Jeffrey Frentzen, editor of Plastic Surgery Practice, asked 3 experts about their beginnings in the body contouring cosmetic surgery.  Participants included Dr. Cuzalina of Tulsa Surgical Arts, Greensburg cosmetic surgeon Michael Kluska and plastic surgeon Dr. Steven R. Cohen of San Diego.

The question posed for this episode was, “How did you become interested in body contouring and what were the first tools you used when working in this area?”

Dr. Cuzalina said the following:

Two years into my practice I met a doctor in Oklahoma who was doing 14 gastric bypass surgeries a week.  We became friends and he’d seen some of my other work on tummy tucks so he began referring me patients.  All of a sudden, I was inundated with all these patients who had open gastric bypass surgery.  At that time with the vertical scar down the middle of their belly, the common solution was to do the inverted T tummy tuck, what’s known as the “fleur-de-lis.”  It worked very well, and it [the surgery scar) was ok because you already had a vertical scar so you can get some really nice tightening around the abdomen.  You end up doing a lot of surgery because they all need not only their belly, but their breasts, arms, thighs and everything done.

Listen to the podcast to catch the rest of the series and hear responses for the other surgeons who participated.  Click here to read more about body contouring surgery in Tulsa, Oklahoma.

Dr. Cuzalina says this:

Over the last five years, when the change happened from open gastric bypass surgery to laparoscopic bypass, I [began] doing very few inverted T tummy tucks and a lot more butt lifts.  So I tend to do the tummy tuck first and the butt lift later, combined with a thigh lift.  But I really don’t like the idea of a circumferential body lift because they are two opposing forces.  It got popular [because] everybody likes to talk about a body lift or belt lipectomy, but when you pull down on the stomach and up on the buttocks, you’re flexing the patient two different directions and can’t get them as tight as you would like.

That’s the one thing that has really changed significantly over the last five years for me.  I’ve stopped doing as many inverted T tummy tucks and I’ve stopped doing as many belt lipectomies. I think I give the patient a much better result if I just do their breast and tummy initially, combined together.  Then later on in a separate stage do their butt lift and possibly thigh lifting.

Dr. Michael Kluska, a cosmetic surgeon in Pittsburgh, and Steven Cohen MD of California are also featured on the podcast discussing this topic.

Listen to it

A study from 2009 (recently published online) examines this latter category by analyzing pre and post-operative photographs from patients who underwent liposuction and fat transplantation into the buttocks – a procedure known as the Brazilian Butt Lift.

To analyze perceptions of female attractiveness, male and female subjects from four different geographical areas (or societies) were asked to complete a questionnaire referencing 20 before and after photos of patients who had undergone enhancement with the Brazilian Butt Lift.  In all post-operative photographs, patients showed a reduced Waist-to-Hip ratio without a significant change in body mass index.

“All four populations tested judged postoperative photographs to be significantly more attractive,” wrote authors of the study.  What’s interesting about these results is not simply that post-operative photographs were judged as more attractive; it’s the cross-cultural element, which lends objectiveness to the entire process.  A similar preference for low Waist-Hip ratio was demonstrated, regardless of the ethnic and socioeconomic differences present in the study participants.

You can read this study, “Cross-cultural consensus for waist-hip ratio and women’s attractiveness” through sciencedirect.com

Proper Nutrition

Bariatric surgery patients may be at risk for nutrient deficiency. According to nutrition doctor Ingrid Kohlstadt MD, nutrients prone to deficiency in bariatric surgery patients include: Calcium, Magnesium, Iron, Protein, Various B vitamins, omega-3s, and omega 6 fatty acids. Ask your doctor about maintaining proper nutrition – immediately after your surgery as well as during the years that follow. [Ingridients.com]

Exercise Programs

Trainers from the American College of Sports Medicine met this month for the 14th annual Health and Fitness Summit, where they outlined the best exercise programs for bariatric surgery patients. They say aerobic exercise should be the core focus for patients because it eases you into regular physical activity. To speed up fat loss and improve your range-of-motion, resistance training and flexibility exercises should be gradually and cautiously integrated into your program. [ACSM]

Body Contouring

After significant weight loss, skin does not contract to a normal level. To remove skin folds and excess tissue, a comprehensive surgical approach is often needed. A body lift can correct sagging skin on the buttocks, abdomen, waist, hips and outer thighs in one procedure, or in staged procedures. Incision locations will vary. It may involve an incision around the body to remove the “belt” of excess skin and fat.

