LENGTH OF SURGERY
Usually 30-90 minutes.
Local anesthetic and intravenous sedation or general anesthesia.
LENGTH OF STAY
Outpatient procedure, home the same day.
Out of bed ﬁrst day; swelling, bruising mostly gone in two to three weeks; back to work within one week if swelling permits; full effect in two months.
Undetectable within mouth.
Serious complications, while possible, are unlikely. Some potential complications can be avoided by carefully following your surgeon’s postoperative instructions.
In addition to the normal risks associated with anesthesia, other risks include:
- Sensory changes: Numbness, pain, and tingling common for two to six weeks; permanent or delayed numbness rare but can result from implant shifting.
- Implant displacement.
- Bone erosion: Rarely a problem.
- Extrusion of implant: Usually requires implant removal
The above-listed risks may be only some of those that your surgeon will discuss with you in greater detail during your consultation.
The buccal fat pad lies beneath the cheekbone. Buccal fat pad removal enhances the midface area by reducing rather than adding volume. An intra-oral incision, similar to that used for placement of an implant, is made between the cheek and gum. The surgeon will remove buccal fat through this incision to achieve a more reﬁned, sculpted cheek contour. As mentioned earlier, this surgery is recommended primarily for patients with decidedly round, full cheeks. As aging generally causes a certain amount of thinning of the cheeks, excessive removal of the buccal fat can actually accelerate an aged appearance.
There will be some brief swelling after buccal fat removal, as well as difﬁculty chewing. And because the patient has undergone surgery involving an intra-oral incision, he or she should generally follow the same postoperative course of care as discussed for cheek augmentation.
Cheek implantation usually takes about 30 to 90 minutes. The procedure can be performed under sedation (twilight) anesthesia although general anesthesia is sometimes used. Whether you are awake and unaware of what is going on, or you are unconscious, you will not feel any pain during the surgical procedure. Cheek implant surgery is an outpatient procedure and patients are generally allowed to return home the same day.
You can expect some tenderness and a tight, stretched feeling for several days. Pain medication, according to your plastic surgeon’s instructions, may be needed for about two to three days; acetaminophen (Tylenol) alone is generally sufficient. Aspirin and certain anti-inflammatory drugs that may cause bleeding are to be strictly avoided. Your surgeon will instruct you concerning oral hygiene and very likely put you on an initial diet restricted to liquids and soft foods following surgery.
Bruising may be minimal, but expect swelling to last for two to three weeks. Keeping your head elevated and applying ice frequently can help reduce swelling. Although rigorous activity should be avoided for the ﬁrst few weeks,
you can resume most normal activities in about a week to 10 days. You should protect your skin from the sun while tissues are healing. If skin incisions were used — usually in conjunction with another procedure — stitches will be removed in ﬁve days; absorbable stitches used for intra-oral incisions will dissolve by themselves.
You should feel able to return to work within two to ﬁve days, however, the degree of your swelling may be a determining factor. Although recovery can vary greatly from individual to individual, and for some, swelling may not completely subside for as much as six months, your ﬁnal result should usually be evident within two months. Following intraoral placement of cheek implants, transient reduction of sensation of your upper lip can occur, but this is rarely permanent.
Most patients are extremely happy with the results of cheek enhancement, whether they have added height and volume to their cheekbones or reduced their “pudgy” cheeks. Even when the change in facial contour is subtle, as is often the case when cheek augmentation is performed to correct a ﬂat malar eminence in a male, this type of surgery nevertheless can produce a signiﬁcant change in facial aesthetics. Beyond being satisﬁed with your more aesthetically pleasing appearance, you might feel a surge in self-conﬁdence and a new freedom to experiment with your new “look” by trying a swept-back hairstyle or more dramatic makeup.
A younger face is more triangular in shape with the chin representing the tip of the triangle. With aging, as the malar areas descend, jowling occurs and the facial shape becomes more rectangular. In individuals whose facial contours have changed as a result of advancing age, as well as in individuals who have congenitally flat cheek areas, malar augmentation can offer significant enhancement of facial aesthetics. Though implants offer the advantage of a permanent structural change, injectable materials may be a good alternative when a lesser degree of augmentation is sufficient and permanency of the result is not mandatory. In the future, with ongoing evolution of soft tissue fillers, injectable treatments may become an even better option with long-lasting results.
Over-augmentation of the malar area, unfortunately, is not uncommon. Old photographs that illustrate how a patient looked in younger years, before aging impacted the facial contours, may be helpful in determining the optimal enhancement. Similarly, images from beauty magazines can be useful tools for the prospective patient to communicate her or his aesthetic goals to the plastic surgeon during a consultation. Injection of saline, which will absorb quickly and harmlessly, into one side of the face is a further technique that can be useful to more accurately deﬁne a patient’s desires. When considering modiﬁcations to the cheek contour, and especially those that are to be relatively permanent, careful preoperative evaluation and good communication between surgeon and patient are essential components of a happy outcome.
Your surgeon will give you instructions about how to prepare for your surgery. He or she will also give you guidelines on eating, drinking and medications, such as avoiding aspirin or anti-inﬂammatory medications that promote bleeding. As with all surgery in general, whether performed in an outpatient facility or in the hospital, you should arrange to have someone drive you to and from surgery and to assist you for a day or two after you return home.
There are a variety of procedures and treatments to enhance your cheeks, and the techniques vary. Some of these involve surgery and some, which use injectable substances to achieve volume, are nonoperative procedures that are discussed in another chapter. The results of soft tissue ﬁllers, whether pharmaceutical ﬁllers or fat, differ from those achieved by facial implants, the latter providing permanent structural changes.
