Body contouring surgery usually involves removing large segments of skin which are then closed by bringing the two sides together. What is not obvious is that the skin is closed over a ‘space’. As the skin is more elastic or flexible than the deeper tissues (such as fat) that lie underneath, closure  of the skin when  large segments of tissue have been removed leaves an open area beneath. As the body abhors a space, it will fill it with fluid. Thus, the need for drains in such surgery.

The reason fluid accumulates in this space under the skin is that wounded tissue weaps. Much like a brushburn that you had on your knee as a child, fluid comes leaking out from the wounded tissue. In the spaces left behind after big skin removals, a large surface area of wounded tissue lies underneath. This will weap fluid for weeks after surgery. Drains are inserted into these spaces to prevent fluid build-up. A soft tube is inserted under the skin through a small opening near the main incision. This drainage tube is then attached to a suction bulb which pulls  fluid out by vacuum pressure. This is known as a closed suction drain. The drains are quite long, up to 18 inches in length. Usually one or more drains are used for surgical site depending on the procedure. (an arm lift needs one drain, a tummy tuck needs two drains, a body lift may need four drains) Some procedures such as breast surgery may not need a drain at all.

The removal of this fluid is of critical importance. While the body can absorb a certain amount of fluid, large amounts that occur after major body contouring surgery can not be absorbed. If allowed to build up, it may be a source of infection but will also not allow the sides of the wound inside to heal together. Therefore, the drains keep most of the fluid out so that adequate internal wound healing can occur. The drains serve as a safety valve until the internal weeping stops.

How long does this internal seeping persist?…or more pertinently, how long will you have to have these drains? It varies by the area and type of surgery. For arm lifts 2 to 3 days, thigh lifts one week, tummy tucks seven to ten days, and body lifts as long as two weeks. Some plastic surgeons use the amount of fluid coming out as the measure of how long they stay. Generally, less than 25 to 30 ccs per day per drain means they may be able to be removed.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

One of the frequent questions patients ask is…how much pain will I have after my body contouring surgery? How much and how long will I hurt? What can I take for the pain? These are, understandably, on the top of many patients concerns.

While most surgeries involve pain, and body contouring surgery is no exception, it is often less than you think and very tolerable for most patients. I frequently hear patients say…’that was much less painful than I thought’. Why is that? There are several reasons. First, really significant surgical pain comes from muscle or bone surgery or entering the body’s cavities, such as the abdomen. Body contouring surgery involves none of that. The removing of skin and fat, while dramatic and often in large pieces, does not involve tissues that have as much pain as structures that lie deeper. Secondly, skin that is cut and moved often goes numb as the tiny nerves that supply feeling to the skin are cut in the process. As a result, the skin nearest the incision line loses feeling for a period of time. As you move further away from the incision, one starts to have feeling again.

Some body contouring procedures cause more pain than others. The most uncomfortable would be those that involve surgery around the abdomen such as the tummy tuck or body lift. Because the long incisions are around an area that moves and twists, common and frequent movements such as getting out of bed or a chair, can be uncomfortable for a while. Other procedures such as arm lifts or breasts lifts cause virtually no pain at all. The discomfort from a thigh lift is somewhere between the tummy tuck and the arm lift.

Beyond the recovery room after your surgery, pain medications by mouth should suffice. I mainly prescribe oral narcotics such as Percocet or Vicodin. Depending upon the procedure(s), narcotic pain medications are usually taken for a week or so after surgery. Thereafter, the use of NSAIDS (non-steroidal anti-inflammatory drugs) such as Motrin, Advil or Aleve can help one wean themselves off of narcotics. It would not be rare to have to take something, particularly at nighttime for up to a month after the surgery.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Body contouring surgery, also known as bariatric plastic surgery, is unique in that many of the operations are long. Removing and reshaping loose hanging skin is tedious. Or to put it more graphically…there is a lot of cutting and sewing to be done in most body contouring surgeries.

While patients almost always ask how long any surgery is (you can argue you are alseep, what does it matter), this is still an understandable question particularly for the waiting families who are not asleep. And in most cases, it is also fairly predictable since after years of doing similar procedures, the plastic surgeon should have a pretty good idea as to how long it takes. The importance of accurately predicting the length of the operation also has economic impact. Since most body contouring surgeries are not covered by insurance, there is a fee per time cost for the use of the operating room and the anesthesiologist. You need to know the time of the operation and the cost upfront.

