A Full Tummy Tuck (With or Without Circumferential Extension) Will Best Correct the Upper Belly and Bellybutton

I've lost 100 lbs. after having a Lap Band put in nearly 4 years ago.  My stomach issues are very unique looking, which is why I'm having the difficulty in determining what procedure I need.  My unwanted fat and loose skin are mainly only above the bellybutton, like they're sitting on a shelf.  I am unsure of which procedure would benefit me the most between simple liposuction, a modified Tummy Tuck, a full Tummy Tuck, or extended.  I'm open to any other suggestions as well.  I believe my skin has shrunk back as much as it can already.  Thoughts?

First and foremost, congratulations on your weight loss! What a wonderful transformation. In addition to your improved health, your figure already looks terrific.

Second, even though you might think that your tummy has "unique" issues, nothing could be further from reality. I see at least one patient per week whose tummy looks like yours.

Third, go for a full tummy tuck.

• After 4 years, your skin is not going to shrink on its own any farther--no matter how much exercise you do.
• Liposuction will not be helpful to treat the upper tummy and bellybutton. Since liposuction is a fat removal technique (without any significant skin tightening), liposuction is the wrong answer. You are already skinny!  The problem is too much skin without good tone, not excess fat.
• Mini tummy tucks are nonsense operations. I have never found the right patient for a mini tummy tuck--even after 8 years of practice!  A mini tummy tuck is for that very rare patient whose problem area is limited to her lower middle abdomen, just above her pubis. Obviously, this is not where you are concerned.
• A standard tummy tuck will work. To minimize "dog ear" formation on the bilateral hips, weight-loss patients generally get their best results when the tummy tuck is extended all the way around circumferentially. Whether you choose to keep the surgery just in the front or all the way around will be your decision. Both are good choices, but the circumferential technique generally produces better contours.
• Do not do a fleur-di-lis abdominoplasty. The vertical portion of the scar is ugly, and the operation is now recognized as obsolete. If any doctor offers you this surgery, run away!  He is out of date!!

Fourth, make sure that your lap band port is exchanged from a high-profile to a low-profile. Now that you are thin, the low-profile port will be less visible. You don't need that extra prominence to find the port anyway; you've got no subcutaneous fat. (Congratulations again!)

Fifth, make sure that your surgeon is certified by the American Board of Plastic Surgery. And, better yet, research whether he specializes in weight-loss patients. I do a lot of post-bariatric contouring, and let me tell you that weight-loss patients are very different from "regular" plastic surgery patients. Your surgeon needs the expertise only garnered from years of experience with your peer group.

Good luck!

Tissue Glue Rather Than Drains (?!)

 

Cohera Medical Inc announced the treatment of the first patient in a study of its lead surgical adhesive product, TissuGlu®. Initiation of the study marks a major milestone in the company's progression of the lead product toward clinical practice.

The clinical investigation is a prospective, open-label, randomized study to investigate the safety of TissuGlu and its effect on wound drainage and associated complications in abdominoplasty, or "tummy tuck," surgeries. The study will compare standard wound closure techniques to standard wound closure techniques plus the application of TissuGlu in 40 patients at three sites near Bonn, Frankfurt and Freiburg, Germany.

"We are delighted to have treated the first patient in the TissuGlu study," said Klaus Walgenbach, M.D., Ph.D., of the Universitatsklinikum Bonn and the principal investigator for the study. "We were very pleased with the procedure and look forward to enrolling more patients."

Currently, patients who undergo abdominoplasty require the insertion of drains to remove fluids that accumulate under the skin at the surgical site. In some cases, drainage is inadequate, and the excess fluid accumulation called seroma requires an additional procedure for removal. TissuGlu adheres the tissue flaps created during the procedure to reduce fluid accumulation, and, ultimately, the duration of use of the surgical drains. With the use of TissuGlu, patients may experience a significant reduction of fluid accumulation and a more comfortable recovery, which may lead to a quicker return to normal activity.

