Abdominal Rejuvenation Surgery

Fall and Winter are great times to consider abdominal rejuvenation surgery

Most surgical body contouring procedures require compression garments be worn four to six weeks postoperatively.  Why?  Because patients will maximize their outcomes.  Due to cooler weather in the fall and winter seasons, many of my patients often dovetail holidays such as Thanksgiving through New Years to gain extra recovery time without missing work or holiday events. Additionally, many women want to be well healed to look great on Spring break vacations to sport their new body contours.  

Here are a few considerations to consider as you explore body contouring surgery:

Having children, weight loss with or without bariatric surgery, aging skin, and previous open abdominal surgery with vertical scars can all contribute to diminished aesthetic appearances of the abdomen.  Additionally, other areas that can diminish the overall appearance of the torso may include unwanted fat contours of the posterior bra line, and posterior flanks (otherwise known as muffin top).  If surgical rejuvenation is something that a prospective patient is considering, then a detailed consultation with a plastic surgeon is necessary to determine the correct approach to yield the best results.  Many factors must be considered such as the quality and quantity of the skin to determine if the underlying fat excess can be adjusted with lipo- contouring alone or with the addition of surgical removal of skin to achieve a nice tight, smooth contour.

Expected improvements with Abdominoplasty:

  • Elimination of lower abdominal excess skin that may hang over the mons pubis (pubic area).
  • Correct abdominal wall integrity lost by separation of the rectus abdominus (front of the abdomen) muscles from pregnancy or congenital anomalies.
  • Contour the mons pubis and provide a sleeker appearance in swim wear and athletic or leisure apparel.
  • Contour excess abdominal fat contours in the upper abdomen and anterior flanks.
  • Create a youthful belly button.

Expected improvements of power assisted lipo-contouring of the posterior flanks:

  • Create a sleeker circumferential contour of the lower torso when combined with abdominal lipo-contouring or abdominoplasty to improve appearance in current fashion trends.
  • May enhance the hour glass silhouette often obscured when a women’s lower rib diameter and the pelvic rim diameter are the same.
  • Often is a great source of gluteal (buttocks) enhancement fat volume while further defining hour glass appearance.

Expected results of power assisted lipo-contouring of the posterior bra line:

  • Eliminates the back-bra line roll that detracts from the overall posterior aesthetics in swimsuits and fitted dresses.
  • May tighten somewhat loose skin in this area if tissues are appropriate for lipo-contouring alone.

Reverse Abdominoplasty, A technique to elevate and remove loose upper abdominal skin and positioning of the scar within the breast folds:

  • An excellent technique when the skin excess resides within the upper abdomen and not positioned hanging over the mons pubis.
  • Can be used in conjunction with a breast lift to provide added vascularized fat volume from the abdomen to fill the upper pole of the breasts in lieu of an implant.
  • May be a better choice on a woman who has upper skin excess with no diastasis rectus and never was pregnant.
  • Lower abdominal excess fat deposition can be lipo-contoured to leave a flat stomach.

 

The non-surgical rhinoplasty; what are the possibilities?

Noses occupy a prominent position on the human face. Many normal anatomic and ethnic variations exist and, depending upon proportionality (e.g. width, length, projection, etc.), the rest of the face can accentuate nasal variations. In some individuals, these variations can and do detract from the overall aesthetics of the face. The key to any surgical or non-surgical intervention by a plastic surgeon is a carefully performed detailed facial analysis. Once analyzed, a surgical or non-surgical approach involving the nose and interplay of the middle and lower third of the human face both in terms of bony structure and soft tissues such as fat pads, muscle of the lips and mouth and chin can greatly enhance the appearance of the nose.

