Posted on March 9, 2010 in Body, Post Pregnancy Body, tummy tuck
I had a patient inquiry about her upper abdominal bulge after a mini tummy tuck. She was only a week out from surgery with another doctor, so she needs to wait to evaluate what is real and what is post surgery changes. But the better question is why?
Why would you get a bulge in your upper belly? And if it is real, what is the fix?
Mini tummy tucks are alluring. As I have said before, everything sounds better when it is mini. Mini M&Ms must not have as many calories. A mini skirt? Oh so alluring. And that mini car? Adorable!
Mini isn’t always better. Pregnancy affects the length of the belly muscles, from your rib cage to your pubic area. I don’t care if you carried high, or carried low, or carried to one side or the other. There will be differences, and when I tighten your muscles I can usually see how you carried. But you will be loosened to some degree throughout the length of your muscles.
I don’t tend to tighten the muscles when I do a mini tummy tuck. If I do tighten the muscles, I do so moderately. In English that means I am not going to tighten you so you can bounce a quarter off your belly. Why not? Trust me, I’d love to have all women after kids have rock hard abs. Heaven knows we deserve them. The issue is the belly button. When doing a limited incision (this includes the endoscopic approach) you can’t get great exposure of the muscles in the upper belly.
To retighten the muscles and let the skin redrape, you need to repair the length of the muscle, from your pubic area to your ribcage. You need big strong suture. I always do a two layer repair. My California girl patients are athletic (keeping them from exercising is tough). If you are active, you will be hard on my repair. Suture and scar are never as strong as your original tissue. So the muscle tightening is important.
You may think, “I carried low.” “My upper belly doesn’t look so bad.” “Why would I need to tighten the upper belly?” If you tighten the muscle only below the belly button, I expect you will bulge in the upper belly. If you tighten both above and below the belly button, but tighten the muscle below the belly button tighter, you will bulge. You must tighten them so there is even tension when you are done.
At one week, you can’t tell what is what. So you should wait. But if your upper belly is truly bulging, the fix? You may need a full tummy tuck to get your desired result.
Posted on November 16, 2009 in Body, Mommy Makeover / Body post baby, Post Pregnancy Body, liposuction, tummy tuck
The belly.
How much does it suck to still look pregnant after your baby is out? I wore my baby like a necklace, always in the baby bjorn, so no one would make the horrid mistake of asking me, “When are you due again?” It is totally unjust, unfair, unreasonable our bellies look like they do after children.
So to fix it you can do liposuction or a tummy tuck. Liposuction only fixes the fat- not the loose skin, stretch marks, loose muscles, or hanging skin. Tummy tucks tighten the skin and muscles, but can’t thin the fat so much (see my blog on why you can’t do both at the same time). Frequently you need one more than the other, so you should do that surgery and avoid the other one.
But what if you need both?
Ah. If you need to tighten the skin, muscles, AND remove thicker fat… which surgery do you do first? Plastic surgeons disagree on this one. Some surgeons advocate liposuction first, stating you will “debulk” (fancy way for saying to thin the area) to allow for better tummy tucking.
I disagree. When you liposuction you create scar under the skin surface. This is not visible or palpable, but it is there. During a tummy tuck your abdominal skin needs to stretch to allow for the removal of the extra skin, ideally putting the scar as low and inconspicuously as possible. If your skin does not stretch well, the scar will end up too high. Imagine trying to stretch a bathing suit (belly with no prior lipo) versus leather (a belly with scar under the skin from prior lipo.) Give me the bathing suit every time. Also the scar under the skin from liposuction affects the blood supply to the skin, causing increased risk of wound healing and infection along the tummy tuck incision.
I know this from personal experience. I had two patients with prior liposuction who did not tell me they had it done. I could see the scar plane during the tummy tuck procedure, and both of them had little healing issues along their scar and did not stretch to where they should. Their liposuction clearly affected their results. Some doctors advocate doing the liposuction and waiting a long time to let the blood supply reestablish. These patients had liposuction years before, and their blood supply was still not that of normal tissue.
Some people are in the grey zone. If you are borderline needing a tummy tuck and your biggest issue is fat, I like to liposuction first. But I recommend this in patients I expect will never need the tummy tuck. For those patients I know need liposuction and a tummy tuck, I like to do a two stage procedure:
1. the tummy tuck (with liposuction to the back/flank/and thighs) at the first stage, and then
2. liposuction of the abdomen at a second surgery.
I focus on your final result. I want your scar as low and hairline as possible. To best achieve that, I need to tuck first, lipo second.
Posted on November 11, 2009 in Body, Post Pregnancy Body, liposuction, tummy tuck
Many women need liposuction and a tummy tuck. The issue for the belly is you can’t beat it up with both at the same time.
