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 December 10, 2009 in Body, scars & scar care, tummy tuck
The belly button.
It has no use after you are born, yet we are quite obsessed about it. Are you an innie? Outie? Many of my young patients pierce it. Many of my moms have one which “winks” after being stretched by babies. Some pregnant women get a small umbilical hernia, so the innie is now an outie.
Egads! When that happens I think you need counseling.
Such a small thing. Such big issues.
Belly button shape after a tummy tuck is a tough thing. I recently fielded a question from a patient who has a slit like belly button after a tummy tuck. That can happen. If your belly button is pulled, it can look stretched.
How can you make a belly button look pretty?
When we do a full tummy tuck, you have a scar going 360 around the belly button. We doctors do all sorts of little tricks to try to tuck the belly button, get it to indent, and hide the scar. I went to a talk once on “aesthetics of the belly button” at our national plastic surgery meeting. (Yes, yes. These are the kind of talks we go to as plastic surgeons.) But belly buttons are important. The belly button shape voted “the best” by the study was slightly hooded on the top and fanned out a little on the bottom.
I try to simulate this. Most of my patients look great. I have patients who’s scars overall are fantastic- hairline, barely visible. If your belly button doesn’t look great, what happened and what can you do?
If your belly button looks too small, it contracted on itself because it is a round scar. I changed the way I inset the belly button to improve this by creating a little advancement flap into the belly button. Also you can try the marble trick to enlarge and round it out.
If your belly button formed a raised scar (keloid or hypertrophic scar) you can try scar creams, massage, silicone gel sheeting, steroid injections, and cutting it out and starting again. In general, I always try to close under little tension. Tension is bad and can lead to raised scars. Keloids though tend to happen more often along the midline. And belly buttons tend to be in the midline.
Funny belly button shape. I find women who are super skinny and have no fat around the belly button are tougher to get pretty belly buttons in because they don’t indent as much, and it is harder to hide the scar. The toughest are women with no indent anymore, where the belly button looks like a shallow saucer. These women are tough as they have blown out their belly button.
But I try. Because what point is having a beautiful flat tummy if you can’t show it off a bit?
Posted on November 23, 2009 in Body, Breast, Mommy Makeover / Body post baby, Skin / Nonsurgical, interesting & new
The government has gone mad.
I get why they would want to tax elective medical procedures. They need money. They have gone wild on spending, and they need new revenue. This new tax is proposed to go into effect January 1, 2010 (!!!).
5%.
They are going to tax every “cosmetic” procedure by 5%. What is truly scary is their definition of cosmetic procedure is broad, and includes whether paid by insurance or otherwise (!!!) Their definition:
COSMETIC SURGERY AND MEDICAL PROCEDURE- ”1. is performed by a licensed medical professional and 2. is not necessary to ameliorate a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or disfiguring disease.”
I understand many of the surgeries I do are not going to save the world. So government thinks “Hmmmmm…. we need money. Cosmetic procedures are a growing business. Let’s tax it.” But taxing cosmetic procedures is a slippery slope. When I do a breast reduction and insurance actually covers it as “medically necessary” (which is tough to get covered these days), will this be taxed? When I do a tummy tuck and repair the muscles, so my patient no longer has back pain, is it cosmetic? One of my general surgery colleagues calls the diastasis a “ventral hernia” and insurance covers it. Am I being discriminated against because I call it what it is- a diastasis, not a hernia? Will my patients pay the tax, but his won’t? Oh but wait. They said they will tax it even if insurance does cover it. So maybe they will tax me AND the general surgeon.
WHAT IS COSMETIC? Is having twins which blow out your belly so you look 5 months pregnant every day of your life a cosmetic repair? or is it reconstruction to get you back to where you were, so you won’t have chronic back pain? Do we just need more women in Congress who have had kids, so they can understand us better?
What is cosmetic? Botox patients who do botox injections to treat migraine headaches- cosmetic or not? Instead of living for months headache free, will they, must they go back to medications which they take after they already have the headache?
