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  He is out of date!!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!

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!...

ATX-101: FDA Approval for Dissolving Fat (?!)

Maybe, I shouldn't have been so quick to disparage injection lipolysis.  Kythera Pharmaceutical's ATX-101 just might prove me wrong.

Back in November 2009, I called attention to the farce of injection lipolysis and mesotherapy, also known as...

• LipoZap
• Lipostabil
• Flabjab
• Lipomelt
• Lipodissolve
• Fat-Away

http://www.pickartplasticsurgeryblog.com/2009/11/whatever-happened-to-lipozap.html

Mesotherapy, injection lipolysis, LipoZap, etc., involved injecting bile acids beneath the skin to melt fat--or at least that was the hope.  Compelling advertising enabled LipoZap centers to spring up throughout the United States and Europe.  As is so often the case, clever marketing preceded any clever science.  Without appropriate testing for safety and efficacy, many patients were swindled, and some were seriously harmed.

Enter Kythera Pharmaceuticals.  Led by executives and researchers from the established biotechnology industry (such as Amgen and Allergan), Kythera seems grounded in science and safety.  ATX-101 is Kythera's fat buster.  Preliminary trials have been completed for dissolving lipomas--benign fatty tumors, affecting 2% of the population, which can be painful and cosmetically displeasing.

The traditional treatment for lipomas has always been surgical excision.  However, surgery always entails risks, such as scarring, infection, damage to critical structures like nerves, etc.  The hope is that ATX-101 will significantly reduce the size or eliminate lipomas without the need for surgery.

If ATX-101 were to work on lipomas, then I don't see why it shouldn't work on those stubborn fat deposits that we have inherited from our parents.  Analogous to current lipoma treatments, stubborn fat is now removed with surgery--liposuction.  Wouldn't it be nice to sign up for a few injections rather than a surgical procedure (albeit a minor one)?

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...

 

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!

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: Over the Muscle Versus Under the Muscle

I want breast implants, but I am confused whether they should be placed on top of the muscle or under the muscle.  What are the advantages and disadvantages of the two techniques?

-Holly S.

Holly, this is a very common question among breast augmentation patients.  The surgical terms are...

• Subglandular implant:  The prosthesis is placed under the breast tissue but on top of the pectoralis major muscle.
• Subpectoral implant (or submuscular implant):  The prosthesis is placed behind the pectoralis major muscle (which is itself behind the breast gland).

Obviously, Holly, you deserve a customized evaluation, and only then can a Board Certified Plastic Surgeon help you make the best decision.  Nevertheless, there are some general advantages and disadvantages of the two options....

Subglandular Implants

Advantages:

• Technically easier operation for the surgeon
• Can be placed without general anesthesia (without going totally to sleep)
• Larger implants can be accomodated
• Potentially, more cleavage can be created
• No surgery on the muscle; therefore, less discomfort
• No surgery on the muscle; therefore, faster recovery time
• More "lift" effect, so that formal breast up-lift operations can be avoided

Disadvantages

• The "look" tends to be more artificial and less natural
• More rippling
• Greater likelihood of capsular contracture
• More difficult to interpret mammograms

Subpectoral Implants

Advantages

• Usually, a more natural breast appearance
• Less rippling
• Lower risk of capsular contracture
• More successful mammogram readings

Disadvantages

• More difficult operation
• Requires general anesthesia
• Can not always produce as much cleavage as the patient might desire
• More discomfort
• Longer recovery time
• Among women with large pectoralis majors, muscle contraction can distort the implant

Practically speaking, I try to convince most of my patients here in Ventura, California (>90%) to undergo subpectoral placements.  The unusual exceptions...

• Extreme fear of general anesthesia
• Very low pain tolerance
• Looking for a "fake" look
• High performance athletes, whose pectoralis major muscles should not be altered
• Body builders, in whom muscle flexion would distort their breasts during competitions
• Male-to-female transsexuals, whose large XY pectoralis major muscles would not accomodate a subpectoral implant

 

 

"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....

 

Sculptra Cosmetic to Hit Ventura (and the Whole USA) Soon

Sculptra is an injectable filler that has been used for HIV-positive patients who suffer facial wasting.  It has been an exciting product because it stimulates the patient's own body to produce more of his/her own collagen.  The Sculptra itself does not provide the bulk; the patient does!

Savvy physicians have realized that there was no reason to limit the use of Sculptra just to HIV/AIDS patients.  Routine aging, sun exposure, and weight loss can contribute to a hollow facial appearance in healthy adults.  Sculptra can "reinflate" areas of HIV-negative faces too:

• to lift the eyebrows
• to camouflage bags around the eyes
• to inflate the cheeks
• to minimize folds and lines around the mouth....
• to straighten the jaw line...

Because of Sculptra's success in the treatment of facial aging in healthy patients, the FDA will soon grant Sculptra the right to be marketed for cosmetic use.

(This is similar to the way the FDA treated Botox.  Initially, Botox was FDA-approved only for purely medical uses, such as facial spasms.  However, with its proven track record and with additional research validating its success and safety in cosmetic situations, Botox was given an additional official indication:  wrinkles.  So, it is legal for Botox's manufacturers to market the product for the "frown lines" between eyebrows.)

Of course, there are a number of fillers on the market that are FDA-approved for cosmetic use.  But none helps you to create your own collagen to the degree that Sculptra does.

Even more importantly, none lasts as long as Sculptra:  at least 3 years.  Let's compare the common fillers in terms of longevity:

• Non-animal stabilized hyaluronic acids (like Restylane and Juvederm):  6-9 months  (Don't be fooled by the advertisements, which purport longevities of a year or more.  These products do not typically last even three seasons.)
• Evolence (the new collagen):  6-9 months
• Radiesse (calcium hydroxylapatite):  8-16 months  (I used to think that this product would last 1-3 years.  Then, I recognized that it wasn't ever lasting 2-3 years, so I told my patients that its longevity was probably 12-18 months.  However, now, I am pretty certain that the product disappears in less than a year in at least half of patients.)
• Sculptra:  at least 36 months  (By the way, I used to think that Sculptra lasted only 2 years.  This is the only product that I initially "undersold."  Now, I confidently tell patients that the can expect 3 years, or even longer.)

So, now you know why I've been raving about Sculptra to all of my patients in Ventura County, California.  Sculptra can create a fuller, fresher, and more youthful appearance, and the result should last as long as some "mini-facelifts."

With FDA approval of Sculptra's cosmetic indications, expect to see a lot of advertising for this product.  It is great, and its manufacturers know it.  So, they're going to get the word out.

Sculptra really is the ideal treatment when patients say, "I still feel like I am 35.  But I look like I'm 50!  I'd love to have plastic surgery, but I can't take time off work."  With just a few injections in a few 30-45 minute sessions, Sculpta can produce natural results that won't make you look like Joan Rivers.  I promise.

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.