance. Most surgeons also consider age as a factor, preferring young patients who have finished growing.

What are the benefits of rhinoplasty?
Benefits of rhinoplasty can range from improved breathing to enhanced appearance and self-confidence.

What are the risks associated with rhinoplasty?
As with any surgery, rhinoplasty does carry some risks. Fortunately, complications are rare and usually minor. Nonetheless, complications may include infection and bleeding.

Will I be put under general anesthesia?
Depending on the preference of the surgeon and/or patient, rhinoplasty can be performed under general or local anesthesia.

What does a rhinoplasty procedure involve?
Surgical techniques for reshaping the nose vary. However, rhinoplasty generally involves the separation of nose skin from its framework of cartilage and bone. This can be done either from an incision inside the nose or through an "open" procedure that requires an external incision in the tissue separating the nostrils. The surgeon then reshapes the nose, replaces the skin over the new framework, and applies a splint to help the nose maintain its shape.

How long does it take to recover from rhinoplasty?
Healing after rhinoplasty is slow and gradual with subtle swelling sometimes persisting for months. However, patients can usually expect to return to work or school within a week or two and to more strenuous activity within two to three weeks.

How long can I expect results to last?
With the exception of changes associated with aging, results are permanent.

Otoplasty (Ear Surgery)

Otoplasty is used to correct external ear deformities. Optimal age for this surgery is at about five, when ears have reached 85% to 90% of their adult size so there is little concern about affecting normal ear growth. However, otoplasty can be performed at any age. Adults and older children can have the procedure under local anesthesia, often with intravenous sedation.

Questions about Otoplasty

What is recovery like?
The surgery is done in the office under sedation and local anesthesia. In very young patients the option of general anesthesia is more appropriate. In these cases, we perform the surgery in a hospital operating room. The patient will wear ear dressings for one week. After the first week, a head band protecting the ears is worn at night for six weeks. There is tenderness, but the discomfort is easily controlled with pain medication.

Are there visible scars?
The incision is hidden in the crease behind the ear and is very hard to detect even in men with very short hair.

Rhytidectomy (Face Lift/Mini Face Lift)

You feel young and vital, but as your skin ages, your face tells a different story. As skin ages, it loses elasticity, creating sags, creases and jowls in the mid and lower portions of the face and neck resulting in a tired, worn-out appearance. A lift may be the solution to more youthful-looking face and neck contours. This versatile and long-lasting surgery is typically performed under conscious sedation on an outpatient basis, although patients may choose general anesthesia in a hospital operating room. Most patients return to normal activities in about two weeks.

What is the difference between a face lift and a mini face lift?
A face lift addresses primarily the neck and jowls. The difference between a face lift and a mini lift is in the length of the incisions. The mini face lift or short scar incision is hidden in the front of the ear and runs up the back of the ear. A face lift is for a more aged neck and jowls. The incision is hidden in front of the ear, runs behind the ear and is extended into the hairline. Once healed, both are very difficult to detect.

What is the recovery like for a face lift?
For all facial procedures we recommend a two-week healing period. Initially, you will have swelling and bruising. By week one, most of the swelling will have subsided and by week two most of the bruising will be gone. If any bruising remains it is easily concealed with makeup. You will want to sleep with your head elevated during recovery and any discomfort is managed with medication. You can resume most everyday activities after two days; walks are encouraged at this time. More rigorous activities are not recommended for three to six weeks. As with all our facial surgeries, you are offered five Curelight treatments to speed your recovery.

Endoscopic Brow Lift

Remove those deep furrows that make you look mad or sad. Using an endoscope, surgeons make tiny incisions hidden along the hairline to carefully rotate the scalp to a higher position without removing any skin. The results are a smooth, natural look. This long-lasting procedure is typically done outpatient using conscious sedation. Most patients return to normal activity in about two weeks. Patients often combine brow lift with blepharoplasty (eyelid surgery).

Questions about Brow Lifts

I don't want to be restricted in my activities too long. When can I ride my horse and exercise again?
A strenuous workout is usually allowed after two to six weeks. You can, however, resume most everyday activities after two days, and walking is encouraged at this time.