1. women are the majority of plastic surgery procedures and patients.
2. this tax won’t affect the wealthy. they’ll do things anyway. this tax will affect much of my patient base- my moms, who are in the middle class.
3.Will this create artificial distinctions between specialties? Looking at botox injections- if it is done to treat wrinkles will you be taxed, but to treat headaches it won’t? Will it only be taxed if I do it, a plastic surgeon for their headaches, and not if done by a neurologist?
4. The bill specifically states if done by a medical professional. Will this spur nonmedical people doing injections (an already scary trend)?
This is a horrifying step. Why should my 40 year old woman’s desire for botox be taxed, and a 50 year old man’s desire for medications for his “erectile dysfunction” not be?
Ahhh. the slippery slope. Once they tax cosmetic procedures, do you think others are not steps behind?
Is a hernia repair cosmetic? If a man has a bulge in his groin from a hernia which reduces easily (means it isn’t stuck, and therefore not a medical emergency) is that a cosmetic repair? It is not a congenital deformity, it isn’t an injury from an accident or trauma, and it isn’t disfiguring. I would argue a hernia is no more disfiguring than breasts which touch your waist and cause you incredible back pain, neck pain, tingling in the fingers, and a hunched posture. Oh. But women asked for that when we had kids and breastfed them to make them healthier.
Forget the removal of that mole. Or sebaceous cyst on your cheek. Those are not disfiguring, congenital, or a result of injury.
Do not tax procedures. It will create a slippery slope, it disproportionately and unfairly affects women, and it will cause weird practices and loopholes which have no business in medicine.
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 November 4, 2009 in Body, Breast, breast reduction, liposuction
I heard the term “moobs” the other day. It conjured up images of men with breasts, the man boob, the “manssiere” (love Seinfeld with the bra for men). So I did what all people do these days to find out information. I googled the term. If you look in the urban dictionary, you will see it defined:
Moobs: A combination of the words “man” and “boobs.” This is what happens when fat gathers in a male’s chest area, and gives him the appearance of having breasts.
Usually seen in overweight males, but can strangely also occur in men who are not really overweight
or my favorite
Moobs: Floppy, Jell-O like protrusions in the male chest area. Usually sported by fat, overweight men or men who attempted sex change. Can be used as a form of communication when jiggled properly
I’m curious about how the moob can be used as a form of communication when jiggled, but that sounds like a whole other blog.
As with all things medicine, we have a technical term for man boobs. We call it gynecomastia. “gyne” female. “mastia” breast.
True gynecomastia is breast tissue in men. It is composed of fat, breast glandular tissue, usually an enlarged areola, and extra skin. When you feel the chest, you will often feel a firm disc of breast tissue behind the areola. These chests do not look like an overweight guy with extra on the chest: usually the areola is enlarged and there is ptosis (droopiess) of the skin. To treat true gynecomastia, we combine liposuction (usually ultrasonic to help break up the fibrous fat and tighten the skin) and direct excision of breast tissue. If needed, this is accompanied by a reduction in the areola and tightening of the skin, though I usually try to steer toward the smallest scars possible. The goal of surgery is to get you to feel comfortable taking your shirt off in public. Scars on the chest aren’t so good for that.
Most cases I see though are not really gynecomastia. Most are due to fat with little or no breast gland component, which you may hear referred to as “pseudogynecomastia” or “lipomastia”. These are most of the “man boobs” or “moobs” you see in photos. The good news is breasts made of fat are easier to treat. In these patients there is less droopiness of the skin, and the areola is normal sized. These chests tend to respond well to simple ultrasonic liposuction.
Adolescent gynecomastia is common and usually temporary. Regardless of age, if you have a case of gyecomastia which is persistent, you need to also look at other causes such as steroids, liver failure, tumors, genetic disorders, marijuana use, and some medications.
Most of my male liposuction patients have liposuction done to their chest. Liposuction is for areas of fat resistant to diet and exercise, a pocket of fat, just like the “love handles” or “abdomen”. Sometimes men in great shape with low body fat percentage preferentially gain fat in the chest. I find many of my patients will not bring it up, but I consider it part of my standard operation for liposuction in men.
