Abdominal Irregularities after a Tummy Tuck in Thousand Oaks: One Week After Surgery

A 45-year-old woman from Thousand Oaks, California, presented to my office for a second opinion after a recent abdominoplasty ("tummy tuck")....

I lost 125 lbs.  Seven days ago, I had a full tummy tuck.  Now, I have a knot directly under my rib cage, to the left of the belly button.  It hurts when I get up or cough.  I have had groin hernias in the past, and it feels similar.  Could it be another hernia related to the tummy tuck?  What can I do?

There are many causes for painful abdominal irregularities one week after an abdominoplasty....

• irregular swelling (such as from inappropriately wearing a post-operative garment)
• seroma (which is a benign fluid collection, such as from a malfunctioning drain)
• hematoma (which is a blood collection, usually from inadequate control of bleeding during the operation)
• inadequate fat excision or liposuction (which is an artistic error)
• fat necrosis (which refers to death of some fat cells, usually from poor blood supply, and which sometimes occurs in obese patients and in smokers)
• abscess (which is an infected collection of pus, and which can result from a seroma or hematoma, but more often than not, is the result of bad luck)

The term hernia refers to a defect in the muscles of the abdominal wall.  This "hole" allows internal organs to protrude out from the abdominal cavity.  A hernia would be unusual at the described location.

Most of the common causes of early, painful irregularities after a tummy tuck can be managed without additional major surgery.  Aspirations (using needles to draw out fluid) and antibiotics are the mainstays of management.  Occasionally, however, returning to the operating room is the most effective way to control acute problems.

SmartLipo and Brazilian Butt Lifting: Can a Patient Use the SmartLipo Fat for Buttock Augmentation?

No.

SmartLipo refers to a proprietary, laser-assisted-liposuction device.  It is cleverly named and marketed.

Like most modern liposuction platforms, SmartLipo combines a fat-melting technology with traditional fat-sucking equipment.  SmartLipo uses an Nd:YAG laser to melt fat; other popular machines employ ultrasound to emulsify the fat.  (Personally, I prefer the VASER ultrasonic device from Sound Surgical Technologies.)

Laser and ultrasound are terrific because they help make fat removal easier and more complete.  Compared to traditional liposuction, laser-assisted and ultrasound-assisted liposuction produce better contouring, with smoother results, with less irregularity, and with tighter skin.

So, melting fat is a good thing--unless you want to use that fat for some other purpose....

Melting fat injures the fat cells.  Injured cells cannot be successfully "transplanted" to another part of the body.

Brazilian butt lifting involves grafting fat cells from unwanted areas (usually, the tummy, back, flanks, or hips) to the buttocks.  If the fat is healthy, it will live.  Living fat will provide volume, thereby enlarging the buttocks.  The subsequent tumescent effect will provide the "lift."

Injured fat will not live, and so attempting a Brazilian butt lift with SmartLipo fat (or VASER fat) is bound to fail.  Moreover, dead fat could cause complications such as irregularities and infections.

If a patient wants simultaneous liposuction and Brazilian butt lifting (or any other fat grafting procedure), I try to customize the process for the patient.

• Where she has really stubborn fat deposits that she just can't stand, I'll use the VASER.  It is the best device for optimal fat removal and contouring.
• However, where she has a little bit of extra fat that is not too much of a concern, I'll recommend traditional liposuction.  With regular liposuction, I can obtain healthy fat cells, and still sculpt the patient's figure.
• Then, I can use that healthy fat for the fat transplantation to the buttocks.

Juvederm and Restylane Nodules: Options for Treatment

Ms. DB presented to my office for a second opinion.  She had had Juvederm injected into her "tear troughs" to fill out the dark circles underneath her eyes.  Unfortunately, she developed a visible nodule beneath her lower eyelid.  To her, it looked worse than the original "dark circle."

On examination...

• The lump was below the lower eyelid.  ("Bags" develop when fat around the eyeball pushes out against the lower eyelid.  The cause can be age or fatigue.  This nodule is too low to be a bag.)
• The nodule was superficial.  (Juvederm is usually injected into the deep layers of the skin or just beneath it.  However, around the eyes, the Juvederm should in placed beneath the muscle that is right underneath the skin--there should be two layers on top of the Juvederm in order to obscure it.  This is the other doctor's mistake; he didn't know the nuances of periorbital Juvederm placement.)
• The lump has the soft, jelly-like consistency of Juvederm, Restylane, and Hydrelle.

There are three solutions, all of which are appropriate and none of which are mutually exclusive.

1. Patience:  Time will take care of such a nodule.  Juvederm typically lasts 6-12 months.  Therefore, we can all assume that the Juvederm will dissolve away on its own.
2. Massage:  I always recommend firm massage for 5 minutes, 5 times per day.  Include up-down, side-side, and circular motions.
3. Hyaluronidase:  Hyaluronidase is an enzyme that specifically dissolves hyaluronic acid products, such as Juvederm, Restylane, and Hydrelle.  It is simple to inject, but may require multiple treatments (to avoid over-dissolving the natural hyaluronic acid in the cheek area).  It usually (but not always) makes a significant improvement.

Ms. DB chose to undergo hyaluronidase immediately after her consultation.  She then massaged patiently for a month.  Fortunately, she had full resolution!

