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  He is out of date!!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!

ATX-101

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KYTHERA BIOPHARMACEUTICALS ANNOUNCES INITIATION OF

PHASE I/II CLINICAL TRIAL FOR LEAD PRODUCT CANDIDATE

LOS ANGELES, January 8, 2007 – Kythera Biopharmaceuticals, Inc. (“Kythera”)

announced today that it has commenced the Company’s first human clinical trial, a

Phase I/II study of ATX-101 for the reduction of localized fat deposits.

“This important milestone not only substantiates our belief in the potential of ATX-101,

but also validates our scientifically and medically rigorous approach to developing

prescription therapeutics in aesthetic and restorative dermatology,” said Keith Leonard,

Kythera’s President and CEO. “We hope ATX-101 will prove to be a new treatment

option for patients, and we are truly excited about the potential of ATX-101 in all

possible medical and aesthetic applications.”

ATX-101 is initially being investigated for the treatment of superficial lipomas, a type of

benign musculoskeletal fatty tumor that may occur in up to 2% of the population.

Lipomas are generally found on the torso, shoulder, arms and legs, and, while generally

asymptomatic, can cause local pain, tenderness or nerve compression. Individuals

seek to have their lipomas removed in order to reduce pain, for aesthetic reasons, or

both.

This ATX-101 clinical trial is being conducted in the United States and is intended to

identify the pharmacokinetics, safety and potential efficacy of ATX-101 in the treatment

of superficial lipomas. The Phase I/II randomized, double blind, placebo-controlled

study is the first of several planned trials to investigate the medical and aesthetic uses

of ATX-101. Kythera licensed the compound from Los Angeles Biomedical Institute at

Harbor-UCLA Medical Center.

“Until now, standard lipoma treatment has been surgical excision, which many patients

opt not to undergo due to the invasiveness and potential for scarring,” said Jay

Birnbaum, Kythera’s Chief Medical Officer. “We are hopeful that treatment with ATX-

101 can significantly reduce the size of, or eliminate, lipomas and thereby provide an

effective non-surgical, minimally invasive treatment option for patients.”

Why Am I Gaining Weight After Liposuction?

I had liposuction of my tummy about a year ago.  My doctor removed 2000 cc.  I didn't lose weight, but I looked good.  But, now, my love handles are growing.  I have a muffin top, and I am up 5 pounds.  What gives?  I thought that I wasn't supposed to gain weight after lipo.  Isn't there some kind of guarantee?

- Heather C., from Oxnard, California

Heather, let's reeducate you about liposuction...

Myth #1:  Liposuction is great for weight loss.

Liposuction is not a good weight loss technique.  Most patients usually lose just 1-2 pounds after liposuction.

Liposuction removes stubborn fat deposits and thereby improves a patient's contours.  Ideal liposuction patients are already at their ideal weights; they just can't lose those darn saddle bags, or tummy pooch, or chin fat, or whatever.

Heather, I am therefore not surprised that you didn't lose much (if any) weight after liposuction.  This is typical.  However, you did get what a good liposuction procedure should provide:  a better appearance and more confidence.

Myth #2:  After liposuction, I won't ever gain weight again.

Liposuction cannot change the future!  If a liposuction patient ingests more calories than she burns, then she will gain weight.  If she wants to lose weight, she should either eat less or exercise more (or better yet, both).

Liposuction removes fat cells.  They are gone and will never come back.  However, if a patient ingests more calories than she burns, then her body will deposit fat somewhere.  It's just less likely to be stored in the liposuctioned area than somewhere else.

Heather, your 5 pounds are being stored preferentially in areas that were not liposuctioned.  Since your tummy was treated, the weight is going elsewhere--to your flanks and hips.  Hence, you have developed love handles and a "muffin top."

If you lose those 5 pounds, I bet that you'll get back your old post-op "look."

Myth #3:  Plastic surgeons can and should guarantee their work.