"Our transition into the clinical development phase brings us closer to helping plastic surgeons to address a critical unmet need and improve patient care," said Patrick Daly, president and chief executive officer of Cohera Medical. "Furthermore, the market opportunity for our company with TissuGlu is very significant, ranging between $500 million and $750 million from 2011 to 2015. If you add the additional applications such as facelift, breast reconstruction and body contouring that we will pursue with TissuGlu, the opportunity increases to between $700 million to more than $1 billion over the same five-year period."

Chad Coberly, J.D., vice president of clinical, regulatory and legal affairs of Cohera Medical, added: "Initiation of this study culminates significant preclinical work by our company and investigators and demonstrates the primary safety profile of this product. This study will enable us to move closer to CE Mark application in Europe and will provide important data in application for a larger U.S.-based trial in 2010."

Preclinical data published in the July 2008 issue of Plastic and Reconstructive Surgery show that TissuGlu prevented seroma formation in an animal abdominoplasty model. Summarized in a paper titled "Lysine-Derived Urethane Surgical Adhesive Prevents Seroma Formation in a Canine Abdominoplasty Model," (Plast. Reconstr. Surg. 2008; Vol. 122, Issue 1: 95-102) the results demonstrated that TissuGlu successfully prevented the formation of seroma in a novel large-animal model designed to evaluate seroma formation. While the control side in all seven animals used in the study demonstrated large, clinically significant seromas, the side treated with TissuGlu showed little or no evidence of fluid accumulation. In addition, histologic analysis of tissue samples from the animals showed no signs of inflammation or foreign body reaction associated with the adhesive.

"The progress with the development of TissuGlu represents a significant next step in the value creation for Cohera Medical's investors," said Doros Platika, M.D., the company's chairman. "Most importantly, it signifies a potential major advance for surgical patients that may help to decrease complications and improve clinical outcomes."

About Cohera Medical

Cohera Medical Inc. is a Pittsburgh-based company that is developing a revolutionary line of surgical adhesives. Cohera Medical's products are based on a unique chemical design that is purely synthetic, easy to use, biocompatible and fully resorbable. The company's lead product in development, TissuGlu, is an adhesive for plastic surgery procedures. TissuGlu adheres flaps of tissue after surgical procedures, eliminating the spaces where fluid accumulates and reducing wound drainage. Cohera Medical is also developing surgical adhesives targeting mesh fixation, small bone fixation and other plastic surgery indications that will fill similar market needs in plastic, orthopedics and general surgery.

Certain statements made throughout this news release that are not historical facts contain forward-looking statements regarding the Company's future plans, objectives and expected performance. Any such forward-looking statements are based on assumptions that the Company believes are reasonable, but are subject to a wide range of risks and uncertainties and, therefore, there can be no assurance that actual results may not differ materially from those expressed or implied by such forward-looking statements.

Source: Cohera Medical Inc

No Insurance Company Will Pay for a Tummy Tuck

I have a PPO.  How can I get my insurance company to pay for a tummy tuck?  Or will I have to pay for it out of pocket?

-Andy in Ventura, California

Dear Andy,

I think that you are confusing 2 separate procedures:

• panniculectomy
• abdominoplasty

A panniculectomy is a functional procedure for removing excess skin and fat.  An insurance company MAY authorize a panniculectomy if...

• The apron of excess abdominal skin impedes walking.
• The apron of excess abdominal skin impedes normal groin hygiene.
• There are recalcitrant fungal infections beneath the skin folds.
• The fungal infections have progressed to bacterial infections, necessitating hospitalization and IV antibiotics.

A panniculectomy is NOT an attractive operation.  The goal is function, not cosmesis.

• There is no tailoring of the skin excess.
• There is no liposuction to contour the flanks.
• The bellybutton is not preserved.
• The muscles are not tightened.
• The abdomen is not optimally flattened.

If your goals are functional, then you should consider a panniculectomy.  Find a Board Certified Plastic Surgeon who accepts your insurance, and then speak with him/her frankly.

If, however, your goals are to have a more attractive torso, then you are looking for an abdominoplasty, better known as a tummy tuck.  An abdominoplasty will take care of everything that a panniculectomy will, but it will also do more....