Medical definition of flap: (American heritage medical dictionary)
noun
“Tissue used in surgical grafting that is only partially detached from its donor site so that it continues to be nourished during transfer to the recipient site.”
Advancement flap (Merriam Webster dictionary)
“A flap of tissue stretched and sutured into place to cover up a defect in a nearby position.”
Blah blah blah. What does this all mean in English?
A tummy tuck is based on something called a flap, a fancy medical term (we do like these fancy terms) to indicate the blood supply to the skin isn’t coming from all directions anymore. When we make our incision, we interrupt the blood flow.
Imagine blood cells are like cars; your arteries are streets; and the incision / scar is where your house is. You need to get your car to your house- in your car you have all the food and supplies to keep your house alive. (Bear with me; this is liberal arts education at work.) Instead of being able to drive straight there, when I cut through the skin those streets are now all dead ends. Hmmm. It’s harder to get home now. And you need to get there to bring in the food and supplies. You need it more than ever. Your house is injured.
When you do a tummy tuck, you cut where a c section scar is and you lift up the fat and skin like a giant apron. (Sorry for the graphic vision, but it is what we do.) This is the flap. We then pull this apron down and cut away the extra. Walah. Tighter belly skin.
This flap needs blood to get to its edge to heal the scar. We don’t want anything which will hurt the blood flow to the edge. Using our nifty example of cars and streets, we need to get as many cars to our house as we can. We need supplies!
But by making the incision, we already blocked many streets. By pulling on the skin to stretch it, we narrow those streets. We need those streets which remain to stay open. And we don’t want anything more to hurt the streets: no making the streets one lane instead of two, no putting road blocks or traffic jams. This is why we don’t do tummy tucks in smokers, and there are increased risks in people with poor blood flow like diabetics, ex smokers, and those with high cholesterol. Their streets are narrow and slow. Not enough cars get through.
If you liposuction this flap at the time of tummy tuck, all those blood vessels carrying oxygen and nutrients to the edge of the flap to heal the large incision would be hurt. Because we made a flap, we really need all the blood flow we can get, so we don’t have problems healing: infection, wound breakdown and opening, or potentially skin loss. (where the skin turns black and dies. eek!)
Some surgeons are cavalier and will liposuction the abdomen at the time of tummy tuck. I am not. There are good studies in our Plastic Surgery literature which studied where it was safe to liposuction at the time of tummy tuck. These zones are consistent. You can safely liposuction your back and love handles, your thighs, your chin…. I am happy to combine these areas with a tummy tuck. But if you need liposuction on the front part of your belly, you need to wait and stage it at a second surgery.
The key to a pretty abdominoplasty is the best scar you can get. Pretty scars come from good solid closures, and no issues with wound healing. We have all seen photos of dead abdominal skin from someone who pushed the limit too far. Remember this is elective, cosmetic surgery. Safe surgery and pretty results are what we need.
So get as many cars to your house as you can.
Posted on October 20, 2009 in Body, Post Pregnancy Body, interesting & new, liposuction
There is a lot of trickery and marketing in liposuction. I have had people ask me, “Do you do liposculpting?” Liposelection, liposculpture, laser liposuction, UAL, Vaser, ultrasonic liposuction- what do these all mean? Please see my liposuction page on my website. Much of this terminology doesn’t mean anything. We all sculpt (or should) when we do liposuction. Ultrasonic, UAL, Vaser are all ultrasonic energy used to break up fibrous fat. Smart lipo, laser liposuction are lasers which are a smaller caliber than ultrasonic, but the purpose is the same: to break up fibrous fat. My favorite marketing gimmick is “We use the new tumnescent procedure.” Perhaps tumnescent is new to that doctor, but it is not a new technique. Everyone uses tumnescent, and it has been around for 20 years. (Tumnescent is infusing the fat with a mixture of anesthetic, epinephrine, and saline prior to fat removal which significantly cuts down on blood loss.)
The laser liposuction while effective, has a small caliber. It is great for a small area like the chin, but not good for more broad fat removal. It is like painting a room with a small paintbrush instead of a big roller. Key to fat removal is smooth. Many of the laser machines say: no anesthesia, no downtime, no need for traditional liposuction. What they don’t tell you is this is only true for small areas. When doing a normal person I will typically get 2-5 liters of fat (4-10 pounds, and no, these are not fat people. We all have more fat than you’d think). When I oriented for the laser liposuction machine, they admitted their photos of 2+ liters of fat involved liposuction with ultrasonic energy. The laser was used as a finishing tool. For those of us adept with ultrasonic, we see no advantage to using another machine. The instructor told me his laser liposuction patients who only used laser had an average BMI of 19. For a 5′6″ woman, this means you weigh 120 pounds. Most of my Palo Alto patients who weigh 120 pounds aren’t in my office looking for liposuction.
