So it is tough.  I was reminded of this today when I saw a patient who had liposuction and a tummy tuck a month ago.  She looks fantastic and is back to normal life, but still doesn’t feel quite back to her old self.  She gave me a beautiful card and present (thank you!!! So so lovely of you!).  What she said I think is particularly poignant and insightful:

“Dear Dr. Greenberg,

Thank you for everything.  It’s been a tough month, but well worth it.  Thank you for your care and support. It has been awesome.”

On the same day I got a card from another tummy tuck patient who is 3 months out.  Her card read,

“I wanted to show and say my appreciation for your services.  I feel like a million bucks and like that I can do just about anything.  Thank you for being such a great doctor.  And thank you for helping me look better than I did 10 years ago!.” 

I warn all patients regardless of how fantastic they may look in the future to expect buyers remorse the first week after abdominoplasty.  Why?  Even if they look great and their friends and family can see a significant change, it is a big surgery and a tough recovery for the first few days in particular.  You are bent over, you have drains, you are wearing a garment, your skin is likely numb, and it hurts.  It is common for you to not “feel” like you look better.  It is common for you to feel weird, puffy, pudgy. 

So what to do?

• know it is normal to have mixed feelings the first week after surgery.  It is a tough recovery, big surgery, and unlike some other big surgeries, it is elective- you chose to do it. 
• know it is going to hurt.  To help with this, I use the pain pump which I implant during surgery, which drips numbing medication along your muscles to minimize the pain.  Also pain pills and muscle relaxants help.
• know you won’t feel “normal” until at least 4-6 weeks out.  At 3 months you will feel even better.
• look at your preop photos.   It is easy to forget what you looked like which drove you to seek help.  Our minds are gentle, and I think the mind freeze frames us at age 29, pre kids and other life tolls. So look at the preop photos to remind yourself.

Talk to your doctor.  If there are things which are bothering you, let them know.  Anxiety of what is normal or not, what is going to stay versus what is normal post op stuff is all important to address.

I remember a colleague of mine studied this when we were in residency at Stanford.  The study was small, but hinted maybe there was a health benefit.  It is an interesting question.  If you reduce the fat cell load, will it affect your body in other ways?  Will it lower cholesterol? Lower triglycerides?  We know when overweight people lose weight, they often show improvement in other ways:  blood pressure improves, cholesterol lowers, and diabetes may reverse.  So it begs the question: if you remove fat by liposuction will you get the same benefits?

My society, the ASPS (American Society of Plastic Surgery) had our annual meeting in Denver this fall.  At it, a new study by Dr. Eric Swanson was presented, showing a dramatic decrease in the triglyceride level of patients following liposuction.    He also found a lower white blood cell count, which is thought to be associated with inflammation, and inflammation has been linked to cardiac disease.

This prospective study looked at 322 patients who underwent liposuction and/or tummy tuck (71% were liposuction only).  Findings:

• Those with normal triglyceride levels had unchanged levels
• Those with elevated or at risk levels (defined as > 150 mg/dl) had an average of 43% reduction in triglyceride levels after surgery.  (this is 2x the amount found when taking medications to do so). 
• The effect was found to be similar for men and women
• White blood cells levels decreased by 11%
• Cholesterol level changes were not significant.

What does this mean?  It is hard to tell.  It is unclear how fat contributes to heart disease.  We talk about how intraabdominal fat and the apple shaped person has a higher risk of heart disease.  Dr. Swanson suggests these findings show fat which is outside of the belly, the subcutaneous fat, is “just as metabolically important.”

To read more of his study, you can look for it.  “Prospective Clinical Study Reveals Significant Reduction in Triglyceride Level and White Cell Count after Liposuction and Abdominoplasty.  No Change in Cholesterol Levels,” presented by Dr. Swanson et al at the Denver ASPS meeting, September 2011.

