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 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 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 7, 2009 in Body, Breast, Mommy Makeover / Body post baby, Skin / Nonsurgical, breast reduction, scars & scar care, tummy tuck
No plastic surgeon can do surgery without a scar.
I know. Shocking the “doctors” on shows like Nip Tuck and every soap opera out there can fix a major accident with not a single scar, but real doctors cannot. In the real world, anytime you cut through the skin there will be a scar.
Our goal is to make that scar as fine, hair lined, tiny, well placed, and invisible as possible. But even a scar which will be a good scar (and fade to nothingness) starts as a scar you can see. I show scars when they are new. Most of the photos on my website are of scars at 6-8 weeks. On some surgeries, like eyelifts or breast augmentations, these scars are almost invisible quickly. Why? Breast augs and eyelifts have small scars, which are hidden and under no tension.
The common surgeries I do with larger scars are breast lifts and breast reductions (both of which I use a shorter, lollipop scar) and tummy tucks. You may be thinking, good heavens woman, why would you show those scars?!? Why are you not like the other plastic surgeons who only show scars at a year when they have faded or have every tummy tuck scar hidden under underwear? I could be cheeky and say, I am not like other plastic surgeons. But the true answer is you pay a price for surgery. I feel strongly you need to know that price, or I guess I should say potential price. I expect most of my patients will have scars which fade well. I don’t have many issues with ugly raised scars, keloids, etc. But I do have some patients who don’t scar well….usually it is a part of the scar…and for their surgery that patient paid a bigger price.
When you lift your breasts so they don’t hang to your knees after breast feeding three kids, the price you pay for cute perkier breasts is a scar. Many years ago I converted from the inferior pedicle technique, where we had a large anchor scar (where it is like the lollipop WITH an additional scar running the entire length and position of an underwire) to the vertical technique. Why? It shapes and holds better, and it is a smaller scar on the skin. If you are trying to limit a scar, why not go all the way and do the cute little donut lift where the scar only goes around the areola? (Excellent question from my educated Bay Area crowd…) That procedure is fraught with issues, and the scar though smaller frequently wrinkles, elevates, and bunches. A larger flat hairline scar is less noticable than a smaller wrinkly one.
Tummy tucks are a great operation to tighten the muscles and get rid of the loose, stretch-marked, muffin top skin, but the price you pay is a scar. Again, particularly in my fair skinned patients, I expect the final scar will be a hairline almost invisible scar. But what if it isn’t? My Bay Area patient base is very well educated. We had our children at older ages, so many of us got used to having a fit, healthy, tighter body. The changes after pregnancy can be tough. When you were hit hard by pregnancy, to get your muscles and skin tight again with a tummy tuck, you need to be okay with the scar. I find the patients who focus on the other changes- the flatter tummy, waist definition, tight skin, no stretch marks, smaller size- will be happy. The patients who are really bothered by the scar have a lower “price” they are willing to pay. I advise these patients to take a black sharpie marker and draw the scar on their belly. Wear underwear, your swimsuit, low rider jeans. If you had a tummy tuck and you were one of the few who did not heal well, would you be okay?
Here may be a place where being a female plastic surgeon who has had kids, pregnancies, and (eek) looser belly muscles and (sigh) looser skin, here may be a place where I am different in how I advise my patients. I watched my body change. I knew it was coming. I wanted these children more than anything. But my body will never be the same. Every person has what price they are willing to pay for perkier-lifted-firmer breasts or a flatter-tighter-waist-defined belly. What amount of risk? sensory change? scar? I can sense when I have a patient who has a low price they are willing to pay. They need a surgery to go perfectly and scarlessly or they will regret it. For these patients I advise them what you have now sucks, but it is G-d given. You earned it with your kids. Do you want to do this?
So I show scars. I show them when they are new and red and visible. The patients who can see these and go forward will be happy. The ones who can’t are usually the ones who had too low of a price and should stick with what they have.
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.
