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 October 23, 2009 in Skin / Nonsurgical, scars & scar care
We plastic surgeons do not do scarless surgery.
We make pretty scars. We hide scars. We try to make small scars. But anytime you cut through skin you will have a scar. In our training, plastic surgeons learn how to make a good skin closure. To do this, we have multiple layers of closure under the skin which you don’t see. We undermine and advance the tissue (a fancy way of saying we loosen the tissue up and move it), so when we close the skin it isn’t under tension. We try to orient the scar with a wrinkle fold (which helps it hide) or put it into a crease or other hidden area.
What can you do to make a scar prettier?
1. Start when the scar is new. When people come in with a scar 6 months or older, there isn’t a lot of change occurring in the scar. It is harder to reverse bad changes, ie it is better to nip it in the bud before it happens. This doesn’t mean you have to put creams on the scar on day one. I usually recommend letting the initial scar heal first, and starting the treatments 2-3 weeks out.
2. Sunscreen. Sun is bad for scars. Particularly here in sunny Palo Alto, we are constantly exposed to the sun. Sun can essentially tattoo the scar, so the color never fully fades.
3. Don’t irritate the scar. (Who would want to irritate a scar? That sounds as bad as waking a sleeping baby.) But we irritate scars without thinking about it: clothing, bras, waistbands, picking at it. When a scar is trying to heal, I think it needs to be left alone. For this reason I found covering the scar with simple paper tape helps.
4. Too dry or too moist is bad. Studies show scars heal better in a moist environment. So the alcohol, hydrogen peroxide cleaning of a scar in general is bad because it dries it out too much. (There are cases where it helps, but usually not.) Too moist and goopy is bad. I see people glop on the neosporin, or cover the scar with a bandaid they don’t change for days on end. One reason I love paper tape is it breathes better than bandaids.
5. Pigmentation. Anyone who has any color in their skin runs the risk of depigmentation (fancy way of saying the scar turns white) or hyperpigmentation (fancy way of saying it turns dark). Other than what we plastic surgeons do at the time of surgery to get a pretty closure, you may need a cream like hydroquinone to help even out color. There may be some lasers which help, but you must always be careful when lasering anyone with colored skin- there are many pitfalls associated with it.
5. Massage. Wait til you are healed, and then you can massage the scar to help it flatten and soften.
6. Mederma, Kelocote (a liquid silicone gel) are my favorite over the counter to help reduce scars. No one knows why silicone gel helps scars, but using silicone gel sheeting on major scars has been done for years.
Other notes:
- I am not a fan of vitamin E for normal scars (not elevated, ropey hypertrophic scars). Vitamin E has been shown to break down scar. It is great for when you have a scar which is too much scar, but on a normal scar it can cause the scar to indent or widen.
- Keloids are out of the scope of this talk. If you have a personal or family history of keloids let your doctor know. A true keloid is difficult to treat. Many patients tell me “I keloid” when they don’t.
- Scars in certain places never heal well. High movement areas like the shoulder and knee, places where you don’t have loose skin like the calf and back, and areas which get constantly irritated like the foot tend to be worse.
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.