Do you need a moob job? As with all things, I encourage patients to fix things they can without surgery. Look for underlying causes. If you are overweight, lose weight. There is much advice from others on what to do: I I have seen sites on cardio, special exercises and diets, herbal supplements, and even a site with the newest male bra. One site has the secret key to burning fat on just the chest. (It is only $50 for the step by step guide, and shhh, you can’t share the secret!) But as I find with a lot of cosmetic surgery, many people try to sell you a rainbow. Most patients I see have moobs of mostly fat, so lose weight. Tone up. And if the fat persists, get liposuction to improve it.
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 10, 2009 in Breast, breast reduction, interesting & new, liposuction
Large pendulous breasts suck. They give you neck pain, shoulder pain, rashes under your breasts. You hunch over due to the weight and droopiness. Forget about jogging. Oh, and the lovely feeling of the breast sticking to your skin on a warm summer night. But the scars of a breast reduction aren’t so nice either, particularly the large anchor style scar of the inferior pedicle technique. (Please do see my lollipop, shorter scar on my vertical breast reduction.)
So you hear about a breast reduction by liposuction with no scar, easier recovery, and can reduce my breast size by 30-50%? Sounds fantastic! Great! Sign me up!
I saw a woman recently for a breast reduction. She presented to me with chronic pain and large, pendulous breasts which were rock hard. She is a smart woman But even she, who is a doctor, was pulled in by the media, hype, flashy office, promise of no scar and quick recovery.
I have to be honest. I went to our national meeting and saw beautiful results of breast reduction by liposuction. I left the meeting and thought, I should look into that. The next day I met my patient. I have never in my decade of private practice seen a breast like hers. It was droopy, hard, painful. She relates to me her story. “I researched the procedure and talked to a few plastic surgeons. I work a lot, and couldn’t take weeks of downtime. I wanted to do something where I would heal quickly. They had a hard time getting the fat out of me. Afterwards, I am bigger than I was before. I have chronic pain throughout the breast every day. I wish I could go back in time.”
Liposuction of the breast has issues.
1. It does not lift. A major benefit of a traditional breast reduction is the lift you get. Most women want the reshaping, firming, and lifting as much as they want the reduction in size. Some surgeons advocate when you remove tissue, the weight of the breast is lighter, so the skin will lift. In younger patients with good skin tone, this may be true. But this leads to the second issue…
2. Breasts, particularly young breasts, have a lot of breast tissue. Breast tissue is dense, firm, and won’t reduce with liposuction. Liposuction can only remove fat. So for many 18 year olds with large breasts, liposuction is not an option as a significant portion of their breast is not fat. Older women (read 60s, 70s, 80s) breasts are mostly fat. But then the liposuction will not correct the drooping, just reduce the size.
3. The lift is important. What bothers large breasted women is neck pain, back pain, poor posture. A study came out of Sweden (where they have nationalized healthcare and it is easier to study such things) showing the act of LIFT improved symptoms. In other words, even if the breasts were not reduced, the pure act of lifting them improved symptoms.
4. What happens to breast tissue when you liposuction? Particularly ultrasonic or laser liposuction? We always worry when we do anything to the breast about
- cancer. could this increase the rate of cancer?
- imaging to look for cancer. could this obscure cancers? give us calcifications?
5. Pathology. Whenever I remove any breast tissue, I always send it to pathology. Rate of breast cancer in women is 1 in 6. When liposuction is done, the tissue is sheared, you have no idea where it came from in the breast, and it usually is not even sent to pathology.
So. I do a lot of liposuction. I have written a chapter in a major plastic surgery 7 volume set on liposuction. I am a fan. But when it comes to the breast, I am timid. The issues I listed are real. And after having met my patient, who is a 50 year old woman with rock hard, scarred, abnormal, painful breasts, I have to wonder if the scar is so bad.