• do not involve surgery and
• can melt your fat away. 
• Some claim to be pain free. 
• many claim to have no downtime

What are they? Do they work?  At my recent favorite plastic surgery meeting ever, the TIPS meeting in San Fran, there was a talk about some of these.  First lets get to how do they work.  They all use different methods:

• mechanical (it breaks fat down)
• thermal (heat)
• ultrasound
• cooling
• external massage (also mechanical)
• injections (chemical)
• water (mechanical)
• RF (heat the tissue)

Wow.  Lots of ways to get rid of fat.  Seems surprising with all of these ways to get rid of fat that we manage to keep it on our bodies.  So, in the interest of not irritating a lot of companies directly by using the names of machines, let me just say some overriding things to think about.

• Many of these machines were brought out under the 510K method of approval.  This does not require as much analysis.  Many studies were done on few patients (less than 10), studied for short periods of time, etc.  Some argue the FDA and governing agencies care much more about safety than the efficacy and reality of their claims.  So if a machine says it “melts fat” and they show a EM (electron microscope) image of a fat cell bursting and leaking its contents, that may be enough proof it works.
• These machines and inventions are expensive.  They are hard to bring to market, the cost to develop and research them is a lot, and they usually have about a 24 month window on the market before the newest greatest thing is out.  The cost for many of the machines for doctors is 90K and above.  That is a lot of patients you have to see to recoup the cost.
• I still believe in the general rule: no downtime =  no results.  Those procedures which give results tend to have more pain, recovery, bruise, etc than those which give no results.
• I do think noninvasive body contouring may be good for SMALL things.  The fat under the chin.  A small irregularity or fat pocket.  For doctors out there, think less than 100cc of fat. 
• Beware of marketing.  I am a broken record on this, but I think the hype of products now is more than the reality of the product.  Many of these companies appeal directly to consumers and media.  Splashy catchy headlines precede the scientific proof.  One of the speakers was talking about how doctors may be implementing procedures which they might not believe in due to the demand of their patients.

Be thoughtful and critical of new machines, products, and claims.

“I went to Dr. Greenberg about 6 years ago. She was the last of the 6 doctors I interviewed in search for a doctor to do my breast augmentation. She was the ONLY one who said she would not do it. I had lost about 100 lbs at the time and had not yet had kids. She said, she would not do the tummy tuck I was considering either as I should wait to have my kids and see her when I was done. She did offer to do some other work on me at the time that would not be damaged by a pregnancy weight gain and would help my overall look in the meantime.

It was a very intense procedure called a Medial Thigh Lift but the results I believe were phenomenal. She did some lipo too to help contour my shape a bit more. It wasn’t to lose more weight, as I had done that already but it was to take out the extra skin I had on my legs and inner thighs and stretch marks that were always very embarrassing.

My scars healed very well and are almost unnoticeable. I have since had 2 kids and now am ready for my “mommy make over.” Again, I interviewed other doctors because I really wanted the “gummy bear” implants. Dr. Greenberg doesn’t do them but does the cohesive gel implants and she did explain the difference to me.

I chose to go with Dr. Greenberg again for this surgery because I knew what her bedside manner was, she was straight forward with me last time about the expected results and she is always more cautious and looks long term for you.

I would highly recommend going to Dr. Greenberg if you are considering any plastic surgery, she is professional and is constantly educating herself as you can read in her blogs. I met with her twice for a consult already before my pre-op and she said to call or email if I have any further questions. We’ve chatted through email and on the phone and for a busy surgeon that says a lot. ”

SB, Inner thigh lift and liposuction patient, San Jose, CA

Now found in the filtered section of Yelp

A single, beautiful, perfect red rose.  It came from the husband of a woman I met yesterday.  This woman came to me for a  tummy tuck consult.  I didn’t do surgery on her.  In fact, I was the only one of many consultations she had who didn’t recommend she do surgery.  “Everyone else was ready to book me for surgery immediately.” 

And I said no. 

So when she told me everyone else was ready to sign her up, I admit, I had to take another look.  And I poked and pulled and prodded again.  Nope. I stick with my original advice.  Not worth it.

I’ve been thinking about her a lot.  How could others advise so differently? This was a woman in the grey zone-  no excess skin when she is standing, a little when she is sitting.  I don’t know if it is because I am a woman, I think about the scar a lot, the cost, the recovery, how much change you will have, what is your expectation, the recovery.  Do I weigh the pros/cons differently?  I don’t know.