“The cheekbones can be made fuller, creating a more sculpted look, using specially designed implants that are placed over them,” says Mark Sofonio, MD, of Palm Springs, California. “The procedure is usually performed through an incision inside the mouth, but it may be done through a lower eyelid or a brow lift incision. Facial implants provide a permanent and predictable result.”
Implants used for cheek augmentation are usually made of medical-grade silicone or another material such as Gortex. They can be placed, either over (malar) or under (submalar) the cheekbones. A malar implant will create a heightened curve of the cheekbone, while a submalar implant is generally used to correct a sunken, or hollow looking, midface. Implants are available in a wide variety of sizes and shapes, which allow the surgeon to custom-ﬁt the implant to each patient’s face. They may be used in conjunction with facial surgery to correct congenital deﬁciencies or to rejuvenate or beautify the facial contour.
The incision for cheek implantation usually is made inside the mouth between the cheek and gum. If the procedure is done in conjunction with a face lift or eyelid surgery, the surgeon most often will use the same incisions for insertion of a facial implant.
“Cheek implants are most often inserted through an intra-oral approach, but they can be inserted through a lower eyelid incision,” says Dr. Terino. “This approach, however, requires greater experience and expertise on the part of the surgeon. That’s because the lower eyelid, generally speaking, is a structure that has to be treated very delicately or it can develop scar tissue leading to complications. If an eyelid incision is used, the surgeon will also need to perform a very secure canthopexy technique to tighten the corner of the eye, preventing the lower lid from pulling down during the healing process.”
To insert the implant, the plastic surgeon stretches the tissue to form a pocket in front of the cheekbone and places the implant into the soft tissue, creating the cheek’s desired contour. Most surgeons feel that using judicious techniques to develop the proper size and location of the implant pocket is sufﬁcient for securing implants in place. Some may add ﬁne sutures, or specially designed screws may be used to hold the implants in place.
The cheeks play an important role in deﬁning an attractive face, and well-deﬁned cheekbones have long been recognized as a hallmark of beauty. Sufficient volume of the cheek contour is essential to a youthful appearance. As people age, however, the fat pads that give cheeks their fullness begin to descend, creating a ﬂat visage. In addition, supportive tissue beneath the skin begins to erode, hastening the appearance of lines and wrinkles.
Aesthetic plastic surgery offers various ways to restore a more youthful appearance to the cheeks. In addition to a cheek or midface lift, discussed elsewhere in this book, there are other methods that can enhance cheek volume and improve contour.
The least invasive method of adding or restoring volume to the cheeks is by injections using a biocompatible soft tissue filler or the patient’s own fat. Although a pleasing appearance may be achieved, repeat treatments are necessary to achieve or maintain the desired results. For more information on injectables, see the “Injectable Treatments for Facial Enhancement” chapter in this book.
Implants made of materials such as silicone, Gortex, or AlloDerm can be implanted to add permanent volume and deﬁnition to the midface.
BUCCAL FAT PAD REMOVAL
Buccal fat reduction is a procedure to remove fat pads from the lower part of the cheeks, achieving a more sculpted look typical of many fashion models. This procedure is generally reserved for individuals with round faces, because removing the fat pads may accelerate an aged look in some individuals
The consultation is a time for you and the surgeon to get to know and feel comfortable with each other. You should feel completely conﬁdent that the surgeon is fully qualiﬁed. If you haven’t read sections in the beginning of this book about choosing a surgeon who is certiﬁed by the American Board of Plastic Surgery, perhaps you should do so now. Your surgeon needs to determine if you are a suitable candidate for surgery and will want to review your entire medical history, including your previous dental and sinus history and any medications you may currently be taking. Several factors will be evaluated, including the current contour of your cheeks, your skin texture, bone structure, facial sensation, and muscle function.
“People who would not be suitable for cheek implants are most often those with very round faces or those whose soft tissues are very thick,” says Edward O. Terino, MD, of Thousand Oaks, California. “Cheek implants ﬁll out the face with precision and permanence, so in some cases they may be beneﬁcial for an older patient. But this depends on a variety of factors that need to be carefully evaluated by the plastic surgeon.”
Your surgeon will analyze the overall structure of your face and how it can be enhanced, as well as identify and discuss any naturally occurring asymmetries. He or she will explain the details of the recommended procedure, such as incision placement and the type of implants or ﬁller material that will be used. Some implant materials may increase the risk for infection or implant mobility, which in turn may increase the risk of other problems. You should discuss the various types of implants with your surgeon, who will recommend what he or she thinks best meets your overall needs. Your surgeon may discuss other procedures that are often done in conjunction with cheek enhancement, such as face lift, brow lift or eyelid surgery, if it appears that those areas of your face also need attention to achieve a rejuvenated appearance and maintain facial harmony.
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Liposuction, also called lipoclastic, the most popular aesthetic procedure performed in the United States, is also perhaps one of the most misunderstood. Although the procedure involves the removal of fat, it is not a replacement for dieting and exercise, and liposuction is not a treatment for generalized obesity.
“Liposuction should not be viewed as a means for weight loss,” says Brian K. Howard, MD, of Roswell, Georgia. “Liposuction is a tool for aesthetically sculpting the body. Although some weight loss may be noted after healing is completed, this is not the reason for having the procedure.”
Otis Allen, MD, of Bloomington, Illinois, adds, “Liposuction remains one of the most commonly requested procedures in all adult age groups and for both sexes. Why? Quite simply, it works — as long as the patient understands that it is best used as a method of ‘spot reduction’ for areas that do not respond to diet and exercise.”
Although adopting a healthy diet and engaging in regular exercise is always a good idea, it is a fact that localized fatty deposits in areas such as the hips, thighs, and abdomen often may be inherited traits that simply cannot be corrected by an improved lifestyle alone. Liposuction can be used to target and reduce unsightly bulges that do not respond to usual weight-loss methods, and to effectively sculpt and recontour various areas of the body.
