November 21, 2011

Plastic Surgery After Weight Loss Works

Before:  48-year-old woman who lost 160 lbs. after bariatric surgery and after becoming an avid cyclist


After a tummy tuck.

092 (2)

Let's be honest.  We have all seen somebody who has had plastic surgery, and whom we can hardly tell whether there is a difference.  We squirm with that facelift patient, "Um. Er.  You look...er..better(?)"  We try our best to wriggle out of the discussion.

I never feel that way with my weight-loss patients.  Abdominoplasties, body lifts, brachioplasties, breast lifts, etc., on bariatric patients typically create dramatic improvements.  The results are not subtle.


December 15, 2010

Urban Myth of Plastic Surgery: Rib Removal

True or False:

Janet Jackson underwent a rib removal to thin her waist.


Women are born with different lengths to their waists.  A long distance between the lower ribs and the pelvic bones is "long waisted"; a short distance between the lower ribs and the pelvic bones is "short waisted."

Long waists (along with a minimum of body fat and lots of working out) create hour-glass figures.  Short waists tend to produce "boxy" torsos.

If you are short-waisted, what can you do to lengthen your waist?  Not much.  Theoretically, removing one (or a few) of the lower ribs would increase the distance between the ribs and the pelvis.  But I don't know of any reputable plastic surgeon who performs costectomies for cosmetic purposes.

Why don't we plastic surgeons remove ribs more frequently?  Because ribs are important!  While God may have used one of Adam's ribs to create Eve, He left the rest in place to ventilate the lungs and to protect the heart, lungs, spleen, liver, kidneys, etc.  Without ribs, you can't breathe, and your critical innards won't be protected against routine falls and bumps.

In various magazines, I have read that Janet Jackson, Cher, Elizabeth Taylor, and others have undergone rib removals.  But this is almost certainly not the case.  This is just an urban myth concocted by jealous journalists.  While many in the Hollywood set have had tummy tucks and liposuction, their beautiful figures are mostly the result of strict diets, consistent exercise, and fortunate genetics.



February 20, 2010

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 among 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 (called the epigastrium) 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!


January 15, 2010

Tissue Glue Rather Than Drains (?!)

There is an old surgical adage:

If a surgeon thinks that the patient might benefit from a drain, he should put it in.  A surgeon never regrets placing a drain.

Patients, however, hate drains.  They are a post-operative nuisance.  Most patients grudgingly accept drains because they minimize fluid collections (called seromata) and infections.

Since drains are so uncomfortable, there have been a number of products and techniques developed to obviate the need for drains....

  • Quilting sutures beneath tissue flaps to minimize "dead space"
  • Tissue glues

Biological tissues glues are particularly exciting because they are quick, effective, and precise.  Unfortunately, there have been no specific research studies which have rigorously documented the safety and efficacy of biological glues for plastic surgery.  A study published in Plastic and Reconstructive Surgery in 2008 proved the success of tissue glues in a canine abdominoplasty ("tummy tuck") model; however, dog and human tissues do respond differently, and the results of an animal model can not necessarily be generalized to human beings.

To investigate human plastic surgery patients' response to biological glues, Cohera Medical, Inc., has just enrolled its first few patients in a study of its TissuGlu.  The clinical investigation is a prospective, open-label, randomized study to investigate the safety of TissuGlu, its effect on wound drainage, and its relationship to complications.  The study will compare 40 abdominoplasty patients in Bonn, Frankfurt, and Freiburg, Germany, who will undergo...

standard wound closure techniques versus

standard wound closure techniques plus the application of TissuGlu

Currently, patients who undergo abdominoplasties require the insertion of one or more drains to remove fluids that accumulate under the skin at the surgical site.  (The old surgical adage remains true in tummy tucks!)  However, TissuGlu will hopefully adhere the flaps created during the procedure to reduce fluid accumulation, and, ultimately, the duration of use of surgical drains.  With the use of TissuGlu, patients may experience a reduction in fluid accumulation, a more comfortable recovery, and a quicker return to normal activity.

If the European trial goes favorably, Cohera will apply for a larger U.S.-based trial later this year.  Let's say our prayers that TissuGlu works!...


December 26, 2009

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...





September 05, 2009

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, 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:




August 21, 2009

"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?



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....

017 241


August 11, 2009

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.


June 16, 2009

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.


February 07, 2009

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.


Blog Design & Consulting by flyte new media