A common nasal variation that many Middle Eastern and Asian descendants have, which they commonly want corrected, is a prominent nasal dorsal hump which slides down an inclined plain to a projecting nasal tip referred as the “poly beak” deformity. Often this is paired with a prominent caudal (lower) septum that plunges downward giving the appearance of a large view of the side nostril. The nasal tip can be further pushed downward during smiling animation if the person has a paired muscle that spans the lower portion of the nose and inserts into the circular muscle of the lips/mouth. Any time the person animates a smile it further pulls the lip upward and the tip of the nose downward. If the lower facial third is diminutive with respect to the middle facial third, such as people with an underbite, the nose in these cases rises to a more prominent position with the overall face. Without question a definitive surgical open septo-rhinoplasty for nasal deformities would provide the best results and, if the individual has the above-mentioned dental-skeletal relationship, adding a chin procedure such as a genioplasty or, if indicated, a chin implant would add harmony with the lower facial third to provide a superior result.

Alternatively, if surgery is not an option, non-surgical approaches can be employed to reduce the appearance of the anatomic variations that might displease the individual. Once again taking a very global detailed facial analysis is imperative to achieving the best results. Primiarily, if a patient presents with the animation deformity of the nasal tip when smiling leading to further lack of nasal tip projection, planned neurotoxin injections such as BOTOX or Dysport can be placed into the depressor muscle under the lip to prevent this action from occurring. If the patient has a retruded chin as we have specified previously, we can enhance the projection with a filler agent such as Radiesse which has the greatest “G prime” number meaning it resists deformity better than any other filler agent. Radiesse can be injected just above the bone on the chin’s tissue to enhance the furthest projection point of the chin creating a more balanced lower facial third making the nose appear less prominent. With respect to the nose itself we can add a hyaluronic acid filler agent such as Juvederm Voluma to the dorsum of the nose to soften the appearance of the nasal hump in conjunction with additional volume added to the nasal tip minimizing the “hook nose” shape. If the plunging caudal (lower) septum gives a greater view of the inside of the nose from a lateral view then adding a filler agent in the nasal mucosa above the lower lateral cartilage may act like a alar strut graft and push the inferior alar rim downward to reduce visualization of the inside of the nose.

If patients have had previous trauma to the dorsum of the nose or have an anatomic variant such as a ski slope deformity, added volume deep to the dorsum and below the skin can build this area up obscuring the underlying deformity. One important point to make is that non-surgical approaches cannot provide a subtraction affect which is needed in a bulbous nasal tip but can provide added volume in other areas such as the chin to balance out the enlargement of a nose.

Bottom line: never chose a provider to perform non-surgical approaches to the nose if they are not already an experienced rhinoplastic surgeon because filler agents are not in-expensive and it takes years of experience to be able to properly analyze and treat noses for optimal results, therefore – invest wisely.

State of the art lipo-abdominoplasty

Many women, after childbearing or significant weight loss, find themselves less than satisfied with their abdominal contour. They may have joined a gym, hired a personal trainer, engaged in cross-fit or boot camp and despite all the blood, sweat and tears still have sagging skin and loose abdominal tissue resulting in bulging of the tummy area. Often the flank areas “muffin top” and the mons pubis and perineum (or genital area) can also cause issues that detract from a sleek look with current athletic leisure wear. Fortunately, board certified plastic surgeons who remain engaged and committed to the continuous evolution of our craft have good options to improve the contour of the abdomen and surrounding areas.

Abdominoplasties have been around for many decades but refinements in techniques have led to better aesthetic outcomes:

  1. Liposuction of the epigastrium (upper central region of abdomen): reduces the skin thickness and can lead to a less bulky appearance when combined with tissue resection of excess loose skin.
  2. Resection of the upper abdominal skin flap sub-fascial fat plan: which can reduce the metabolic load of the flap by eliminating the poorly vascularized fat plain while diminishing the overall thickness of the skin.
  3. Discontinuous undermining of the abdominal skin flap off the costal (rib) margin: to allow further inferior repositioning of the skin flap to lower the final incisional scar to hide better in undergarments and or bathing suits.
  4. Progressive tension suture plication technique of the upper abdominal skin flap: to aide in the obliteration of dead space to reduce and or eliminates the amount of time that drains are necessary and to further sculpt the underlying abdominal shape.
  5. Fascial plication of the inferior edge of the upper skin flap to the lower abdominal wall to prevent scar migration superiorly.
  6. Resuspension, lipocontouring, and reshaping of the mons pubis to provide a sleeker appearance in leggings and yoga pants.
  7. A vertical narrow appearing belly button.
  8. Contouring the flanks with liposuction simultaneously with the abdominoplasty for more circumferential rejuvenation.