Alexander G. Nein, MD, of Nashville, Tennessee, also emphasizes that liposuction is not a substitute for weight loss: “Liposuction is ideally suited to treating focal areas of fat accumulation — those lumps and bulges that can make it difﬁcult to wear certain styles of clothing and can cause self-consciousness or even lack of self-esteem. Whole body liposuction is generally impractical.’
“I prefer the term ‘liposculpting’ rather than ‘liposuction,'” offers William G. Armiger, MD, of Annapolis, Maryland. “The word ‘suction’ implies simply sucking off a glob of fat from a certain area. In reality, liposculpting is a technique to optimize your particular body form. Everyone’s result is different. However, the vision that the physician has initially, before the operation begins, is the key. Your doctor must be able to see the three dimensional you and devise the most appropriate sculpting procedure to smoothly transition to each of those regions of concern.”
Liposuction is sometimes used in conjunction with surgical procedures that entail skin and or tissue removal, such as a face and neck lift, breast reduction and abdominoplasty. The procedure can also be used for removal of benign fatty tumors.
Perhaps because it seems like a relatively simple operation, liposuction has attracted a wide range of practitioners with varying qualifications. However, liposuction is serious surgery, and it is essential to verify that your doctor has accredited training that qualiﬁes him or her to perform this procedure. A physician who is certiﬁed by the American Board of Plastic Surgery has completed an accredited residency training program in plastic surgery and is well qualified to perform liposuction of the face and all body areas. In some cases, dermatologists have received additional training in liposuction; the procedures they perform usually are limited to very small areas of localized fat. A facial plastic surgeon, whose primary specialty is otolaryngology, is also trained to perform liposuction of the face and neck. Your choice of physician should always be based on training, qualiﬁcations, and experience. Also important, however, is the fact that a board-certiﬁed plastic surgeon has the range of training and experience to be able to advise you on whether liposuction or perhaps some other surgical procedure may be best suited to achieving your goals.
“Because liposuction is practiced by specialists other than plastic surgeons, not all of whom have the same wide range of surgical training, patients can be misled,” says Otto Placik, MD, of Arlington Heights, Illinois. “A plastic surgeon can appropriately advise them as to whether they are a good candidate for liposuction, or whether a different surgical procedure such as abdominoplasty, brachioplasty, breast reduction, or thigh lift, may be a better option to achieve the results they are looking for.”
Robert Wald, MD, of Fullerton, California, adds, “Liposuction is a procedure that requires a lot of artistry and experience. The purpose of this procedure is to contour the body. The surgeon is sculpting and shaping. He or she must develop a well-designed surgical plan and mark the patient properly before beginning to operate. The surgeon’s good clinical judgment, based on training and experience, is a vital component of successful liposuction.” People at a normal, stable weight, with ﬁrm and elastic skin tone who have excessive fatty deposits limited to speciﬁc body areas are the ideal candidates for liposuction.
“If the patient’s weight remains stable, the results from liposuction will be permanent,” says Alexander G. Nein, MD, of Nashville, Tennessee. Good physical health is also very important. Although in the hands of an experienced and qualiﬁed surgeon, serious complications are rare, the risks increase signiﬁcantly for people with medical problems, such as heart or lung disease, poor blood circulation, and diabetes. Those who have recently had surgery near the area they want contoured also may run a greater risk of complications. Age is not necessarily an important factor in considering safety, yet if older patients have reduced skin elasticity, their results may not be as good as those achieved in younger patients with better quality skin. That’s because liposuction removes only fat and not loose, excess skin which may require another type of procedure such as a tummy tuck or a lower body lift, discussed elsewhere in this book.
“Patient selection is probably more important in liposuction than any other procedure,” comments James D. McMahan, MD, of Columbus, Ohio. “The ideal patient for liposuction is young, healthy, close to their ideal body weight with very elastic skin and just a few bulges they want to remove. Those patients do extremely well. Their skin looks great and it looks like they never had the operation, which is what you want. But it really depends on the individual patient. I’ve had 70-year-olds who did phenomenally, and I’ve seen people in their 20s who were not good candidates because their skin quality was so poor.” Michael Rose, MD, of Shruvsbury, New Jersey, adds, “My general feeling is that, in women, liposuction is well-suited for body contouring in an individual who has not yet had children. After child-bearing, the skinreduction techniques such as abdominoplasty and body lifting are usually necessary.”
In addition to good physical health, realistic motivations and expectations about what the procedure can accomplish contribute to a patient’s chances of achieving a satisfying outcome. Provided you are a good candidate for the procedure, liposuction can eliminate or lessen fatty deposits in problem areas of the body. These include the abdomen, hips, buttocks, back, thighs, knees, calves, ankles, upper arms, jowls, cheeks, and neck (“double chin”).
Liposuction can also be used, either alone or with skin excision surgery, to reduce enlarged breasts in men (gynecomastia), which is a common condition among adolescent and adult males, and for breast reduction in women. (Liposuction-only breast reduction is discussed in the chapter on Breast Reduction in this book.) Liposuction can be performed on several areas of the body at the same time, and it can also be done in conjunction with certain other aesthetic plastic surgery procedures. Depending on the amount and type of surgery you will undergo, your surgeon may suggest performing it in one, two, or more sessions. As stated previously, liposuction is not a method for weight loss, and it should not be used as a treatment for obesity.