. 

But I do think there are women whom surgery is not the right choice for.  And I will tell you.  ”No surgery” was the right advice for her.  And I think they both knew it.  She hugged me, and told me she knew I was right.  And her husband, who fantastically thinks she is perfect as she is, clearly agrees.

Thank you lovely couple for the beautiful rose.

Communication with your doctor is SO important.  When you don’t like your belly, it is important to figure out why.  I think this woman’s question could have been better written- Communication 101: Make sure you and your doctor are on the same page.

Is it

• stretch marks?
• hanging skin?
• loose skin when you sit?
• the muffin top?
• wrinkling around the belly button?
• you look pregnant?
• loose muscles?
• is the problem mostly above the belly button? Below?

You need to be very clear about what bothers you. This patient was bothered by loose skin above her belly button.  She then had her first tummy tuck, a mini tummy tuck.   Ug.  She was destined to be unhappy with her results, as a mini tummy tuck does not tighten the skin above the belly button.

This communication is a dual thing- your surgeon should be blunt in their communication and let you know what will be improved.  There is a lot of verbage out there.  What I call a mini tummy tuck may not be what Dr. X calls a mini.   I have had patients who think they had “full tummy tucks” who only had a mini.  Ask your doctors for specifics.  “By doing a mini tummy tuck,  the scar will be on the abdomen here.  There will be no scar around the belly button.  Your belly button will move down a bit.  This will not tighten the skin above the belly button at all.  This will not tighten your muscles.” 

There are all sorts of variations.   Is your issue Fat? Skin? Muscle?  In what order? Tummy tucks involve removing skin, tightening muscles, and sometimes liposuction.  There are things which are not safe (full tummy tuck and liposuctioning the anterior abdomen).  And again, the names are confusing: full tummy tuck, mini tummy tuck, mommytuck (what is that?), hybrid tummy tuck (a trademarked name for what is likely a mini tummy tuck with muscle tightening by Dr. Moelleken), lipotuck (those that overestimate the tightening effects of liposuction), etc etc.  You get my drift.

Expectation is everything.  If this patient is considering a third surgery, I would recommend sitting in front of the mirror and write down her ultimate wish list.  Some things are not achievable.  (Where is that fairy godmother and her wand?)  Also I would recommend getting a second opinion, just to have two board certified plastic surgeons looking at the same thing.  If there is controversy, consider a third opinion. 

There is a law of diminishing returns with multiple surgeries.  Many times the enemy of good is going for the “better.”  And some things can’t be done.

I know it is tempting.  You likely look smaller already.  How much did I lose?   Let me just get on this scale and see…

EEK! And then I get the frantic email.  “Dr. Greenberg, I just weighed myself and I weigh more than I did before surgery!”  Sometimes it is the day of surgery, other times a day or two after.  It doesn’t matter.  You won’t show any weight loss in this timeframe, and it has nothing to do with the surgery.

• Liposuction is not a weight loss technique.
• Tumnescent, the fluid we inject into your body before we remove the fat, is largely still in your tissue.  You are like a giant sponge.  This fluid stays in your tissue until a couple days after surgery.
• Around 3 days out, you will find you are peeing.  A lot.  Your body mobilizes the fluid from your tissue.  You will still weigh more than you think you should.
• Swelling.  Your body is not normal after surgery.  It is injured.  A controlled, sculpted, purposeful injury.  When your body is injured it likes to swell.  This has weight and volume to it.
• Your body will swell more than normal for weeks.  Know those dents you get in your ankles from your socks? This is normal swelling.  After liposuction surgery, particularly if you had your thighs done, you will swell more, and it is harder to get rid of it.  It will go back to normal. 

The more you avoid swelling, the better.  SO….Keep your legs elevated when you can after surgery.  Gravity pulls the fluid into the legs, and it makes your swelling worse.  I have an herbal regimen I recommend which helps some with swelling and bruise.  Avoid things which make you bleed- Vitamin E, aspirin, advil NSAID products, fish oil.  The more bruising, the more swelling.   I don’t recommend diuretics (water pills).  When you have normal functioning kidneys, your body will get rid of the excess fluid as it needs to.  Let it work.

