Patients present for abdominoplasty procedures as well as the tummy tuck revision to my Beverly Hills office and surgical practice. These patients often present unhappy with dog ears as well as lower abdominal fulness as well as scarring along the lower abdominal wall. Other problems can include inadequate plication of the upper rectus diastasis. As a result, these patients may present for secondary advancement abdominoplasty which can be a mini tummy tuck from the lower abdominal wall where tissue is simply removed full thickness and the hip dog ears are excised with conventional tumescent liposuction of the iliac crest rolls, flanks and lower abdominal flap.
The example show a patient who has had abdominoplasty reconstruction, secondary revisions in which the flaps were debulked by just that, as described above. First, the 4:1 glandular excision of dermoglandular tissue along the bilateral hips was accomplished with full thickness resection down to the external oblique ascia. These were then closed and tumescent liposuction in bi-directional fashion of the muffin tops was then accomplished. This allowed for beautiful smoothing of the hips and the lower flank areas.
Now attention is focused to the bulking of the lower abdominal flap at which time tissue is removed from the previous scar superiorly. This allowed smoothing out of the bulge. If necessary, a portion of Scarpa’s fascia is excised, the lower fat pad is, and this allows a beautiful flattening of the lower abdominal wall. These scars can be revised by simple excision of the scars and advancement after undermining in order to reduce tension on the incision sites. Larger abdominal dead space areas may require JP drain placement; however, in the majority of my secondary small tummy tuck revisions no drains were used.
Combined secondary advancement dog ear excision, lower abdominal debulking and tumescent liposuctioning of the entire abdominal wall leads to excellent results from a stage or secondary tummy tuck procedure.
Patients present to me with significant laxity of their breasts after breastfeeding their children or significant weight loss. The question is to whether to do implants with a lift versus implants alone. It is very evident, as in the example below, that the implant with the lift has given this patient the greatest upper pole fullness that she desired. Some patients do desire fuller, rounder breasts. This can often not be performed without a mastopexy. Without the skin removal and tightening, although roundness to the shape of the breast with a bra can be obtained, without it, it will sag. The example here shows a patient with grade 3 ptosis and nipple greater than 3 cm below the fold. She has significant stretch marks and widespread areolas. She understood that scarring associated with a breast lift is the tradeoff and she desired to proceed, wanting the roundest, fullest breast possible. A style 68, high profile saline 500 cc implant was filled to 550 under the muscle and a formal mastopexy with skin removal from around the areolar and vertically along the inframammary fold was performed. Her three months results show great fullness to the breasts with excellent shapes and a narrowed tapered appearance associated with a high profile bag. Please remember that the scarring associated with breast lifts is sometimes unpredictable and that is your tradeoff for a tighter, rounder breast, especially with severe grade 3 ptosis.
Although the majority of Board Certified Plastic Surgeons have training in general surgery, there are surgical procedures that we perform that I believe would be better for the patient to have a combined plastic and general surgeon in the operating room. Today, we are performing an abdominal wall reconstruction. The patient has an epigastric hernia and a periumbilical hernia. These patients with significantly large hernias, I believe personally, should have repaired concurrently with a Board Certified General Surgeon. Mesh graft reconstruction is often required and this is a surgery that is performed by general surgeons on a weekly basis. In order to reduce the risk of recurrence, abdominal hernia reconstruction should be performed often with Marlex mesh of Polypropylene mesh graft reconstruction. I have worked with the same general surgeon now for over 15 years. He is experienced with over 35 years of general surgery with understanding of the abdominal wall and reconstruction. Large fascial defects again may require reinforcement of the abdominal wall. Simply suturing the rectus diastasis together often leads to recurrence. With large breast reduction surgeries, we also often have our general surgeon in the operating room to help with reducing OR time, anesthesia time and bleeding. Finally, with breast reconstruction, if we are concerned about possible recurrence or metastasis, it is nice to have a second set of eyes, especially as a general surgeon, with the knowledge of the breast in order to survey for possible recurrence of breast tumors. As Board Certified Plastic Surgeons, our number one goal is to yield the most predictable and safe results to our patients. Having a Board Certified General Surgeon for the above situations I believe greatly enhances the overall experience to the patient.
Recently, the FDA approved the new Cellulaze laser, which is an nD Yag 1440 nanometer laser, specifically used for removing cellulite throughout the body. It is especially used for removing cellulite along the lateral thigh, infragluteal fold and the buttock areas. Cellulite is associated with the dimpling of the skin with three specific components. The first are small pseudo-herniations of fat in the subdermis. The second is fibrous stria which attaches the subdermis deep to the fascia creating pits and contour irregularities. The third is thinning out of the elasticity and collagen of the skin. The Cellulaze laser has a handpiece which is used in three different directions in order to accomplish the three specific components to reduce cellulite. In the first setting, several hundred joules are used with the handpiece down the 6 o’clock position in order to emulsify the deep fat which causes the mountain and lumps that are seen within the skin. The handpiece is then rotated 90 degrees and the side laser at 90 degrees sub sizes the fiber septae permanently, preventing them from reattaching. Finally, approximately 50 to 75 percent of the joules are then used with the laser directed up to the 12 o’clock position directly under the skin allowing for collagen formation and tightening of the subdermis and dermis. The results of the Cynosure Cellulaze laser is the first FDA-approved and only approved laser for removal of cellulite. We have acquired the Cellulaze laser from Cynosure and have been certified with the use of this laser. Only your plastic surgeon can use this laser. Nurses are not allowed due to the intensity of the nD Yag. Both the number of joules and the heat specifically within the compartments are monitored throughout the procedure. Normal settings can include settings at 8.8 watts, 25 Hertz and approximately 1000 to 1200 joules per 5×5 cm square grid box. Up to 40 boxes can be performed at one setting. Most patients are placed under IV sedation or general anesthetic.
For the lateral saddlebags, removing the cellulite specifically, I prefer to use 8.8 watts, 25 Hertz, 12.5% of the 6000 joules distributed to the fat, 12.5% to the fiber septae and 75% upward under the skin to tighten the skin. Temperatures should be no more than 45 to 47 degrees, although we keep the temperature between 38 and 42 degrees. The results from the Cellulaze cellulite removal can take up to a year. Patients between three and six months see the best final results.