Liposuction will not remove cellulite and in some instances could worsen its appearance. That’s because fat deposits targeted by liposuction are beneath the cellulite. When the fat volume is reduced, the cellulite “dimples” may be more noticeable. Skin tone is one of the most important aspects that can affect the quality of liposuction results. The fat cells targeted for removal by liposuction are immediately beneath the skin and above the muscle. The better the skin tone, the more readily skin will contract to ﬁt the newly contoured body shape. There are several factors that inﬂuence skin tone quality; these include tightness, thickness, stretch marks, prior sun exposure, and the patient’s age. Some areas of the body may not respond to liposuction as well as others. The inner thighs, calves, and areas with natural skin creases, such as the buttock crease, are more likely to yield less satisfactory results. However, this is not always the case. In addition to the surgeon’s experience in treating difficult or delicate areas of the body with liposuction, there are many other factors that must be considered — for example, the degree of correction needed, the quality of your skin, and your expectations for results.
Depending on your expectations, desires, and the extent of your fat deposits and excess skin, your surgeon will advise you whether a full abdominoplasty, a limited abdominoplasty, liposuction alone, or a combination of abdominoplasty and liposuction will yield the best result.
“Determining the correct abdominoplasty procedure requires an accurate analysis of the underlying muscular and skeletal structures, fatty deposits and skin condition. People think of a tummy tuck as a way of eliminating fat, but more often it is a way of correcting loose muscle and skin tone,” says Dr. Placik.
“It is essential that the doctor assess the muscle tissue layer, fatty tissue layer, and the skin to properly individualize the procedure for each patient,” says Stephen Goldstein, MD, of Englewood, Colorado. “After a woman has had children, the layer of connective tissue between the muscle and the skin loosens and the muscles drift. The essential job of an abdominoplasty is to bring these back together. I am fastidious in how I bring the muscles back together, doing it multi-dimensionally by performing a vertical and horizontal tightening. Because we are treating the whole torso, we almost always incorporate ultrasonic liposuction, and the combination provides excellent results.”
“Today’s abdominoplasty procedures range from a mini to a full,” explains Daniel C. Morello, MD, of White Plains, New York. “The mini has a shorter incision, lower muscle plication, some liposuction, and a ﬂoat of the umbilicus where it’s transected and moved down a little. The components of a full abdominoplasty vary between individual patients, and this highlights the need for a good surgical plan ahead of time. A full abdominoplasty, however, always includes excision of skin and subjacent fat, liposuction of fatty deposition, and muscle repair below and or above the umbilicus.”
“Gone are the days of offering only a “standard” tummy tuck or liposuction. The wide range of abdominal contouring procedures now available requires a more complex individualization for each prospective patient,” agrees Lee H. Colony, MD, of East Lansing, Michigan. “Sometimes, patients are best served with a circumferential approach to body contouring that addresses the back, ﬂanks, and buttocks along with the abdomen, including both liposuction and skin tightening. These procedures may also create recovery challenges that must be addressed. Conversely, for patients interested in limiting recuperation time, tummy-contouring procedures can be modiﬁed to provide acceptable results with less interruption to activities. It is our job as plastic surgeons to understand patient goals and guide patients in choosing the options that best suit their speciﬁc needs.”
“Abdominoplasty with combined body lift procedures can be performed successfully and safely in one stage, provided they are conducted by an experienced surgeon who performs these procedures regularly and who works with a highly competent team that implements a strict and well-conceived protocol in a fully accredited surgical facility equipped to provide a comprehensive level of care,” agrees Christopher K. Patronella, MD, of Houston, Texas.
“Abdominoplasty is one of the most dramatic procedures we do. A major change in the patient’s shape can be created because we have the advantage of cutting and tightening excess skin, tightening muscle, and combining that with liposuction. I do all three in contouring the trunk; the procedure is circumferential and can improve the waist and the entire midsection,” says David J. Levens, MD, of Coral Springs, Florida
Your surgeon will ask if you are planning to lose a signiﬁcant amount of weight or might become pregnant in the future. Patients who realistically think they will be successful in achieving their desired amount of weight loss may be advised to postpone surgery
“I won’t perform this procedure on patients who are more than 50 percent above their ideal body weight,” says Dr. Sloan. “Patients need to be in good health, and they have to quit smoking. The risks increase greatly if these conditions aren’t met, and I believe it is the surgeon’s responsibility to educate patients aboutthese risks.”
Since vertical abdominal muscles that can be tightened during an abdominoplasty may separate again during pregnancy, your surgeon may advise you to delay surgery until you have had your last pregnancy.
“Patients should avoid any large ﬂux in weight after abdominoplasty,” says Dr. Abramson. “Gaining weight after surgery can compromise results, and if someone loses weight after surgery, they may have extra skin. So a patient should be at a weight they can maintain before they have surgery, and maintaining an exercise program after surgery is also helpful.”
Your plastic surgeon will need to review your entire medical history, including any medications you may currently be taking, whether you suffer from any allergies or medical conditions, and if you have had any prior surgeries. He or she will examine you to determine the extent of the excess fat and loose skin in your abdominal region, assess the condition of your abdominal muscles and evaluate the quality of your skin tone. “
“The principles of functional anatomy that plastic surgeons have developed to more effectively rejuvenate the face have now been applied to the abdomen, torso, and extremities, allowing us to achieve improved results,” says Steven J. Smith, MD, of Knoxville, Tennessee. “One thing we have learned is that the muscle structure needs to be respected and not altered, so the normal function of the muscles is actually enhanced by improving their direction of pull. For instance, when fascia becomes irreversibly stretched with pregnancy, it must be reconstructed to approximate a more youthful anatomy.”
“Abdominoplasty must be tailored to the individual patient,” says Fereydoon S. Mahjouri, MD, of Fridley, Minnesota. “Aging, obesity, and pregnancies can stretch the abdominal skin in horizontal dimensions, vertical dimensions or both. This can be assessed by examining patients in different positions — standing, diving, sitting, and lying on their back or sides. The shape, location, and length of incisions should therefore be adjusted accordingly. Our patients are encouraged to bring their preferred underwear or swimwear for individual tailoring of the incision lines.”
