Friday Figure Fix: Learning about lipo

You'll forgive me the facetious bit culled from the wire earlier this week. Sometimes stories like that are just too good to pass up in this line of work.

So let's get down to business, and talk about liposuction (or, lipo for short). As a real, live female plastic surgeon, I'd like to clear up a few misconceptions about this very popular procedure.

1. Lipo will help me melt the pounds away.

Sorry, nope - lipo is not a substitute for weight loss.

There are a lot of surgical procedures out there these days that are designed to help overweight or obese patients lose weight. Liposuction is NOT one of them. If you've been downing the Double-Doubles with fries and a shake regularly, thinking that a little plastic surgery can take care of that one day, you are incorrect.

Liposuction is a fabulous tool in the plastic surgical armamentarium, but it is designed for body contouring in a person who is at, or pretty close to, their ideal weight. Why is that? For one, the results are much better and much more appreciated. More importantly, it's safer for the patient. Speaking of safety...

2. Lipo isn't really surgery.

True liposuction absolutely, positively is real surgery. Every day, there is always some gimmicky new product appearing that promises "lipo" but with no scars, no surgery, no pain, no downtime (you know what they say about things that sound too good to be true...); sometimes they use flashy words like "laser" or phrases like "melt the fat away". These gimmicks are NOT liposuction.

Real liposuction is a tried and true method of body contouring that has been utilized by plastic surgeons for decades. It involves making a small incision in the skin (= surgery), inserting a long metal tube into the fatty layer beneath the skin (= surgery), and sucking out the fat in an informed and controlled manner (= surgery). There may or may not be additional technology involved (e.g. power-assisted lipo and ultrasound-assisted lipo). The surgery may be performed while the patient is awake (but anesthetized so that they are comfortable) or asleep. The procedure may be done in an office setting or in the operating room. This brings us to our next debunkable lipo myth...

3. Anyone can do lipo.

Well, sure. But really?

If I were looking for someone to do a surgical procedure on me, I would check first to make sure they have a valid medical license. You would be surprised.

Then I would check to see what kind of training they have had - they may be an M.D., but did they do their residency in pathology, or do they have a surgical background (because of what we learned in #2)?

And finally, call it a personal bias, but I would also want a plastic surgeon to do my liposuction. Why? Because our years of training include everything you've ever wanted to know about liposuction - how to do it, how to do it well, what complications can occur and how to take care of them. Your plastic surgeon is not just some bearer of a certificate from a weekend course. Our extensive training has taught us to deal with the entire body - "the skin and all its contents" as some like to say; we understand how everything in the body relates to each other, which is important when it's your health and your body.

So right, anyone can do lipo. But why would you want them to?

Who needs lipo?

Not this lady - apparently putting off her diet plan and having a little more to love saved her life.

Friday Figure Fix: Special "Extreme Makeover" Edition

Heidi Montag's cover story, from People, January 15, 2010

Let's take a slight diversion from the usual Friday Figure Fix posts and address a topic that has been on the minds of many folks out there. Being a plastic surgeon always stimulates a lot of interesting small talk, and after this story took over the gossip headlines a few weeks ago, the ensuing conversations about this dramatic figure fix were no exception.

Most of the folks who brought up Ms. Montag's transformation were frankly a bit horrified, and were curious if that's an example of what most plastic surgeons - specifically, me - do.

As a disclaimer, I have never met nor taken care of Ms. Montag, so all the information that I have regarding her surgeries is the same as what you've got - from People, Us Weekly, and the vast Interwebs. It seems like she had 10 separate procedures under one anesthetic on one day, performed by one plastic surgeon, uneventfully.

Honestly, as a medical professional, I can't judge this particular case, since I don't know the patient, surgeon, or specific circumstances.

But in general? I do judge - that's part of my responsibility as a plastic surgeon. Even if it's a "cosmetic" procedure - or rather, especially if it is - I need to make sure that my patient needs whatever surgery they initially came to see me for. Sometimes what someone wants isn't what they need; sometimes, for a variety of reasons, they don't need anything. As much as I love operating, I have to be honest with myself and my patient - there should be no moral dilemma there at all.