 

Just as fashion changes occur so must the plastic surgeon respond to effectively provide aesthetic outcomes that provide body contours that complement the new overlying clothing. The above-mentioned refinements can produce superior results compared to traditional abdominoplasties. If you would like to initiate a consult to see if you are a candidate for abdominoplasty please contact The Lucas Center, Plastic Surgery in Knoxville TN at thelucascenter.com, or 865-218-6210.

Why avoiding muscle coverage in augmentation mammoplasties results in fewer long term complications

As a plastic surgeon who trained in the late 1990’s and who has been in practice eighteen+ years I have witnessed many changes and evolutions in breast augmentation surgery.  As I started my practice we were only afforded the use of saline implants for our cosmetic patients. These devices yielded less than satisfying results due to rippling, a very stereotypical augmented round shaped breast. The saline filled plastic bags demanded that the surgeon place the implants partially under the muscle to soften the outline and attempt to hide the rippled appearance of the implant.  However, the outer edges of the breast could not be covered by the chest muscle and still showed the underlying implant.   Additionally, the visual results were pleasing at first but, over time, the constant chest muscle contraction overtop of the smooth round saline implant resulted in compressing the water inferior and laterally similar to a water hammer affect. The net result over many years is an over-expanded pocket that becomes larger than the implant and, in a reclined position, the device falls off the chest wall and into the armpit resulting in widely displaced implants and breasts without cleavage.  Additionally, a less than desirable appearance occurred when a woman bent forward and the weight of the implant, combined with the over-stretched skin of the upper pole resulted in significant pleating of the saline implant.

Today I do not offer saline implants to my patients because I feel the results are so inferior compared to silicone gel devices. I was trained originally in the nineties to perform mostly a blunt dissection of the muscle off the chest wall and create larger pocket sizes than the implant. The modern surgical approach utilizes finesse with meticulous dissection to create bloodless fields and to make a pocket size similar to the width and height of the device. I currently offer all types of silicone gel implants ranging from shaped to round devices with varying degrees of cohesiveness and surface textures customized to the individual needs of each patient.  Looking at data collected from industry experts and reviewing my own personal results over the years I have concluded that the pectoralis major muscle, even if elevated with great precision, may introduce a number of variables overtime that reduce the long-term control of outcomes by surgeons.  It is my goal to provide patients with an excellently executed surgical procedure combined with a customized implant choice leading to a desired outcome for many years, without the need for multiple revisions. Therefore, if an individual’s breast anatomy has adequate thickness in the upper pole for optimal coverage over the implant without the need for additional thickness of the muscle then I will proceed with a sub-glandular/ sub-fascial placement of the implant.  If there is slightly less than adequate thickness I will recommend simultaneous autologous fat grafting to enhance the upper pole breast tissue as opposed to elevating the muscle.

Historically speaking, other indications for utilizing muscle in augmentation mammoplasty procedures was to reduce capsular contracture rates.  Most experts feel that biofilm is the major mechanism leading to capsular contracture. Bacteria flora in the breast ducts can be introduced onto the surface of the implant during surgery setting up colonization leading to many antigens triggering our immune system resulting in an array of events such as capsular contracture and even implant associated lymphomas. This idea, even with a dual plane placement of an implant under partial muscle coverage, reduces the surface area of the breast directly in contact with the device. Data shows a reduction in at least one percentage point in capsular contracture in the subpectoral plane compared to sub-glandular placement. However, thanks to the contributions of surgeon- researchers such as Dr. Bill Adams, our society has good benchmark data regarding the most appropriate irrigation solutions to combat the most likely bacteria present to control biofilm as well as intraoperative techniques to minimize bacterial loads on the implant during the procedure. Utilizing all this data has led to a very low capsular contracture rate even in the sub-glandular plane of my patients, thus, I feel the risk benefit ratio still favors avoiding the muscle.  