Do Silicone Breast Implants Cause Lymphoma?

Probably not.

A group of Dutch plastic surgeons noticed that two of their patients developed anaplastic large-cell lymphoma after silicone breast augmentations.  Because this is a particularly rare form of cancer, the surgeons searched the Dutch national database to determine whether any other women had developed anaplastic large-cell lymphoma after silicone breast implantations.  A total of 13 women were identified--over 10 times more women than expected!

This sounds terrifying, I admit.  However, I think that this research is really more inflammatory than substantive.

• First, anaplastic large-cell lymphoma is extremely rare.  The incidence in the American population is 1 in 10 million.  Even if a woman has a 10- or 20-fold greater risk of developing this cancer, the risk is still just 1 in a million.
• Second, silicone breast implants almost certainly did not cause the cancer.  Silicone has been used for decades in a variety of medical implants--heart valves, artificial hips and knees, special IVs for long-term antibiotics or chemotherapy, etc.  If silicone was the problem, why wouldn't patients with artificial knees not have an increased risk of developing this rare lymphoma?
• Third, silicone implants have been extensively evaluated for safety.  It is sad but true to consider that more money has been spent in the scientific development of silicone breast implants than any other medical product.
• Fourth, decades-long evaluations of silicone implants in New England, Canada, and Scandinavia have never generated this data before.  Could the Dutch finding be a statistical anomaly?
• Or could another statistical issue be at play?  Could there be a confounding variable?  A confounding variable is an extraneous influence that may not be independent of the so-called cause or the effect.  For instance, women who undergo silicone breast augmentations may be more likely to engage in some type of behavior that is the true cause of the anaplastic large-cell lymphoma.  Are Dutch women who choose silicone breast augmentations more likely to smoke (or engage in some other known deleterious activity) than Dutch women who are not interested in breast augmentation?  Is, then, the issue not the silione implants but the smoking?

Certainly, cancer of any sort should not be taken lightly.  I will certainly be more vigilant in my evaluation of my patients after breast augmentation surgery.  And I will make sure that women who are considering this surgery know about the Dutch surgeons' finding.

Nevertheless, silicone implants will remain my favorite choice for breast enlargement and one of the best choices for breast reconstruction.

Rhinoplasties and Glasses

Many patients wonder how they will wear their glasses after a rhinoplasty ("nose job").  Obviously, plastic surgeons prohibit any pressure on the healing nose, even the light footplates from glasses.

(My preference is to protect the healing nose with a splint for two weeks, and to avoid glasses on the nose for three weeks.)

Frequently, the best solution is to use contact lenses, rather than glasses.  However, among patients who prefer glasses, a simple option is a long strip of tape to secure the central portion of the glasses to the forehead.  The glasses should "hover" just above the bridge of the nose, without resting on it directly.

Certainly, this looks goofy, but it should be acceptable when a patient is at home or at her desk.  And the final result will be worth it!

Re-do Nose Jobs in Ventura: How Many Rhinoplasties is Too Many?

Recently, a patient from Ventura, California, named Ms. CE presented to my office with the following story:

I am a 36-year-old woman, and I have had three cosmetic operations on my nose.  [By the way, all the operations were performed in Beverly Hills--certainly a much over-rated spot for plastic surgery.]  Yet, I am still unhappy.  I have trouble breathing through both nostrils (especially the right), and I don't like the way it looks.  Is it possible for me to have another surgery, or should I just live with my nose?

This is a very tough situation.  Re-do nose jobs (also known as secondary rhinoplasties, or tertiary rhinoplasties, or--in this patient's case--quaternary rhinoplasties) are extremely challenging.  Amongst aesthetic plastic surgery operations, they are considered the most difficult of surgeries.  Just look at Michael Jackson; no amount of money, time, expertise, or intelligence is going to help his nose!

The problem with repeat surgery is that each operation creates scar tissue, weakens nasal support, and reduces the blood supply to the nose.  If the operation does not go perfectly, then the situation is progressively more difficult to remedy.

When I meet a patient to discuss re-do rhinoplasties, I carefully evaluate...

• the quality of the overlying skin
• the quality and presence of the structural support (the cartilage and the bone)
• the quality and condition of the inner nasal lining (the mucosa)
• whether there are functional airway problems (such as collapsed nasal passages)
• the overall aesthetics

Sometimes, the skin, cartilage, bone, and mucosa are perfectly healthy--almost as if the first surgery had left no scar tissue.  In these rare circumstances, there is a good chance that a secondary procedure will be completely successful.

More frequently, however, there is significant scarring and failure of the cartilages.  In these circumstances, the patient and I must make compromises.  She and I must identify the area or issue that bothers her most, and then we need to focus on that.

In the case of Ms. CE the issue that bothered her most was her breathing.  Based upon her degree of scarring, I thought that it would be unlikely that I could optimize both her airway and her appearance.  So, my revision surgery focused on opering up her nostrils so that she can breathe better during exercise and sports.

After she had healed from surgery, I used Juvederm and Radiesse to remold her nose non-surgically.  Her aesthetic appearance is now acceptable, albeit not perfect.

If Ms. CE had been unreasonable--expecting me to correct both her airway and her appearance with a heroic fourth rhinoplasty--I would have had to decline surgery altogether.  Repeat surgery is just not as accurate and predictable as I wish it were.