Beyond determining whether a patient needs a particular surgical procedure and which procedures are appropriate, a plastic surgeon also needs to use judgment as to what is safe, in terms of number of procedures performed and the combination of surgeries. It's more than a simple matter of safety under general anesthesia or during the recovery period for the patient; it's also a matter of surgeon fatigue during the operation. Believe me, no one wants a tired, cranky surgeon.

Luckily for me, I have a fantastic partner in Dr. Weintraub at Duet. Having a second pair of highly skilled hands to help is wonderful, for both our patients and for us. But that doesn't mean that we're wild advocates of the "extreme makeover" philosophy; to the contrary, I think it makes us both a little more circumspect when we're discussing figure fixes, which makes and keeps our patients happy.

Friday Figure Fix: Taming the tummy, part two

As Jim, the incredibly well-trained instructor for my figure-drawing class, explained one day, everyone has a little convexity to the lower part of their abdomen. Armed with a piece of chalk at the chalkboard, he deftly illustrated that a little curve to the belly is how the human body comes naturally; with a straight, or even concave, line below the belly button, the drawn figure looks odd.

This is how the human form is meant to look, he insisted, pointing with his stub of chalk to the curvy line he had drawn, which in his magical hands looked perfectly like a belly. This just isn't right, no matter what they tell you, Jim said of the flat abdomen he drew beside it.

There's no arguing with Jim, especially when he's pretty much spot on (an old plastic surgery mantra: there are no straight lines on the human body), but that doesn't mean that we can't aspire to be sleeker versions of ourselves.


Last Friday, we investigated the most common reasons why bellies go bad, why women get poochy after pregnancy, and why some of us just didn't win in the genetic skin lotto.

Today, let's delve into the world of abdominoplasty, or tummy tuck, the plastic surgeon's answer to the problem of "the flat belly".

The simplest scenario would be this, the patient of every plastic surgeon's dreams: a thin, healthy, young(ish) woman who had finished bearing her children and upon exam had no muscle separation (that pesky diastasis I mentioned last week), only a little extra skin on the lower part of her belly. Our straightforward case would be represented by the left side of the drawing below, where there is just the slightest "pooch" of extra skin and fat below the belly button:


This simple scenario would be addressed by a relatively simple procedure, the so-called "mini-tummy tuck". Since there is no weakness of the abdominal muscle/wall, the excess skin can be trimmed, leaving the patient with a small scar low on the belly (represented by the pink line on the right side of the drawing). This type of incision would be similar to a c-section scar, easily concealed by underwear or a bikini bottom.

Since the surgery time is relatively short (about one to one and a half hours) and no muscle work is done, patients can go home after a mini-abdominoplasty and enjoy a relatively quick recovery (around a week).

However, most of us aren't that lucky (that is, we're not exactly thin, young, and have remarkably intact abdominal walls), so the "flat belly solution" is more complicated. What this entails is a full-out abdominoplasty.

We know we have a muscle issue (that six-pack just isn't doing it anymore), where the abdominal muscles have become lax and separated, as I've illustrated (below, left):


As plastic surgeons, a huge part of our training and practice mission is to restore anatomy and function. So a major component of the abdominoplasty is the muscle plication (above, middle), where the abdominal muscles are realigned and tightened, resulting in a "corset"-like effect. The extra skin (often from above the belly button to just above the pubic bone) is removed.

The result (above, right): a waist that's slightly cinched in, a flatter, tighter belly, a slight lift of the pubic mound (yes, gravity affects everything), and scars hidden in the shadows of the umbilicus and low across the belly, from hip to hip (again, represented by the pink lines). The circumferential belly button scar usually fades pretty imperceptibly, and anyone wearing a reasonable set of underpants won't be showing off the lower abdominal scar. A small (but wonderful) bonus for moms who undergo tummy tucks is the removal of those impossible stretch marks where the skin is excised.

The full abdominoplasty takes a little longer (two to two and a half hours) and is also performed under general anesthesia. If patients are healthy and have reliable help around, they can go home after the operation; if not, they spend at least one night in a medical recovery center or hospital. Recuperation after this surgery is a bit longer as well (the muscle tightening is pretty painful - imagine doing ten thousand crunches, but worse), anywhere from two to six weeks.