Lengths of surgery time will certainly vary based on the plastic surgeon. A longer or shorter operative time doesn’t make one plastic surgeon better or worse than another. Every plastic surgeon operates at their own speed and comfort zone. So don’t compare plastic surgeons by time. A longer or shorter operative time doesn’t necessarily mean a better or worse result. As I always says…I don’t get any rewards for being fast…I only get rewards (and patient happiness) from a good result, regardless of the time it took to get there. Nobody has yet to tell me….’Doc, the result is terrible but it was really fast!’

With that thought in mind, here are some approximate operative times based on some of the most common body contouring procedures. Abdominoplasty/Panniculectomy 2 - 4 hours, Arm Lift 2 - 2.5 hours, Back Lift 1 -2 hours, Body Lift 4 - 6 hours, Breast Lift/Reduction 2 - 3 hours, Facelift 2 - 3 hours, and Thigh Lift 2 - 3 hours.

Also remember that operative includes other events than actual surgery. The measurement of operative time starts the second you walk into the operating room and doesn’t stop ticking until you are wheeled out on a stretcher. So events such as prepping and draping, positioning and turning you during surgery, and the application of dressings all counts as surgery time.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana]

Indianapolis

What does body contouring surgery cost? Because surgical fees vary across the country and even within any given city, it is impossible to provide an accurate answer for any specific procedure on a general basis.

The first question most patients will ask, however, about body contouring surgery costs is whether their health insurance will pay for part or any of the surgical procedure. As a general rule, there are very few body contouring procedures that insurance will cover. This may seem unfair to many, but the reality is health insurances don’t consider most of the excess skin as causing any significant medical problems. Removal of the abdominal overhang, or pannus, may occasionally be covered due to skin rashes and its weight, but problems of the breast, arms, back, and thighs are almost always rejected.

Therefore, it is best to think of paying out of pocket for most or all of the body contouring procedures. The cost of a procedure is always a combination of three fees…use of the operating room, anesthesiologist’s charge, and the time of your plastic surgeon. Two of these costs are fixed, the operating room and anesthesiologist. They charge by time and at a fixed rate. The longer the operation is, the more their costs will be. Your plastic surgeon’s fee is variable…it is completely up to the plastic surgeon as to what they want to charge and whether they may offer discounts for multiple procedures. Additional charges may be incurred for overnight stays, postoperative garments, and any preoperative lab work. The good thing about elective surgery costs is that they are fully disclosed up front in their totality.

The issues surrounding elective surgery costs and payment are fairly universal across the country. After your consultation, you will receive a surgical quote at some point which will detail the costs. You will likely be required to place a deposit before booking your surgery. Full payment is usually required in many plastic surgery practices one or two weeks before your surgery. Make sure you read and understand the cancellation policy as unforeseen circumstances do occur to some patients and they have to reschedule or cancel their booked surgery.

Also, be aware and be clear on your plastic surgeon’s policy regarding revisional surgery. The need for revisional surgery due to complications or adverse results is not rare in major body contouring surgery.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

With the euphoria that often comes with the anticipation of major body contouring surgery after a lot of weight loss (and who can blame you after all this time and effort you have put into it), is the reality of what plastic surgery can and can not do. I have observed that all body contouring surgery in the weight loss patient will have a very profound effect. This is unlike some cosmetic surgeries in the non-weight loss patient where the problems are smaller…and the results are subsequently smaller. It is not really possible to remove a lot of sagging skin and fat and not see dramatic changes. And most extreme weight loss patients appropriately see the ‘big picture’ as opposed to some smaller details which may be a focus for other types of patients. For this reason, body contouring patients are usually pretty satisfied with their results.

Despite the largely satisfied patient, body contouring like all surgery has some realities that every patient needs to know. First, the surgery is basically a trade-off of one problem for another. You are exchanging loose hanging skin for scars. And, in general, most of these scars are not great by plastic surgery standards. That is the nature of body contouring surgery…..a lot of scars. If you combine a lot of different procedures together or in stages (for example, circumferential body lift and arm lift) there is going to be a dramatic change but at the price of substantial scarring. Some scars may look great but many others won’t. You must be prepared for the scars…and the time it takes for them to mature and settle down. (6 months to a year)

Secondly, many body contouring surgeries take longer to recover from than one may anticipate. This is particularly true in often often performed combination surgeries. Your bariatric surgery may have been done laparoscopically with small incisions and a reasonable recovery, but body contouring surgery is quite different. Long scars, tightening up body areas, and drains make for a significant recovery. While the actual recovery will vary dependent upon what procedures are performed, circumferential body lifts, abdominoplasties, and the various forms of thigh lifts need 4 to 6 weeks for a really complete recovery. Complete recovery means getting past some healing nuisance issues such as seromas, small wound openings, and spitting sutures. When you think about returning to work, plan on 1/2 days for the first week back and full days the week after. A big surgery means…a big recovery. Don’t underestimate it!