I will weigh you, so you can’t go hog wild on Ben and Jerrys during your recovery- you can gain weight in a bad way.  But give your body time to heal.

So put the scale away.

For now.

http://www.bodypostbaby.com/belly/can-a-tummy-tuck-help-back-pain/

When I met you just a few short months ago, I walked into your office just “a shell of a woman”. I was a Mom of two wonderful children that I totally adored, I have the most amazing husband anyone could ever want, a house in the mountains that I just loved living in. Someone may wonder how I became just a shell of a woman while having everything I had ever wanted?

Well it was because of my “war wounds” from having children. I was so embarrassed to show you my stomach I was in near tears, but when I heard your very soothing voice saying, “Oh sweetie”, right there and then I knew you understood my journey and my pain. Thank you for not being like other Plastic Surgeons. Thank you for not making me feel small or vain for wanting to get my stomach back to a somewhat normal looking stomach. Thank you for helping to never hear again “Oh when are you due” and my answer was, “I am not pregnant I am just fat”. But I wasn’t fat. I had some dumb ass lady rub my stomach and give the “aaawwww” as if I was expecting-that did it. Well that and the 4 days of crying over it. Thank you for admitting that my breasts were “just fine” and “leave them alone”, my husband totally agreed with you too!

You gave me hope that I could look and feel like a sexy lady again. Saying thank you never seems like enough to you and to Marty for everything you have given me. By you and your great work I was able to lose 7 inches off my waist! Yes world, you read that correctly 7 INCHES! This surgery was never about weight loss, it was all about correcting my super blown out stomach.

Right now I feel like the character of “Buddy Love” from “The Nutty Professor”, I swear every time I go into a store to shop for myself, I want to scream, “SPANDEX! I WANT SPANDEX!” While I do know that there is a load and/or age limit on Spandex, it’s really funny to say it to people!

Just flat out bless you for filling my “shell” and giving my family back their Momma. I swear if I ever want any type of “tune up” no other Plastic Surgeon will ever touch me.

Sincerely yours,
KG

KG, Abdominoplasty and umbilical hernia repair, Santa Cruz foothills

I got a question from a woman worried she ripped out her internal sutures two weeks after a tummy tuck when she fell.  How would she know?

Tummy tucks are a two layer repair.

• The top layer is skin- that is the scar you see.
• The internal layer is a corset of your muscles.  All women after childbirth have some separation of their rectus muscles (the six pack).  This separation is the “diastasis.” It is why you have the bulge in your belly when you are not constantly sucking it in.  We plastic surgeons sew the muscles back together as part of the abdominoplasty repair.  Why can’t you just do more sit ups?  Can’t I fix it with pilates?  No. (sorry!)  There is no muscle which crosses the midline, so when the muscles separate, you can’t “bring them back together.”  Stitching them together is the only answer.

When we repair the separation, we normally use very strong suture, and we do two layers.  I know you Bay Area women will be tough on my repair. I do one layer of interrupted sutures (so if one loosens the whole thing won’t unzip) reinforced by a layer of running suture.

You CAN pull out the internal sutures.  When we stitch you closed, your body needs to scar it into place.  After a tummy tuck we don’t let you do any exercise, heavy lifting, or straining for weeks.  I don’t let my patients work out their core (sit ups, pilates) for three months after surgery.  Wound tensile strength is weakest at 3 weeks out. (!!)

Give your belly time to really cement in. 

So even though it is hard for my Bay Area uber athletic types, no exercise at all for 4-6 weeks minimum and no core for 3 months.  Even if you follow these instructions to a tee, scarred sutured tissue is never as strong as your original tissue.  But alas we don’t have the option of having the body and tissue of a 20 year old with no kids.

So

Back to the original question.  At two weeks out, if you had an abrupt move and you tore a stitch, it would not be subtle- you would most likely have had a sharp pain, bruising, and a bulge in the area.  You have to see your doctor.