One step beyond the tummy tuck I describe above is the circumferential abdominoplasty. Now this is a procedure most commonly done for patients with massive weight loss. After losing so much weight, not only is the skin of their bellies stretched out and hanging, but it continues like this all the way around the hips, flanks, and back. The circumferential abdominoplasty (also, belt lipectomy) addresses this by continuing the skin excision all the way around as well; the end result is an improved contour, in exchange for a scar that rings the waist like a belt.

Tummy tucks are often done in conjunction with liposuction, to smooth out the contours of the upper abdomen and flanks; but lipo is a whole topic on its own, which we will tackle on another Friday.

Breaking news from Britain: Man-boobs on the decline

Apparently, male breast reduction procedures have skyrocketed in popularity at our plastic surgery colleagues' offices across the Atlantic. (A gentle word of warning: the graphic that accompanies the above-linked BBC article is rather in-your-face.)

Gynecomastia - the official medical term for what everyone's taken to calling "man-boobs" (or even "moobs" for short - ugh) - is not a new problem, and certainly something that we plastic surgeons are familiar with, even here in the high-powered, relatively crunchy San Francisco Bay Area.

Rarely, men who notice their breasts are growing (men do have a smidge of breast tissue) discover an underlying medical problem, like a hormone imbalance (due to medications, prescription or slightly less than legal - classically, marijuana is a known culprit) or even breast cancer.

More often than not, gynecomastia is due to excess fatty tissue and is treated with surgery, either liposuction, surgical reduction/excision, or a combination of both.

For those men who aren't quite ready for surgery, though, there's always this option.

Friday Figure Fix: Taming the tummy

Perhaps the most common request Dr. Weintraub and I get at our plastic surgery office in Palo Alto is the "tummy tuck" or abdominoplasty.

Typically, the requestor is a woman (which doesn't surprise us, and as female plastic surgeons, we totally feel it ourselves and sympathize wholly). There are basically two camps of patients: folks who have lost a bit of weight (either through diet and exercise or with medical/surgical assistance - like lap-bands or gastric bypass) and moms who are done having babies.

People who come to us at Duet for a tummy tuck consultation aren't conceding defeat to fat. Believe me, these patients are in great shape, highly motivated, with super-active careers. They may still be hanging on to that pesky extra five or ten pounds, but they are not fat. They have come to our office because they finally realize that no matter how many crunches or how healthy their diets, the little (or big) pooch that hangs beneath their belly button is not going away.

Exhibit A:


This is what prevents us from wearing the size of skinny jeans we truly are. This is what morphs into the dreaded "muffin top". This is where the bulk of those ugly stretch marks live. But why?

Like the saggy upper arms and brachioplasty discussed last week, it's mostly a skin problem. Those blessed with youth and good genes can get rely on our skin's inherent elasticity; the rest of us suffer with skin that doesn't go back to the way it was before the pregnancy or weight gain. The severity is exaggerated in many of our gastric-bypass patients, who have lost weight so quickly that their skin couldn't keep up, resulting in unflattering sharpei-like folds.

Luckily (hmmph?) for us women, we can blame one more culprit for the loss of our figures: pregnancy. As the uterus expands to accommodate the growing bundle of joy, the belly stretches out as well - not just the skin, but everything underneath as well:

Top to bottom, outside in: the skin of your belly stretches (epidermis and dermis; when the latter tears, we get stretch marks), as do the underlying fat and abdominal wall. Unfortunately, that abdominal wall (the six-pack of rectus muscles plus the enveloping fascia) doesn't have a lot of resiliency, resulting in this problem:


See how the belly goes from softly rounded in the relaxed photo on the left to sort of pointy in the photo on the right (taken while flexing in a sit-up)? That, ladies and gentlemen, is the abdominal diastasis.

Not quite a hernia (where your bowels are seeking to escape through an actual opening in the abdominal wall), but close - your abdominal contents bulge at an area of weakness. This particular area of weakness associated with pregnancy is the space created by your six-pack muscles moving farther apart to accommodate the growing fetus.

Exhibit B:


Don't get me wrong. This is great for the baby, but once mom's ready to move on, the fascia is too stretched out, the muscles don't return to their original position, and mom gets a poochy, flabby waist that contributes to the thick appearance of the belly.

So we've got a skin problem, a muscle/abdominal wall problem, and maybe a teeny little fat problem. What's a girl (or guy) to do?

Stay tuned for next week's Friday Figure Fix: all about abdominoplasty.