Other post-weight loss procedures can treat localized problems around the body. Brachioplasty for example, can treat sagging skin in the arms and thighplasty can remove excess tissue in the upper thighs. [Post Bariatric Body Contouring]

• Smartlipo versus Conventional Liposuction: The difference
• Target Areas With SmartLipo Laser Liposuction
• Smartlipo Before & After Pictures

Smartlipo works with a very small cannula, or tube, approximately 1.0 mm to 2.0 mm in diameter containing a laser fiber is inserted into the skin. The cannula is moved back and forth delivering the laser’s energy to the fat cells, causing them to rupture and easily drain away. The laser energy also interacts with the dermis, resulting in collagen shrinkage.

Learn more about SmartLipo in Tulsa, Oklahoma

Everyone would love to have a flat tummy, preferably without surgery, yet this may be the only choice for many. The number of tummy tucks performed in the U.S. has dramatically increased over the last several years. A few reasons for this big increase is more acceptance in the general public for cosmetic procedures and a larger number of patients having bariatric procedures with massive weight loss and hanging skin. Also, the rise in advertising new, minimally invasive, “lunchtime laser this” or “laser that” have all contributed to more tummy tucks for better or worse.

Granted, the development of the lipo-abdominoplasty or “modified Avelar type” tummy tuck has been a wonderful new technique for the appropriate patient. However, there is no such thing as a minimally invasive abdominoplasty. Just because a surgery can be performed under local anesthesia does not make it “minimally invasive.”  A rush to abandon traditional techniques is not wise simply because a new procedure sounds great. For abdominal rejuvenation, traditional abdominoplasty should still occupy a major portion of one’s surgical gamut.

Figure 1. 35 year old female before and one month after a full lipo-abdominoplasty in order to both excise skin from pubis to above the umbilicus, as well as debulk the upper abdominal fat with liposuction and very limited or no undermining.

Diagnosis & Treatment Planning

Determining who is best treated with a traditional abdominoplasty is based on an evaluation of tissue from xiphoid to pubis. Deciding whether there is skin laxity that would not shrink well with liposuction alone is a basic initial assessment.

Abdominal skin laxity isolated below the umbilicus can typically be treated with a mini abdominoplasty. This classic patient is the well-built female after a C-section with limited hanging skin over her existing scar. Any rectus diastasis must be noted and, if severe, considered for repair. Significant skin laxity both above and below the umbilicus typically is best treated with a full abdominoplasty whether it be via traditional or via lipoabdominoplasty (Modified Avelar) in order to tighten the skin of the entire abdomen (Fig. 1).

Advantages of a Traditional Full Abdominoplasty over a Full Lipoabdominoplasty:

1. More skin volume and striae can be excised
2. Lower resulting scar
3. Maximum access for hernia and rectus diastasis repair

Advantages of the Lipoabdominoplasty vs. Traditional Abdominoplasty:

1. Theoretically better blood supply from limited undermining  (ex. safer for the patient who has an upper right open cholecystectomy scar)
2. Ability to safely liposuction upper abdominal fat simultaneously

The “grey area” of diagnostic dilemmas can be challenging.  For instance, an abdomen with minimal rectus diastasis and only slight skin laxity immediately above the umbilicus can occasionally be treated with a mini tummy tuck with an umbilical float if the existing umbilicus is somewhat high relative to the anterior iliac crest. This occasionally develops following childbirth or after a patient has had abdominal liposuction where the resulting internal fibrosis during healing leads to an abnormally high appearing umbilicus with a shortened distance between the ribs and belly button. Floating the umbilicus down 1-2 cm can be helpful for an isolated few patients but carries risk of having an odd-looking low belly button in the wrong patient. Additionally, an umbilical float burns a bridge if a full tummy becomes necessary in the future since the stalk has been amputated from below and would likely result in umbilical necrosis from future periumbilical incisions.