• The extra skin and fat (that creates the "apron" and/or the "roll") will be removed.
• The skin will be pulled taut, and will be tailored to your frame.
• The bellybutton is reconstructed and rejuvenated.
• The "six-pack" muscles are tightened.
• The abdomen is flattened.
• Often, some liposuction is done on the flanks to optimize the waist.

Obviously, no insurance company is going to pay for you to look cuter.  Medical insurance is supposed to help defray medical expenses.  An unattractive belly is not a medical problem; it is an aesthetic issue.  So, an abdominoplasty would be your financial responsibility.

There is one more caveat:  Sometimes, a patient suffers medical problems from an abdominal "apron."  Moreover, he/she wants not only functional relief but also aesthetic improvement.  In this circumstance, the surgeon can help the patient obtain authorization for a panniculectomy.  The patient might then pay the difference for a full tummy tuck.  In effect, the patient is getting the best of both worlds:  functional improvement (covered by the insurance company) and cosmetic enhancement.  Check out this example below...

 

Protruding abdomen? Consider a Tummy Tuck

My belly looks like a "prune."  I've had two kids.  I watch my weight.  I exercise daily.  What else can I do?

-Nicole

  

Nicole, you could consider an abdominoplasty.

An abdominoplasty is commonly known as a tummy tuck.  It is a major surgical procedure to improve the appearance of the tummy by...

• removing excess skin (and most of the pregnancy-related stretch marks!) from the lower and middle abdomen
• removing excess fat from the tummy
• tightening the abdominal muscles (whose laxity produces a protrusion of the central belly)
• rejuvenating the bellybutton

The best candidates for a tummy tuck usually...

• are in good shape
• have an abdominal "roll" that won't respond to dieting
• have loose skin that won't tighten with exercise
• have stretched abdominal muscles, due to multiple pregnancies
• have lost significant amounts of weight

An abdominoplasty is NOT...

• a weight loss technique
• for a patient who intends to lose more weight
• for a women who plans more pregnancies (The vertical muscles which are tightened during surgery can separate again after a pregnancy.)
• for patients who scar very poorly

Overall, an abdominoplasty can dramatically improve the appearance of a post-partum abdomen.  However, patients should bear in mind that...

• there will be a permanent scar that extends from hip to hip (about 3 times the length of a C-section)
• the recovery can be prolonged (2-4 weeks is typical.)
• smoking must be stopped for 4 months--2 months before and 2 months after surgery (Tobacco may lead to poor healing.)
• poor healing may necessitate a secondary operation

Our questioner Nicole did great:

 

"My Blood is Thin. Can I Still Have a Tummy Tuck?"

I have von Willebrand disease.  So, my platelets don't function properly, and my blood is thin.  Can I still have a cosmetic tummy tuck?

-Nicole

Yes!

There are variety of situations that cause the blood to be thin....

• von Willebrand disease
• hemophilia
• the prescription use of warfarin (also known as Coumadin)
• the over-the-counter use of aspirin, ibuprofen, naproxen, etc., for headaches or other pains

In most circumstances, the blood can be safely thickened so that it will clot normally even during major operations.  Tummy tucks typically produce very little bleeding, so Nicole's surgery went perfectly....

 

Package Deals in Plastic Surgery: Why They Make Sense

I have increasingly seen advertisements for plastic surgery "packages":

• New mommy makeovers:
  • Breast enhancement
  • Tummy tuck
  • Liposuction

• Surgical facial rejuvenation:
  • Browlift
  • Eyelids
  • Facelift
  • Necklift

• Non-surgical anti-aging:
  • Fotofacial/intense pulsed light lasers
  • Botox or Dysport
  • Fillers (like Juvederm, Restylane, Radiesse, or Sculptra)

My wife has been skeptical.  "Aren't those packages just gimmicks to sell additional services?"

Yes, but that's a good thing.  These bundled procedures do work well together.  Combining services can lead to results that are greater than the sum of their individual parts.