Plastic surgeons can't, in good faith, ever guarantee their work.  There are too many variables.  Biological systems (i.e., human bodies) are far too complex for any person to perfectly control in all instances.  Abnormal healing, infections, and other acts of God can mar the results of the best surgeons.  Patients themselves overindulge in sweets, forget to exercise, forget to follow post-operative instructions, etc.  And, yes, even superstar surgeons have bad days; Michael Jordan didn't dominate every basketball game.

Rather than a guarantee, Heather, your surgeon should have offered you a frank discussion about liposuction, including all the risks.  In my pre-operative conversations, I always inform patients that weight gain after liposuction can detract from the final result.

I hope that this helps, Heather.  Try to lose those 5 pounds; skip desserts and increase your exercise regimen.  Then, recheck your figure.  You'll probably look great again...without the muffin top!

Patient Dies in Florida After Liposuction...Performed by an Occupational Medicine Specialist

Awful stories of bad plastic surgery outcomes abound on the internet.  Unfortunately, there is a common theme:  The plastic surgery is often NOT performed by plastic surgeons.

Rohie Kah-Orukotan, who was herself a nurse, died after liposuction surgery on September 25, 2009, in Broward County, Florida.  The operation had been performed in a medical spa by Dr. Omar J. Brito Marin, an occupational medicine specialist, who had taken a three-day course on cosmetic surgery procedures.

This case nearly brings me to tears.  Not only is she an attractive young lady with a bright future, but the circumstances surrounding her death are unsafe and bizarre.

• Her physician is an occupational medicine specialist.
• • What the heck is that?!  I have been a physician for 13 years, and I don't even know what an occupational medicine specialist is.
  • Everyone should know what a real plastic surgeon is--a physician who has been certified by the American Board of Plastic Surgery. 
  • How could a nurse not know the difference? 
• He took a three-day course on cosmetic surgery.
• • I spent close to seven years in surgical training after four years of medical school. 
  • How could a nurse not know that a three-day course over a long weekend is not adequate?
  • Couldn't she have found a Board Certified Plastic Surgeon with years of training?
• The surgery was performed in a medical spa.
• • Liposuction is real surgery.  It should be performed in a real operating room!
  • Safety equipment and appropriate monitoring is essential to ensure good outcomes.
  • Board Certified Plastic Surgeon are required to use accredited facilities.  No occupational medicine specialist would even be let in the door to a certified facility.
  • How could a nurse not know that it is unsafe to have surgery in a spa where people usually just get massages?
• Apparently, the liposuction was performed with carboxytherapy, which supposedly reduces stretch marks and cellulite.
• • I have never even heard of carboxytherapy.
  • There is certainly NO scientific evidence that carboxytherapy reduces stretch marks and cellulite.
  • Carboxytherapy is NOT a standardized liposuction technique.
  • (For discussions of other liposuction gimmicks, check out http://www.pickartplasticsurgeryblog.com/2009/10/waterjet-assisted-liposuction-breakthrough-or-gimmick.html or http://www.pickartplasticsurgeryblog.com/2009/01/smartlipo-and-brazilian-butt-lifting-can-a-patient-use-the-smartlipo-fat-for-buttock-augmentation.html) 
  • How could a nurse fail to know that she was being duped with a gimmicky procedure?

This case teaches me that even professionals can be tricked.  If a nurse can be convinced to undergo gimmicky liposuction in the back room of a spa by a non-surgeon after he trained over a long-weekend, then the lay public is in deep trouble.

Water-Jet Assisted Liposuction: Breakthrough or Gimmick?

More than in any other surgical technique, liposuction technology is marketed directly to consumers with little (to no) scientific evidence.  Some background...

• Standard suction assisted lipectomy employs a strong vacuum to remove stubborn fat deposits.
• Most surgeons add tumescent fluid to numb the surgical area and to constrict blood vessels (and thereby minimize bleeding).
• Power assisted liposuction involves a vibrating handle to minimize surgeon effort when removing the fat.
• Ultrasonic assisted liposuction uses ultrasonic energy to melt the fat before it is sucked out.
• Laser assisted liposuction uses a laser for melting fat before it is vacuumed out.
• Water-jet assisted liposuction supposedly limits intra-operative tissue distortion caused by the tumescent anesthetic fluid.

