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 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.
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.