I see patients for redo liposuction all the time. The two major factors are 1. not enough fat was removed. 2. uneven fat removal. Revisions are tougher: you now have scar under the skin. I find you need ultrasonic energy to break up this scar to help achieve a smooth result. If you are irregular but still have a lot of fat, the fix is easier. If you are too thin in an area, the only fix is fat grafting, which is difficult.
So. My biases:
- Board Certified Plastic Surgeon. We operate and train as general surgeons before plastic surgery. We do tummy tucks and other abdominal procedures. We know the anatomy better.
- Board Certified Anesthesia Doctor. Many horror stories are from anesthesia and fluid issues. This is elective surgery. You need to be safe.
- Don’t spot treat. No one has fat just in their outer thighs or lower belly. Treat it all or have a funny body shape down the road. (Unfortunately we all fall off our good eating and exercise wagon at some point.)
- This should be done in an accredited OR. Outpatient ORs should be “Quad A” certified. True board certified plastic surgeons can operate in a hospital. Hospitals do not grant operating privileges for liposuction to nonsurgeons: dermatologists, family practice, internal medicine. Hence many of these doctors will do surgery under local anesthesia in their office.
- Ultrasonic or laser energy is good to help break up fat. For anything above a small area like the chin, ultrasonic is better. With both you need to use traditional liposuction (SAL) to remove the liquefied fat, or you will get a seroma (a collection of fluid under the skin).
- If your skin is loose, you are older, or you have a lot of fat, you will get some skin irregularity.
- Stable weight. If you yo-yo or gain weight, you will create new fat cells and ruin your result.
Posted on October 14, 2009 in Body, Post Pregnancy Body, tummy tuck
Tummy tucks hurt.
I know I know. Clearly G-d is not a woman. How can something as miraculous as a baby wreak such havoc on our bodies? And then, when we decide “Okay. I am going to suck it up, get the scar, and go through the surgery,” why oh why does it hurt so much?
Tummy tucks are a two layer repair. The first layer is inside, and looks like an internal corset. This layer permanently sutures the fascia tighter. We don’t sew the muscle when we do a tummy tuck. If you ever try to sew muscle, you know sutures don’t hold. You need something stronger, more leathery… something with ooomph in it. So we use fascia.
You would think the long scar on the skin is what hurts. It looks like it should hurt, eh? But it doesn’t. Right after surgery, just like in a Csection, your abdominal skin is numb. The part hurting you is the muscle repair. If you are a typical Bay Area athelete (read triathalon, marathon, “I’ll just bike to the coast today,” or my favorite “I went for a 5 mile hike, but I stayed on the flat parts”), your muscles are well developed and may hurt more.
I use a pain pump which I feel is helpful for my patients after surgery. It is not a PCA, the morphine pain pump with a little button you push and runs via IV. This is a pump filled with a numbing medication, marcaine, and has two small catheters which drip the numbing medication internally along your muscles. You don’t do anything. It lasts for 3 days. I like it. It cuts down on the number of pain pills you take, which makes you feel less woozy and helps with constipation. And it helps keep you from feeling severe pain from right after surgery. There is a lot of research supporting prevention of pain- if you can keep the first pain wave from happening, staying “ahead of the pain,” you do better.
So, pain pumps have been a nice addition to our tummy tuck patients. They don’t stop the ouch all together, but they help.
Posted on October 5, 2009 in Body, Mommy Makeover / Body post baby, Post Pregnancy Body, liposuction
Liposuction is tricky. I do a lot of liposuction; I have published on liposuction; I fix other people’s liposuction.
There are pitfalls and risks to liposuction. If you can lose the weight on your own, do it. I think liposuction is great for diet and exercise resistant fat, but there can be issues. I do not candy coat these risks, among them irregularities, discoloration, sensory change, and loss of result if you gain weight. If you have loose skin, are older with poor skin tone, or have a large amount of fat removed, you will get some irregularities.
I believe using machines like ultrasonic energy or laser energy are good to help break up fat, allowing more, smooth fat removal. I believe you need an assortment of cannulas in different shapes and sizes. I believe you need to come at things from different angles to achieve smooth fat removal. I believe you should not treat one area like your outer thighs- your fat comes in units ( ”the thighs” “the torso” ) and should be treated as a unit to prevent funny body shape in the future. I believe you need a board certified anesthesia doctor who understands how liposuction and tumnescent is different from other surgeries to give your anesthesia.
Currently, what I see scares me. Smart lipo, slim lipo, and other laser liposuction companies need to sell machines. There aren’t many board certified plastic surgeons, so they target other specialties like family practice, ob / gyn, even internal medicine.
