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.

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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.


February 12, 2011

New Weight Loss Drugs NOT Safe, FDA Rules

As obesity rates continue to rise, the need for a safe and effective weight loss drug is urgent.  Yet, 3 promising therapies have been halted in the pipeline this past year.

The FDA has declined to approve the diet drug Contrave.  Instead, the FDA has asked its manufacturer, Orexigen Therapeutics, to conduct a study "of sufficient size and duration" to examine the potential heart risks of the drug, which is a combination of naltrexone and bupropion HCL.

Last December, a majority of members of the US Food and Drug Administration (FDA)'s Endocrinologic and Metabolic Drugs Advisory Committee gave a thumbs-up to Contrave, something they had not done for two other diet drugs they had reviewed earlier in the year.

Lorcaserin (Arena Pharmaceuticals) and phentermine/controlled-release topiramate (proposed name: Qnexa, Vivus) were the other two proposed diet drugs not recommended by the FDA advisory committees reviewing the evidence for both drugs last year.  The FDA has subsequently rejected their marketing applications, asking for more data.

Yet another diet drug, sibutramine (Meridia, Abbott Laboratories), was yanked from the market earlier in the year due to concerns about its cardiovascular safety.

Had Contrave been given the green light, as many predicted following the advisory committee's deliberations, it would have been the first new diet drug on the US market in the past decade.

Dr Sanjay Kaul (Cedars Sinai, Los Angeles, CA), one of the seven FDA panelists who voted against Contrave's approval back in December 2010, said the FDA, which more often than not follows its advisors' recommendations, made "the right decision" and not a very surprising one.

"I went on record saying that the 13 to 7 vote is going to create a buzz that is not going to accurately reflect the tepid enthusiasm for this drug. Even the individuals who voted for the drug were not very enthusiastic for it."

In fact, Kaul points out, ambivalence and mixed feelings were a hallmark of the Contrave panel discussions:  three panel members who voted to recommend approval also voted for preapproval studies, while two who voted for postapproval studies also voted against approval.

The bottom line for Kaul was the fact that the modest weight loss achieved with Contrave was unlikely to translate into tangible morbidity/mortality benefits to offset any risks.  "You can never establish safety in preapproval assessment, so there is always some degree of risk that you are willing to trade off, providing the benefit is large enough. And in my opinion, the benefit [with Contrave] was very modest," Kaul said.

So, what are obese patients to do?  Since it doesn't look like there will be any pharmacological solutions in the near future, I would recommend seeing a bariatric surgeon for gastric bypass or laparoscopic gastric band.  While I don't offer those procedures in my own practice, I have been impressed with their efficacy and relative safety.


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 30, 2009

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


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)?


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...





October 27, 2009

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!


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 25, 2009

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


  • 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


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

Subpectoral Implants


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


  • 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




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....

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