“Abdominoplasty begins with a thorough examination and assessment of each patient,” agrees Dr. Moore. “I consider the whole patient — overall health and anatomical structure — to determine if he or she is a good candidate for the procedure. If they are in good health, I then examine them from all perspectives. I analyze the full body from the front and back, assessing the upper back, the ﬂank area, hips, and saddleback areas. I also assess the degree of skin elasticity, muscle laxity, and stretch marks. We check many factors, including if they have intra-abdominal fullness, or masses, and if they have signiﬁcant intra-abdominal fat versus subcutaneous fat, to accurately plan our course of action.”
Patients whose abdominal fullness is primarily due to intra-abdominal fat (fat that surrounds or forms a protective cover over the internal organs) most likely will not be good candidates for abdominoplasty. In fact, such patients will be probably be advised to work on their diet and exercise, since these are often the only solutions to reducing intra-abdominal fat. Patients with intra-abdominal fat often present with a large, distended belly. This condition is far more common in men and commonly referred to as “beer belly.”
If you have scars from previous abdominal surgeries, your surgeon will discuss how this may impact the placement and ﬁnal appearance of your abdominoplasty incisions. Depending on the situation, he or she may recommend against abdominoplasty. On the other hand, your surgeon may feel that your previous scars can be revised and improved upon by undergoing a tummy tuck.
“Abdominoplasty can sometimes be used to eradicate unsightly scars and transform them into inconspicuous ones,” states Dr. Placik. “People may have vertical scars beneath the umbilicus (belly button), appendectomy or hernia scars, or they’ve had multiple procedures resulting in numerous scars. I have often been able to eliminate these scars, leaving patients with one scar that can be hidden below the bikini line. The vast majority of stretch marks located on the lower abdomen can also usually be eliminated.”
Although designed to follow natural skin creases and to fall within bikini lines, the length of scars will vary from patient to patient. Your surgeon should describe the planned procedure in detail, including the surgical technique and where resulting scars will be placed. Placement of scars cannot always be ideal, depending on each patient’s anatomy and the amount of correction required.
“The abdominoplasty procedure may inﬂuence skin tightness, fatty contour of the abdomen, muscle position, or all three of these variables, depending on the individual. As with any surgical procedure that excises skin, there is a necessity of scars. Surgical incisions are designed to end up in the least conspicuous positions,” saysJohn E. Hamacher, MD, of Madison, Wisconsin.
“Occasionally, abdominal appearance can be improved with just liposuction,” adds Stephen A. Bernsten, MD, also of Madison. “A surgical plan should be clearly outlined during the comprehensive preoperative consultation and evaluation with your aesthetic surgeon.” “In an abdominoplasty, it is important to pay attention to waistline and hip shape and the amount of skin and fat to be removed. Also, the position and length of the scar must be carefully considered,” agrees Gloria A. de Olarte, MD, of Pasadena, California.
“Nearly all patients requesting an abdominoplasty beneﬁt from liposuction of the hips,” adds Alphonso Oliva, MD, of Spokane, Washington. “The length of the abdominal incision should be commensurate with the amount of lipectomy performed. Patients tolerate long incisions with good contour much better than short incisions with contour irregularities.”
“Abdominoplasty is a great procedure for patients who may have achieved their ideal body weight but are still troubled by loose, excess skin, stretch marks, and laxity in the abdominal wall, which frequently occurs as a result of pregnancy. It is, however, a procedure with trade-offs. Patients have to understand that even though the scar can usually be hidden within the bathing suit or underwear line, there is a permanent scar involved, and this is major surgery,” says Robert Wald, MD, of Fullerton, California. “Safety is key. I require that my patients spend at least one night in an aftercare facility with nursing care following surgery, and that they adhere closely to the guidelines they are given to help ensure a safe recovery.”
In a limited abdominoplasty, incisions frequently do not extend beyond the pubic area. In a full abdominoplasty, they generally span the hips and, in some cases, may even extend toward the back. To remove loose skin above the navel may require another incision around the belly button. The visibility and appearance of scars can vary greatly from person to person. Depending upon an individual’s healing characteristics, the ﬁnal scars may be ﬂat and almost invisible or noticeably raised and wide.
“There is no scar that is more feared preoperatively by patients and less of a concern postoperatively than the abdominoplasty scar,” offers James Platis, MD, of Chicago, Illinois. “The wonderful thing about abdominoplasty is that visible, unattractive skin that may be loose or may have stretch marks can be traded for a beautifully contoured abdomen and waistline with a hidden scar below the panty line. It always seems to be such a big concern for patients before surgery, but it never seems to be a problem afterward.”
Although the vast majority of patients are very satisﬁed with their abdominoplasty surgery, it is impossible to guarantee perfect results. Any type of surgery may require minor revisions to achieve an optimal final outcome. In addition, abdominoplasty carries certain risks that should be explained in detail by your surgeon. You will want to ask what measures your surgeon and or anesthesia provider plans to take in order to minimize these risks as much as possible.
“For the most part, patients love the operation,” states Seth R. Thaller, MD, of Miami, Florida. “However, there are risks, and patients need to know what the potential complications are. One of the risks of this type of surgery is blood clots. What we do to minimize this type of complication is give our patients pre- and peri-operative blood thinners. We also use compression stockings on our patients and, following surgery, keep them ambulated and well hydrated.”