Recently I have seen a slew of patients coming in for a tummy tuck. One patient called my office frantically, “I need to come in immediately, I had liposuction of my belly. They removed a lot of fat, but now I need you to do a tummy tuck.” When I met her, I knew her doctor was not a plastic surgeon. She had loose skin, very irregular fat removal, and thick fat which had not been touched on her love handles and back. The correct surgery for her would have been a tummy tuck, with liposuction of her back and love handles. Instead, because of her liposuction on her belly, her skin is scarred in a wrinkled, uneven pattern. It is loose on the surface, but now will not stretch because of the scar under her skin from her liposuction. I can’t pull out the wrinkles. I can’t fix it.
Anyone can call themselves a plastic surgeon. Anyone can decide “I will do liposuction” and start doing it. You need to do your research ahead of time. A nonplastic surgeon can’t do a tummy tuck. They don’t have the same decision making, because they can’t do the other surgical procedures. They don’t understand sometimes the fat you leave behind is more important. Doing liposuction right the first time is important.
Posted on September 16, 2009 in Body, Post Pregnancy Body
Body
When thinking about body alterations, it is important to identify whether your dissatisfaction is driven by excess fat, excess skin, or a combination of both. To help identify if your skin tone is good, look for stretch marks, fine wrinkling, or sagging of the skin. As we age, our skin tone naturally declines, but treatments such as liposuction, abdominoplasty, and body lift can improve the appearance of these areas. The following questions will help guide you to possible appropriate procedures for you.
Abdomen
Do you have stretch marks? Overhanging skin? Muscles stretched from pregnancy or weight loss? Have you been pregnant before?
If you have excess fat, can you ‘pinch an inch’? Is the fat resistant to diet and exercise? Are you within 20 percent of your ideal weight? Is your weight stable? Is your skin tone good?
Treatment options include liposuction, an abdominoplasty (also known as “tummy tuck”), a mini-abdominoplasty, or a combination.
Love Handles/Flank
This is an area where liposuction is great, EVEN if you have stretch marks. It is also a very common area for men to need help with. Can you “pinch an inch?” Is this where you hold your weight? Do you have a bulge that comes over pant waistlines or is visible in shirts or dresses? Do you have an “apple” shape?
Inner Thigh
We all hate it when our thighs rub together. To analyze your skin tone, look for fine wrinkling or sagging of the skin. You can pinch the skin together to get an idea of how much excess fat you have. If you have a bulge, but the skin is not wrinkled or sagging, liposuction is a good alternative. If you have fine wrinkling or sagging of the skin, you may need to undergo a medial thigh lift to remove excess skin.
Outer Thigh
Do you have a “pear” shape? Do your pants pull tightly at the level just below the bottom? Do you have to buy pants that are too large in the waist in order to get the thighs to fit? Liposuction works well in this area.
Arms
Do you have skin that hangs down when you put your arms out horizontally? Are you embarrassed to wear tank tops? Have you undergone significant weight loss? If you have a lot of loose skin, you may need skin removal, known as a brachioplasty. If your skin tone is good, liposuction works well to give good muscle contour and definition.
Posted on September 11, 2009 in Body, Post Pregnancy Body, tummy tuck
Aaaah.
So that age old question: “How does that giant baby fit into my belly?” It does so by moving the other things around and stretching your muscles and skin. Your abdominal muscles are the rectus muscles (the “six pack”) and oblique muscles. The muscles of the abdomen do not cross the midline. This central line is called the linea alba. It is made of a leathery substance called fascia. When you are pregnant, your muscles separate in the middle. This separation between the muscles is the diastasis. Everyone who has had a pregnancy has some separation. This is the reason you can’t “suck it in” as tightly as you did before pregnancy. This is also part of why your waist gets wider.
The amount of separation varies. Some people have a small amount, some a wide. It tends to get worse with the number of pregnancies and the amount of weight you gain. (Another reason that large babies should give their moms large presents on mother’s day.) Some women have poor genetics though and get a lot of loosening with their first child. If your diastasis is bad, you will have a flat belly lying down, and then look pregnant when you stand up. When your abdominal muscles are loose, you may have back pain due to weak abdominal strength.
Since no muscles cross this midline, you can’t tighten it up again with exercise. (To many a husband’s chagrin. So tell him that his “honey you just need to do more sit ups” will not work.) A diastasis is fixed with a tummy tuck.
A tummy tuck is two parts. That bottom part is internal and fixes the diastasis separation. You can’t see it. It is a corset which brings those muscles back together. I use a two layer muscle tightening approach; both layers are permenant sutures. This will tighten your core again as it brings the muscles together.
The second layer to a tummy tuck is removing excess skin.
A hernia is a true hole in the abdominal wall. This commonly occurs at the belly button, and is why some women are no longer an “innie” after pregnancy. Sometimes people will call a diastasis a “ventral hernia.” Most women have a simple separation where the sheet of tissue keeping the “insides in” is still intact, not a hole.