Additionally, another way to reduce capsular contracture in the sub-glandular plane is to place textured rather than smooth devices. The data is quite clear:  there is a 50% reduction in capsular contracture rates with textured vs smooth devices sub-glandularly.  But wait, it gets more controversial – textured implants have an increased risk of developing implant associated atypical lymphomas (ALCL).  Fortunately, the number of confirmed cases is very low compared to the very large denominator of all patients who have received breast implants since the late 1960’s.  In fact, the likelihood of being hit by a car while walking on the street is far greater than developing ALCL.  As far as I can glean from the data, there is no stratification of ALCL of textured devised in the sub-glandular vs sub-pectoral plane.  It is my belief without proof that the inflammation of textured devices under a dynamic muscle is greater than a textured device in the sub-glandular non-dynamic plane. The overwhelming majority of plastic surgeons in the United States utilize smooth implants mostly because, in the late 1990’s, textured saline implants resulted in poor outcomes with greater rippling under the muscle and higher deflation rates compared to smooth implants.  However, surgeons in Europe were never forced to use saline implants and always had the availability of silicone gel devices.  They have mostly embraced textured gels with excellent results and very low ALCL rates.  Based on all of the risk-benefit analysis combined, I prefer a sub-glandular textured breast implant for the vast majority of my aesthetic breast patients.  This device has the least capsular contracture rate with the least amount of risk for implant malposition inferiorly-laterally, and avoids a waterfall effect of the inferior pole breast tissue falling away from the implant which is held to the chest wall muscle, and avoiding any unnecessary muscle animation deformity of the breast during pectoralis muscle activation. I have also found the soft touch gels which are more cohesive than the workhorse responsive gels but less stiff than the highly cohesive gels to minimize rippling of gels in rather thin breast tissue patients. Even in the breast reconstructive realm where there is even less overlying tissue, the push for pre-pectoral placement of silicone gels completely wrapped in acellular dermal matrix material is gaining favor to avoid muscle animation deformities. For the prospective patient reading this blog don’t be hampered by simply listening to your girlfriend who had implants some fifteen years ago and tells you to have a augmentation with saline under the muscle because that is what she had and she is happy.  I applaud you for exploring implant options and encourage you to seek modern options with less long term negative outcomes with sub-glandular placement of textured implants.

 

Gluteal enhancement and lift with expanded volume lipofilling

Based on the most recent data from the 2018 American Society of Plastic Surgery statistics: buttock augmentation and lift continues to increase in popularity. Some of the enticement that draws prospective patients to seek this operation is the fact that areas of unwanted fat distribution such as excess flanks, bra line fat, abdomen, and thigh tissue excess can be lipo-contoured to give improved body shape while being the donor site to provide needed fat to be placed into the buttock to correct volume and aesthetic form to the gluteal region. This is one example of robbing Peter to pay Paul that benefits both.

Many varied techniques exist to perform this operation but clearly the best approach that provides excellent outcomes and safety is the expanded volume lipofilling technique described by Drs. Wall and DelVecchio and I have incorporated their methods into my practice. The approach allows for efficient application of fat with an oscillating cannula and an expanded tip which actually creates an enlarged space while simultaneously layering the area with fat. The gravest risk associated with this procedure is being unfamiliar with the anatomy and losing reference of the tip of the cannula and injecting the gluteus muscle with a small diameter tip which can cannulate rather large veins which are confluent with a venous network which ultimately returns to the heart and lungs. A large bolus of fat can act just like an emboli of blood clot and can result in death. Several cases in South America and in the state of Florida have resulted with this outcome. Understanding the human anatomy is very important to prevent this outcome as well as using large cannulas that are two big to enter the venous system and always pointing the tips toward the skin. The process starts by filling areas of deficiencies laterally and superiorly followed by inferiorly to achieve an attractive buttock.