Substantial weight loss, muscle weakness following multiple pregnancies, or heredity can all cause or contribute to loose, wrinkled abdominal skin and excess fat in the lower abdomen. If your only complaint is the appearance of a protruding abdomen, and if your skin tone is good, it may be that liposuction is the only treatment you’ll need. But if you also have loose skin and lack of tone in the abdominal area, then an abdominoplasty, commonly called a tummy tuck, may be recommended for you.
“Abdominoplasty has become one of the most popular procedures I perform,” says Chester Sakura, MD, of Albuquerque, New Mexico. “Today, the modern woman wants to regain her ﬁgure after childbearing, wear fitted clothing and look natural in her overall contour, both sitting and standing. The optimal results in abdominoplasty are achieved by careful attention to incision placement, skin and fat removal, re-creating a natural umbilicus (belly button) and proper but not excessive tightening of the loose stomach muscles.”
“This is a wonderful operation for women who, following pregnancy, have developed loose abdominal skin and abdominal wall weakness,” says Alexander G. Nein, MD, of Nashville, Tennessee. “Our patients appreciate the fact that we can help them get rid of the excess skin of the stomach that is unaffected by diet or exercise. The fact is that diet and exercise simply cannot remove the skin laxity that comes from pregnancy and/or weight ﬂuctuations. An abdominoplasty, on the other hand, can return the abdomen to a beautiful shape that looks great in slacks and swimwear.”
“Tummy tucks are very commonly requested following childbirth or weight loss,” agrees Otis Allen, MD, of Bloomington, Illinois. “This procedure is not a substitute for weight loss but is very useful for tightening muscles and restoring contours. Patients are often surprised to learn that the removed skin and fat usually weighs less than three pounds. Often this surgery results in clothing ﬁtting better, rather than a smaller dress size.”
Abdominoplasty is a major surgical procedure that tightens the skin and, when necessary, can reduce fat and modify muscles. A full abdominoplasty generally requires a horizontal incision just above or within the pubic area. The length of the incision and the resulting scar, which extends laterally toward the pelvic bones, depends largely on the amount and location of the skin to be removed. The contour of this incision will vary somewhat according to abdominal structure and personal preferences — such as the style of swimwear or undergarments that you typically wear. Based on these and other factors, your plastic surgeon will discuss with you the incision length and contour that he or she recommends for achieving the best result in your particular case.
Men and women who are not obese but are troubled by a bulging abdomen that won’t respond to diet or exercise and by loose skin in the abdominal area may be good candidates for an abdominoplasty.
“Patients for abdominoplasty range from those who just need some tightening of the skin, without any muscle plication, to those who have excess skin and fat, and considerable muscle laxity,” says William H. Huffaker, MD, of St. Louis, Missouri. “What we are able to accomplish makes a signiﬁcant difference in their appearance and their lives. The results of their abdominoplasty can often inspire them to take better care of themselves. Many of these patients begin to eat better and exercise regularly, which of course adds further improvement to their health and appearance.”
Women who have had multiple pregnancies are the most likely to have a condition called diastasis in which the muscles of their abdominal wall have separated vertically and cannot return to normal; this condition can be successfully treated at the time of the abdominoplasty.
“The effects of pregnancy on the abdomen are fairly obvious,” says James M. Nachbar, MD, of Scottsdale, Arizona. “The uterus is usually about the size of an orange. During pregnancy, however, the growth of the baby stretches the uterus, which then presses on the inside of the muscle wall of the abdomen. At the front of the abdomen, the two vertically oriented rectus muscles (the ‘six-pack’ muscles) get pulled apart, and actually separate. Once that has happened, nothing other than surgery can bring these muscles back together. Exercise can’t do it, since there is no muscle in the midline for you to exercise.”
“Tummy tucks are performed to correct problems with the abdomen resulting from pregnancy, weight loss, or weakened muscles. The muscles and skin become stretched and can’t return to their normal position. Unfortunately, sit-ups and leg lifts don’t correct the problem,” agrees Allen O. Guinn, III, MD, of Lee’s Summit, Missouri. “Weight loss helps, but usually the problem is an excess of skin and muscle length. The muscles need to be tightened and the excess skin and fat surgically removed. The operation is tailored to the individual needs of the patient, from where the incision is placed, to whether it is a mini, moderate or full tummy tuck.”
An abdominoplasty, or tummy tuck, can effectively remove loose skin and excess fat from the abdominal area, tighten the underlying structure, and restore a more youthful body contour. It can also remove stretch marks in the lower abdomen. By horizontally tightening the fascia (a sheet of connective tissue extending from the rib cage to the pubic bone between the layers of fat and muscle), an abdominoplasty may somewhat narrow your waist. The procedure will leave the skin tighter, effectively making the body look leaner and more youthful. An abdominoplasty will, however, produce a permanently visible scar. This scar can usually be positioned so that it remains completely hidden by your usual style of swimwear and undergarments.
“Body contour surgery has entered a new era in which the simple removal and ‘tightening’ of the skin is no longer the end point. What is critical is restoring contour and youthful fullness in the areas of the buttocks, hips and thighs,” says Lawrence S. Reed, MD, of New York, New York
“This understanding of form has been too long overlooked. As body sculpture continues to rise in popularity, we can expect an even greater appreciation of restoration of contour and volume, which is a critical part of the overall rejuvenation process.”
Any stretch marks in the upper abdomen, higher than the belly button, will not be improved by an abdominoplasty. A tummy tuck will not narrow your hips. If you have localized fat deposits in your hips, your plastic surgeon may recommend liposuction of these areas in order to improve your body proportions. In some instances, for safety reasons, it may be recommended to postpone liposuction and perform it separately from your abdominoplasty. The determination of when such combined procedures are appropriate will be made by your plastic surgeon after evaluating your medical history, current health and the extent of surgery required in your particular case.