Traditional Tummy Tuck Technique

The planned incision is marked from “hip bone to hip bone” below any lower abdominal existing scars or an average of 2 cm inferior to the existing pubic hair line.

The periumbilical incision is marked for the ideal desired depth and shape along with a vertical mark along the entire midline from xiphoid to pubis. Optional marking of the costal margins and estimated skin excision can be performed. Additional marks vertically in a parasagittal manner may be helpful for closure without “dogear” formation.

Liposuction, if performed at all, is limited to areas lateral to the horizontal incision, low waist and pubis following tumescent infiltration. No liposuction should be performed in any other abdominal areas during a traditional abdominoplasty to avoid flap perfusion compromise. Thinning the lateral incision of fat can help prevent dog-ear formation along with careful medial advancement of the flap on closure.

Dissection is performed over the rectus sheath up to the xiphoid process. Next, the patient is flexed at approximately 30° and the amount of skin marked for excision. After excision of the lower skin-fat flap, excess deep fat of the upper abdomen can be carefully excised with scissors down to scarpa’s fascia.

Extreme caution must be taken with this technique to avoid over thinning of the flap. Midline rectus plication using permanent suture such as Nurolon or Prolene is per formed and drain placement prior to final layer closure. Scarpa’s fascia can be plicated down to rectus fascia in the pubic area to avoid “riding up” of the incision line. A number of methods can be used to determine the location for the umbilicus. It is important is to use your midline mark to avoid lateral displacement and carefully mark the height above the pubis to prevent torsion on the stalk.

“Ideal” Cosmetic Abdominal Surgery Treatment Protocols

• Liposuction Only: Lipohypertrophy with good skin and muscle tone
• Mini Abdominoplasty with Liposuction: Lipohypertrophy with skin laxity limited to the lower abdomen below the umbilicus and hopefully minimal rectus diastasis
• Mini Abdominoplasty with Umbilical Float: Minor skin laxity that extends 1-2 cm above the umbilicus which appears unusually high (above iliac crests)
• Full Lipoabdominoplasty (Modified Avelar): Skin laxity above and below the umbilicus with moderate to heavy upper abdominal fat and limited rectus diastasis
• Full Traditional Abdominoplasty: Severe skin laxity above and below the umbilicus with or without rectus diastasis and limited excess upper abdominal lipohypertrophy (Figure 2)
• Endoscopic Abdominoplasty: Great skin tone with moderate rectus diastasis and lipohypertrophy (rarely indicated and a “super” mini tuck may be just as well)

Figure 2. 40 year old before and 3 months after a full traditional abdominoplasty

Pearls for Great Tummy Tuck Results

1. Use extreme caution when combining liposuction (especially aggressive liposuction) with any abdominal flap to avoid potential ischemia.
2. Avoid smokers and patients with heavy intra-abdominal fat or “barrel” chest.
3. Do not hesitate to use a full abdominoplasty for a male patient with extreme skin laxity. Men tend to heal often better than women after abdominoplasty.
4. Verify umbilicus position using several methods: palpation from below, midline marks, hip bone level, 7-10 cm above pubis or incision line and distance from umbilicus to incision 1/3 that of umbilicus to xiphoid.

Conclusion

A traditional abdominoplasty is ideal for patients with significant skin laxity above and below the umbilicus along with severe rectus diastasis in relatively thin, multiparous women or post massive weight loss patients (Figure 4).

Using more conservative techniques for this class of patient may create problems that are difficult to correct. Minimally invasive laser or liposuction techniques are simply not indicated for major belly laxity. There are plenty of good techniques; the challenge is selecting the one that best suits each individual patient. Keep the classic tummy tuck in your repertoire.

Figure 4. 48 year old before and 3 months aftera full "traditional" abdominoplasty required to tighten severely loose skin above and below the umbilicus as well as repair rectus diastasis from xiphoid to pubis.