Consider the "new mommy makeover."  All women know that pregnancies and breast feeding cause both the breasts and the abdomen to swell.  In many women, the skin never snaps back to its pre-pregnancy elasticity.  Lifting or augmenting the breasts makes the chest look great.  However, the whole torso is not balanced until the tummy is also flattened and tightened.  So, combining breast enhancement with a tummy tuck does produce the best proportions.

Non-surgical solutions can also be performed concurrently to optimize results.  For example, the "11's" between the eyebrows will usually respond to Botox or Dysport; a 60-80% improvement is typical.  However, for some patients, 60-80% is not good enough; they want 90% erasure of the wrinkle.  So, adding a little bit of filler beneath the relaxed wrinkles (such as with Restylane or Juvederm) can nearly eradicate the 11's.

Fillers can even be used to enhance a surgery.  Everybody knows that a face/neck lift can improve the cheeks, jowls, jaw line, and neckline.  However, the area around the mouth is usually not rejuvenated.  So, I will often recommend Restylane or Juvederm to minimize the "smoker's lines" radiating from the lips.  Combining these fillers with the face/neck lift can produce the most harmonious result.

Multiple Plastic Surgeries in Mexico: Don't Do It!

I am going to have a tummy tuck, breast lift, and breast augmentation done at the same time with a board-certified doctor in Mexico. He says he can also do minor liposuction and inject the fat in the buttocks to give me a more smooth look.  He says this is included on all tummy tuck patients if they wish to do so, but I am a little nervous. Is it possible to have the three procedures done, along with the lipo and Brazilian butt lift?

- Housewife in San Diego

I am sorry to pick on you "Housewife in San Diego," but your question is very concerning to me. Frankly, I don't think you are being safe.

You're surgery is going to be far too long....

Dual-plane breast augmentations        1 1/2 hours

Wise-pattern (anchor) mastopexies     3-4 hours

Tummy tuck                                      3 hours

My math indicates that you're now up to about 8 hours.  Frankly, that's already pushing it.

I try to avoid operating on a cosmetic patient for longer than 6 hours at a time.  If she is young and very healthy, then maybe I'll do 8 hours. If I think that the case is going to last longer than 8 hours, I never do the operation in an out-patient surgery center.  I do these ultra-long procedures in a real American hospital with all of the safety precautions. The patient stays overnight for close monitoring by an excellent nursing staff.

OK, but now you want to add Brazilian butt lifting.  (Truthfully, I don't think BBL even works. It has never produced long-term success in my hands, and so I don't do this procedure at all anymore.  But anyways...)

Liposuction                                         1/2 hour

Brazilian butt lifting                              1 hour

So, now you've been in the operating room for at least 9 hours. 9 hours is way too long since I bet, Housewife in San Diego, that you will not be having your surgery in a fully accredited hospital.

Sorry. But this plan sounds unsafe.

Practicing in Ventura County, California, I take care of 5-10 patients annually, whose aesthetic surgeries were botched during Mexican plastic surgery adventures. To me, the thought of obtaining medical care—especially surgery—outside of the USA is ridiculous. Many plastic surgery procedures come with significant risks.  For example, most honest American/European/Asian research studies of breast reductions report 30-40% rates of complications!  For tummy tucks, 25-35%!  Many of these complications do not manifest themselves for 2-3 weeks.

So, Housewife in San Diego, what are you going to do if you have a complication?  Drive back to Mexico?  Who is going to take care of your complication at 2 am?

Well, in my community, I do. So, yes, I am bitter. I do resent going to the emergency room in the middle of the night to take care of a patient who had bad surgery done by a foreign doctor who had no intention of looking after her.

And, frequently, my hands are tied because I do not know the details of the surgery. Is the patient supplied with information regarding antibiotic usage? Suture type? Implant size and manufacturer? The answer is always, “No.” Have the patients and I ever been able to obtain this information from the foreign surgeon? Almost never.  Ultimately, my management of the patient’s complications is necessarily suboptimal because I do not have the specifics.