The results are very satisfying for both the patients as well as myself because we create pleasing hour-glass figures by eliminating unwanted contours of the upper and mid- back and sculpting the flanks to get rid of the muffin tops and enhance the aesthetic curves of the back as it sweeps to the buttock. If this sounds like it could apply to you and you wish to have a consult to perform body sculpting with buttock enhancement please contact my office either by thelucascenter.com , or 865-218-6210 to schedule an appointment.

Are you considering liposuction for body contouring? Here is why you should choose SAFE liposculpting as the procedure of choice.

The trend continues: a high demand for body contouring by women and men. In recent years cryolipolysis (CoolSculpting) has received lots of hype just like LASER-liposuction did before it. Even though it is a non-surgical procedure it still requires a large time commitment and significant cost to the patient with limited results due to its lack of skin tightening. Liposuction, in its basic form, has been employed for many decades and, with proper patient selection and appropriate execution of good techniques, can produce results which sculpt the human form to a more pleasing shape without surgical excision of skin. I have been in practice for seventeen years and I have seen many modifications of liposuction with various added energy sources such as ultrasonic, water pulses, LASER, and mechanical oscillation cannulas. Regardless of the technology the most important variable is the surgeon who is performing the liposuction. They should be a Board Certified Plastic Surgeon who understands the concept of even skin flap elevation, the normal desired anatomy of the body part, the concept of wound contracture related to inflammation and collagen deposition, and the understanding of the potential life- threatening complications which need to be minimized or avoided. Liposuction is surgery whether performed in an office, surgery center or hospital and appropriate judgement and skill is required. So, do your homework and choose wisely to ensure predictable safe outcomes.

Liposuction to improve or enhance the shape of the body can result in unwanted contour irregularities of the skin. This can be the result of incomplete fibrous tissue release and or skin retraction or uneven removal of the underlying fat. Even in experienced hands some contour deformities can occur requiring minimal revisions. In my hands, the most predictable lipocontouring technique is the one championed by Dr. Simeon Wall called PAL/SAFE which is not a completely new concept but has led to much more precision and artful outcomes. Essentially it employs the use of a power added handpiece attached to an oscillating cannula. I also utilize a technique by Dr. Dan DelVecchio called SST (simultaneous separation and tumescence) to enhance the pace of the surgery. The essential features of the amalgamation of these two concepts include infusing a wetting solution containing dilute epinephrine and lidocaine retrograde through an oscillating expanded basket cannula which allows the surgeon to immediately wet the fat and prevent bleeding while also breaking up the fibrous encasement surrounding the fat cells under the outer skin. This is also when any cellulite (ligaments that bridge deeper tissue to the dermis of skin) can be released as well. The key principle is to completely release the fat to be freely mobile while still attached to a blood supply and the overlying skin is completely released. The second stage is the aspiration of the unwanted fat volume of a given area to create the new shape. The last step is the equilibration of the remaining fat left behind and re-distributing relative areas of excess fat to areas of deficiencies with a cannula similar to racking pea gravel to an even level throughout the area of concern leaving behind an even surface. The concept of the skin re-distribution or retraction can occur evenly if the overlying skin is released and the skin quality is acceptable for the technique. Loose hanging skin with lots of stretch marks are not candidates for any contouring without associated skin resection such as tummy tucks.

Liposuction to create new body contours can be a very effective technique with the right trained surgeon and the appropriate candidate. The precision advanced techniques described above are the best way, in my opinion,to ensure good results with minimizing contour irregularities. Therefore, I prefer to use the MicroAire PAL system with SAFE and SST concepts for my body contouring procedures. To inquire about a consult and to see if this procedure is right for you please contact my office, The Lucas Center, at 865-218-6210 or email thelucascenter.com