“Very often, women who come in after their childbearing is ﬁnished need both a breast augmentation with some lift and some abdominal work,” says Peter Hyans, MD, of Summit, New Jersey. “If they are of relatively normal weight and their abdominal problem is mainly conﬁned to skin laxity, I combine the procedures. If they need a signiﬁcant amount of liposuction, however, I will not combine them. I usually keep these patients in the hospital overnight.”
“Abdominoplasty is an outstanding technique for restoring or improving the contour of the abdomen following pregnancy or massive weight loss. Because it most frequently involves dealing with changes of the abdomen as a consequence of pregnancy, I often combine it with other procedures — whether it is restoring the size and shape of the breast, or liposuction of the inner and outer thighs,” agrees Otto Placik, MD, of Arlington Heights, Illinois.
“Although I rarely suggest surgery on areas a patient does not mention, I feel it is very important in patients seeking an abdominoplasty to evaluate their upper outer hips or ﬂanks. For a number of these patients, liposuction of these areas is essential to achieve balance and proportion with their new ﬁgure,” says Eric Mariotti, MD, of Concord, California.
“Combining flank and hip contouring of the back with some liposuction in the front can give these abdominoplasty patients a beautiful outcome,” agrees John R. Moore, MD, of Franklin, Tennessee.
“Ninety percent of my patients undergoing abdominoplasty also have liposuction of the sides and around the back. This is by far the most signiﬁcant aspect in narrowing the waist,” says Steven K. White, Sr., MD, of Myrtle Beach, South Carolina. Liposuction of the abdominal region itself is often performed in conjunction with abdominoplasty and is considered by some surgeons to be an intrinsic part of the procedure.
“Many people require some liposuction as part of this procedure, and this can be done at the same time without doing two separate procedures. It’s less costly and the patients have one recovery period,” says David L. Abramson, MD, of New York, New York.
“The two most important questions about tummy tuck are: How much liposuction can we safely do with a tummy tuck procedure and still provide a safe operation, and what roles do factors like a patient’s age, hormonal replacement therapy, and weight play in the safety of tummy tuck procedures?” says George Sanders, MD, of Encino, California. “More and more patients in their 60s are requesting abdominoplasty. We want to provide the safest procedure possible and minimize the risk of blood clots. One approach I use is to avoid, as much as possible, tightening the abdominal muscles. Basically, the less surgery one does, the safer the patient is.”
“I will not do very much liposuction at the same time as I perform an abdominoplasty,” says Gene Sloan, MD
of Little Rock, Arkansas. “I place the patient’s safety ﬁrst, and I’m very conservative in my approach.”
“I think liposuction is an invaluable adjunct to abdominoplasty,” says D’Arcy A. Honeycutt, MD, of Bismarck, North Dakota. “I’ve had some great results by the judicious use of liposuction. I limit my undermining, however, so that I avoid any possible wound healing problems. I also may liposuction the anterior hips, the ﬂanks, and the waist. So that the mons pubis maintains its correct position, I always sew it into place before performing liposuction. These patients will often have back rolls and hip rolls, and I turn them from side to side on the operating table in order to effectively reach these areas with the liposuction cannula.”
“An abdominoplasty shouldn’t just be viewed as just removing excess skin and fat from the abdomen,” agrees Jonathan Freed, MD, Auburn, California. “I like to contour everything from the breast down to the pubic bone, and on the back to the back of the hips. It’s important to include as much liposuction as possible. However, I perform 75 percent of my abdominoplasties as two-stage procedures. The second stage comes about four months later when I do a small, 30-minute touch-up liposuction on the lower abdomen.”
“I use a combination of liposuction and skin excision to tailor the surgery to the patient’s physique,” adds Kaveh Alizadeh, MD, of Garden City, New York. “I combine all my abdominoplasties with a little bit of liposuction in the waist area so the abdomen and waist ﬂow together and form a natural contour,” says David V. Poole, MD, of Altamonte Springs, Florida. “That way you don’t end up with a ﬂat tummy and a wide-looking hip or waist area. I won’t do liposuction above the incision, on the abdominal flap, as I think you risk having some healing problems.”
Gynecomastia, excessive fat or glandular tissue in the male breast, is a much more common problem among adolescents and older men than its lack of publicity would indicate. An estimated 40 to 60 percent of men suffer from this condition, which can occur in either one or both breasts, at some time in their lives. The cause of gynecomastia is not well understood, but it is suspected that hormonal changes often play a role. Anabolic steroids that contain estrogen, marijuana use, and prescribed hormones are a factor in some instances. Massive weight loss can also result in hanging breasts that detract from a man’s appearance.
Plastic surgery offers a solution for men who are troubled by this embarrassing condition. Through the use of liposuction, which alone may be adequate to reduce breast size in many male patients, and surgical procedures to remove skin or skin and glandular tissue in other cases, plastic surgeons can create a ﬁrmer, ﬂatter, and better contoured male chest.
“Men rarely speak about their breasts,” says Paul J. LoVerme, MD, of Verona, New Jersey. “It’s an area of embarrassment if they are larger than normal. Most of the men that I treat have long wanted to reduce their breast size but ﬁnd it difﬁcult to admit, even to a surgeon, that there is a problem.”
The best candidates for gynecomastia treatment are healthy, emotionally stable adolescent and adult males whose condition has been persistent and stable for a signiﬁcant period of time. This surgery is not intended as a weight-loss method, and surgeons may discourage obese or overweight men who have not first tried dieting and exercise from undergoing the procedure. Candidates whose condition may be related to marijuana or anabolic steroid use should stop using these substances; in some cases, though not always, discontinuance may cause breast fullness to diminish.
Tell your doctor if you are planning to lose a signiﬁcant amount of weight, since your plastic surgeon may recommend that you stabilize your weight before having the procedure.