If all you knew about plastic surgery was learned from daytime television, then you would think that plastic surgeons perform liposuction...

• in their offices
• under local anesthesia--with tumescent fluid alone
• employing lasers to melt the fat
• water jets to minimize distortion

The truth is much less sexy.  The vast majority of Board Certified Plastic Surgeons prefer...

• an accredited surgical facility rather than the back room of their office
• heavy sedation--either "twilight sleep" or general anesthesia provided by an appropriately trained anesthetist
• some quantity of tumescent fluid for additional comfort and to decrease bleeding
• performing the actual liposuction with... standard techniques, power assisted devices, or ultrasonic machines

While I do like ultrasonic assisted liposuction (and I use the VASER system), as a Board Certified Plastic Surgeon, I have to admit that there are no good scientific studies documenting the superiority of ultrasound or laser-assisted liposuction relative to standard or power-assisted tumescent liposuction.

The water-jet is so new on the scene that there are exactly ZERO articles about it in the most prestigious plastic surgery publication Plastic & Reconstructive Surgery.  So, is water jet liposuction a breakthrough or gimmick?  I have absolutely no idea.

The best study on laser-assisted liposuction (from Chile, and published in Plastic & Reconstructive Surgery in 2006) demonstrated no major clinical differences between standard liposuction and laser assisted liposuction.  However, there were higher concentrations of free fat molecules floating in the blood of the laser patients, which alerts me to the possibility of potential damage to the liver, kidneys, or lungs.

So, truthfully, when patients ask me about laser and water-jet liposuction, I don't even know what to tell them.  In the past, I have mentioned the potential dangers of minimally tested technologies, and patients have actually become angry at me for my skepticism!  It's amazing to me that my caution turns people off.  Typically, patients express disbelief that lasers or water could be anything but positive.

The effects of marketing can obviously be pernicious.  It's incredible that the makers of these product have been able to convince the public of their products' efficacies before they have even convinced the surgical community!  Crazy!!

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:

 

Breast Augmentation Through the Belly Button? Don't Be Fooled

Many women would like breast implants, but they are turned off by the thought of visible scars...

• around the areola, or
• in the fold beneath the breast, or
• in the arm pit

So, some surgeons offer breast implants through the bellybutton.  Termed the TUBA (Trans-Umbilical Breast Augmentation), I have seen more disasters with this technique than any other....

• How can the surgeon expect to do finesse work from a foot away?  The belly button is too far away from the breasts.
• Hence, the implants are never placed 100% correctly.
• And the breasts are frequently asymmetric.
• How do you control operative bleeding from a distance?
• Hence, there are more bleeding complications with the TUBA.
• The long-term complication of bleeding around an implant is capsular contracture (hardening and disfigurement of the prosthesis).
• Surgeons cannot use silicone implants for TUBAs.  They are limited to saline, which are suboptimal for most patients.

I try to dissuade patients from undergoing TUBAs.  Los Angeles and Beverly Hills are filled with TUBA practitioners who have no intention of correcting their own mistakes.  So, in my practice in Ventura, California, I have to revise the breast implants on at least 5-10 TUBA patients each year.

On the other hand, non-surgical, "scarless" breast augmentations may be available soon....

• Commercially available fillers, similar to Restylane and Juvederm, have been trialled in Europe.  These products are injected into the breasts to produce small augmentations (maybe 1/2 of a cup).  While the fillers might last only 6-12 months, their placement involves no general anesthesia, no cutting, and no down-time--just a few needle pokes.
• Fat grafting may have efficacy.  Imagine liposuctioning fat from your tummy or hips, and then injecting it into your breasts.  It's a two-fer!  The big problem is the issue of cancer.  Will the fat cause breast cancer?  Will scarring from the fat transplant obscure tumors on mammograms?
• Vacuum?  Could you apply a vacuum to your existing breasts to stimulate their growth?  Sustained tension on your teeth allows your orthodontist to correct your smile.  Little people have been stretched to increase their height.  Why not suck the breasts bigger?!  This is an awfully compelling area of research which I hope pans out.

"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.