I certainly admit that not every physician in the United States is outstanding. In fact, while there are approximately 60,000 American physicians performing cosmetic procedures, only 6,000 of us are certified by the American Board of Plastic Surgery. Certainly, we need to clean up our own backyard.

Likewise, I am more than happy to refer patients to any number of outstanding Mexican plastic surgeons. Many of the world’s leaders in plastic surgery come from Mexico, particularly Mexico City.

But if you're going to get plastic surgery in Mexico, then do it right. Make sure that the surgeon is truly Board Certified. Which Board? The plastic surgery board or the general surgery board?  Is the facility accredited? What's the policy for complications? Who do you call in the middle of the night?

After you've found a Mexican plastic surgeon who gives you all of the "right" answers, then plan to stay in Mexico near his clinic while you recuperate.  Make sure that you follow-up with the surgeon who did the actual surgery.

Because of the need for prolonged follow-up, even my Mexican colleagues who are fantastic surgeons are not right for my Californian patients.  Follow-up is a crucial part of any surgery.  Surgical care does not end when you leave the operating room!  Patients need to be nursed through complications--some of which don't manifest for 4-8 weeks.  Patients also need reassurance; they must have the opportunity to come to see me, any day of the week and any time of day, to make sure that their experiences are “normal.”  Patients need continued compassion.

And a doctor can’t do any of those old-fashioned duties across the border.

Moreover, a doctor needs to see his/her results. How can I make improvements in my technique if I don’t get to see my results after complete healing?  This might be the biggest flaw of the cross-border surgeons.  They don’t even know that they are continuing to make mistakes, because they never see their own complications.

Some things just shouldn’t be “out-sourced.” Medical care is one of them.

Abdominal Irregularities after a Tummy Tuck in Oxnard: One Year After Surgery

A few days after seeing another surgeon's patient, who was unhappy with a painful abdominal bulge one week after a tummy tuck, into my office walks in another dissatisfied 45-year-old tummy tuck patient from Oxnard--but she is one year after her surgery.

I had a tummy tuck approximately 12 months ago.  My upper abdomen is perfect, but, right underneath my belly button on the right side, there is a bulge.  I have no idea what this is from.  Is it a weakness in my muscles?

The potential causes of this irregularity are different one year after surgery than they are immediately after an operation....

• inadequate fat excision or liposuction at the time of the surgery (which is an artistic error)
• inadequate or asymmetrical skin excision (which is also an artistic error)
• muscular weakness (either because the stitches used to tighten the muscles came loose or because recent weight fluctuations re-stretched out the muscles in some areas)
• chronic seroma (which is a benign fluid collection that never fully resolves on its own)
• organized hematoma (which is the scar that replaces an undrained blood collection)
• organized fat necrosis (which is the scar that replaces dead fat cells)

In most of the above circumstances, repeat surgery is required to correct the complication.  However, a mini-abdominoplasty approach is usually adequate, and the full incision does not usually need to be reopened.

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.

Body Contouring after Weight Loss: A Conversation Via Email

I thought that post-bariatric patients who are interested in body contouring may find this electronic conversation informative.

    

    

“Anna L.” and I got to know each other after she used the “contact us” function from my web site…

    

At this moment I'm researching costs before I book an appointment.  I would like to have a high and a low estimate for a complete body lift and breast enlargement surgery (1 cup size larger with silicone gel implants). I understand that the estimate will be very “rough” without a proper consultation.

    

Please understand that I live in Edmonton, Alberta, so even the initial consultation will entail a large cost for me due to the travel.

    

I think that excess skin will need to be removed from my abdomen, thighs, arms, back, and buttocks. A breast lift is not needed; there is no sagging there.  In addition I would like to have the muscles repaired/tightened in the abdomen. The excesses skin removal is needed due to a weight loss of 160 pounds.

    

Second, I would like to know if these procedures can be done at one time, rather than separated over weeks or months.  Please e-mail me!

    

Thank you for your time and take care,

Anna

    

    

My long-winded response (with information about body lifting, breast augmentations, pricing, and staging procedures):