Your surgeon will also need to review your entire medical history, including any medications you may be taking, whether you suffer from any allergies or medical conditions, and if you have had any prior surgeries.
In addition to examining your breasts, your plastic surgeon will want to determine whether your gynecomastia might be related to a medical problem, such as impaired liver function or the use of medications or other drugs. In cases where a medical problem is the suspected cause, your surgeon will refer you to an appropriate specialist for further diagnosis. Your surgeon also may advise a breast X-ray, both to rule out the remote possibility of breast cancer and to obtain data concerning the breast’s composition. The amount of fat and glandular tissue within the breasts is a factor in determining the best surgical approach to address your problem.
Your surgeon will give you instructions about how to prepare for surgery. He or she will also give you guidelines on eating, drinking and medications, such as avoiding aspirin or anti-inﬂammatory medications that promote bleeding.
Breast reduction surgery to treat gynecomastia is usually performed as an outpatient procedure. In some cases, however, your surgeon may recommend an overnight hospital stay. Whether you go home the day of surgery or the next day, you should arrange to have someone drive you to and from surgery and to help you out for a day or two after you return home.
The correction of gynecomastia is frequently performed under general anesthesia and sometimes under sedation (twilight) anesthesia, in which both a local anesthetic and sedation are used so the patient is awake but largely unaware of what is going on. The surgery usually takes about an hour and a half to perform; more extensive surgery can take signiﬁcantly longer. No matter what type of anesthesia you have, you will not feel any pain during the surgical procedure.
In cases where the breast enlargement is primarily caused by excess fatty tissue, liposuction may be the only treatment necessary. Surgeons may use traditional liposuction, also called suction-assisted lipoplasty (SAL), or related techniques such as ultrasound-assisted liposuction (UAL), Vaser-assisted liposuction (VAL) or power-assisted liposuction (PAL). Some surgeons ﬁnd these newer techniques sometimes offer an advantage in treating ﬁbrous tissue, which may be present in the male breast and other select areas of the body. UAL, VAL or PAL can be used alone or in combination with SAL.
“I find that for male gynecomastia, as well as for treating the back and areas of liposuction revision, I have better results when I add either ultrasound or power-assisted liposuction,” says Malcolm Roth, MD, of New York, New York.
“Newer techniques such as ultrasonic liposuction have made male breast reduction a reliable procedure with a low complication rate and natural-appearing results. I use a device called the Vaser to emulsify and remove the unwanted fat,” says Dr. LoVerme.
In situations where only liposuction is necessary, usually a small incision of less than a half-inch in length is made around the edge of the areola, the dark skin that surrounds the nipple. The surgeon then inserts a cannula, which is a very slim hollow tube attached to a suction device, usually a vacuum pump. Using his or her surgical and artistic skill, the surgeon uses the cannula to break up the fatty tissue and literally vacuum it out, decreasing breast fullness. Skin that is healthy and elastic will then “shrink” to the new chest contour. However, if very large quantities of fat have been removed, some skin may also have to be excised to create a new, tighter contour. This may be done at a later time, after the initial results have been evaluated.
If, rather than fatty tissue, the primary component of your gynecomastia is dense glandular tissue, your surgeon may need to remove it using an excisional technique, often combined with liposuction to eliminate any excess fat.
To excise glandular tissue, your surgeon will make an incision, usually at the edge of the areola or in the underarm area. He or she will then work through the incision to remove excess glandular tissue, fat and skin. “In my practice, about 65 percent of men also need excision of glandular tissue to prevent a protruding nipple,” says Dr. LoVerme. “The incisions are in the armpit or sometimes around the areola, which is the pigmented skin surrounding the nipple. I have never had a conspicuous areolar scar in a male patient.”
In cases where a very large quantity of skin needs to be removed, additional or larger incisions that could result in more noticeable scars may be necessary. This could include an incision in the crease underneath the breast. A small drain is often inserted to prevent the build-up of excess ﬂuids. The incisions will be closed and most likely covered with a dressing. Your surgeon may also wrap your chest with an elastic bandage to help keep the tissues ﬁrmly in place as they heal.
You can expect to feel mild to moderate discomfort for a few days after the surgery, which your surgeon will alleviate with prescription medications. Swelling and bruising are normal, and the worst of it should dissipate within the ﬁrst few weeks following surgery, although it may not completely disappear and ﬁnal results of your surgery may not be apparent for three or more months. Your surgeon will probably instruct you to wear an elastic pressure garment continuously for the ﬁrst week or two and to continue wearing it at night for even longer. This will help reduce swelling. Any stitches will be removed about one to two weeks following the procedure. Although you will probably be advised to refrain from sexual activity for a week or two, strenuous exercise for up to three weeks, and any activity that may risk a blow to the chest area for at least four weeks, it is important for your recovery that you resume some activity almost immediately. You will be encouraged to begin walking around on the day of your surgery and should be able to return to work as early as a day or two after surgery if you feel well enough. You should be able to resume all of your normal activities about one month following your surgery. However, you should refrain from exposing your surgical scars to the sun for at least six months.
Correction of gynecomastia eliminates a signiﬁcant source of embarrassment and anxiety for a young or adult male. Enhanced self-conﬁdence and a greatly improved body image can be expected. The results of surgery are usually permanent. However, if an adolescent is treated prior to stabilization of his condition, and additional breast development occurs, reoperation may be necessary. In addition, in some instances signiﬁcant weight gain can lead to recurrence of the condition. Asymmetry, a difference in volume between the two breasts, if signiﬁcant, may require revision
If you’re not happy with your plastic surgery procedure, you may want to think about a revision surgery. Dr. Peter Fodor from Beverly Hills tells us what’s involved.