I don't want scars, how big are they and are they visible?
Since this surgery is endoscopic, all incisions - usually six small ones -- are within the hairline and not visible. No scalp skin is removed and hair does not need to be shaved.

Blepharoplasty (Eyelid Surgery)

Eyelid surgery (blepharoplasty) is very affordable and one of our most popular procedures. Correcting droopy eyelids and under-eye bags will rejuvenate the eyes and can transform one's whole look from tired and heavy to refreshed and relaxed.

Questions about Eyelid Surgery

What does the procedure involve?
On the upper lid, the doctor makes a very fine incision in the crease of the eyelid. Excess fat and skin are removed and the incision is closed. Once healed, the scars are nearly invisible.

On the lower lid, there are two different approaches.

One is called transconjunctival (through the inside of the lid) where excess fat is either removed, repositioned or both. No skin is removed and there is no visible scar.

The other lower lid approach is most effective when there is excess skin as well as bags. A very fine incision is made near the lash line. The fat is either removed or repositioned. Sometimes the cheek muscle is slightly elevated, then excess skin is removed. Stitches are removed after four days.

How long is recovery?
Initially there is swelling and bruising. This usually resolves in two to three weeks. Most patients return to work after a week or two, using make-up to mask any remaining bruises.

Midface Lift

Reduce sagging or sinking cheeks, eye bags and folds along the nose and corners of the mouth. Using incisions below natural lash lines, midface tissue is lifted and reattached improving that sunken appearance under the eyes, redefining cheekbones and reducing folds around the mouth and nose.

Questions about Midface Lifts

I have never heard of a midface lift, what exactly does it do?
A midface lift addresses the portion of the face from the lower eyelid through the cheeks. Imagine subtly lifting your cheeks up to your lower lids and removing excess skin. It is particularly effective if you have hollowing under the eyes and deep nasal labial folds.

How is this different from a lower blepharoplasty (eyelid surgery)?
A lower blepharoplasty is best if you have bulges and excess skin under the eye. A midface lift improves hollowing under your eyes and sagging cheeks.

Abdominoplasty (Tummy Tuck)

This procedure tightens the abdomen by removing excess skin and fat often developed during pregnancy or major weight loss. It may also include abdominal muscle tightening.

Questions about Abdominoplasty

Is a tummy tuck a good way to lose weight?

No. Abdominoplasty is not used to treat overweight or obesity issues. Patients intending to lose weight should reach weight stability before having any body-contouring surgery.

Are there alternative treatments to a tummy tuck?

If there is good skin tone and localized fatty deposits, liposuction may be a surgical alternative. Suction-assisted lipectomy or other body-contouring elective surgeries may also be combined with abdominoplasty. Diet and exercise programs may reduce excess body fat and improve body contour without surgery.

How long is recovery from abdominoplasty?

On average a week to ten days with proper follow-up and at home care.

Will there be scars?

Yes, every surgery has a scar. This one is placed below the bikini line/lower abdomen which is easily hidden by everyday basic undergarments or a bathing suit. Incision placement varies depending upon the amount of skin removed.

Earlobe Repair

Repair torn, damaged, gauged or stretched earlobes with this simple procedure done right in our office. The procedure will be slightly different for each patient. Sutures are typically removed after between five and seven days.

Fat Transfer

Facial fat loss combined with loss of skin tone and muscle tone is part of the natural aging process and one of the primary causes of an older-looking face. Fat transfer takes years off your face, restoring youthful volume using your own living tissue.

Questions about Fat Transfer for the Face

How is this procedure done?

Fat transfer is a two-step process. First surgeons harvest fat (most commonly from the inner thighs) using tumescent fluid -- a dilution of local anesthetic and epinephrine. The fluid numbs the area and minimizes bleeding. Fat is gently suctioned out through small tubes.

Stage two involves injecting the harvested fat into intramuscular or subcutaneous areas around the eyes, cheeks and mouth. The patient and doctor determine the exact placement during a pre-operative consultation.

Are there alternative treatments to fat transfer?

Non-surgical, injectable dermal fillers provide wrinkle reduction lasting six months to a year. Solid implants can be used to enhance volume in certain areas of the face including the chin, cheeks and jawline.

What is the recovery time for fat transfer?

Bruising and swelling can last from two to four weeks. Curelight treatments can help reduce healing time.