Third, there are some skin issues that plastic surgery will not improve. Specifically, cellulite and stretch marks (otherwise known as striae). Tightening the skin will make some improvement in their appearance but will not eliminate them. Only those skin irregularities within the zone of the skin cut out will be permanently removed.

Lastly, few forms of plastic surgery are ever permanent and body contouring changes are no exception. Time, gravity, and changes in your weight will not have a positive impact on your long-term results. After a few months, there is some skin relaxation (never returning to what it once was) so tissues may not feel as tight as right after surgery. (sometimes this is a good thing!) Like the effort that got you through the weight loss, the maintenance of those results and the body contouring changes will depend on maintaining good exercise and eating habits.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

While some patients may be anxious to get on with the ‘final’ stage of their weight loss journey, it is important to wait until at least several months after you have reached your weight loss goal. This allows your body a period to recover and adjust metabolically to the new weight, allows time for the skin to accomodate to your now smaller frame, and allows you to acquire new eating habits for long-term weight maintenance.

While there is no magic waiting period, most plastic surgeons would like their patients to have a stable weight for close to six months before considering elective body contouring surgery. A stable weight means minimal fluctuations of only a few pounds. Patients who have had gastric bypass, due to intestinal absorption changes, aren’t usually ready for body contouring surgery for a year or longer after the surgery. Patients who have had the lapband procedure lose weight at a much slower rate and it may be much longer than a year after their procedure. Extreme weight loss patients who have done it on their own without surgery can be done within six months after they have hit a stable weight.

The most important reason to wait is to allow your body time to recover. Wound healing for almost every body contouring procedure requires a lot of nutrients and energy to heal properly. You want your energy stores and your immune function to be in the best shape possible. In short, you don’t want to be malnourished going into major surgery. (particularly when it is ‘elective’) Many extreme weight loss patients have some metabolic deficiency. In a recent article published in the August 2008 issue of Plastic and Reconstructive Surgery by Agha-Mohammadi et al, they state that many post-bariatric surgery patients have protein-calorie malnutrition as well as various vitamins and mineral deficiencies that may limit optimal health and healing. With the stress of major body contouring surgery, even a mild nutritional problem may become apparent in the postoperative period as evidenced by wound healing problems.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

In large weight loss patients, through bariatric surgery or from their own dieting program, excess skin is almost always left behind. If the excess skin is considerable, this results in a ‘new’ problem. The body may be smaller, but the large folds of skin cause problems of personal embarrassment, the need to still buy larger clothing, and the potential for problems of skin irritation, rashes, or infections from the overhanging heavy skin. Unfortunately, the very process that got you to this point will not get rid of loose skin. No amount of dieting, exercise, or wishful thinking will make the skin snap back into place or make it go away. This is a surgical problem that is best addressed with body contouring surgery.

Reshaping the body after weight loss are plastic surgery procedures that are specifically designed to remove excess skin and fat and reshape specific body areas. Body contouring surgery can remove large amounts of sagging skin and fat that are often dramatic in size. While the removed pieces may look large, they often weigh a lot less than you would think. Think of body contouring surgery as restoring shape and contour to certain areas of the body rather than any more significant weight loss. These surgical procedures will not only remove excess skin but will tighten areas as well. Almost every body contouring surgery is about the actual excision (cutting out) of loose tissue, liposuction (fat removal only) actually plays a very minor role in this type of plastic surgery although it is occasionally used.

While body contouring surgery can produce some dramatic changes that can improve your physical and psychological health, there is a trade-off. That being of scars. Every body contouring surgery results in significant scarring…that is the long-term price that you must pay. I have yet to find a large weight loss patient who balks at that trade-off but remember you are trading off one problem for another…..excess skin and fat for scars. So be certain that this trade-off is a good one. If one is highly concerned about a lot of scarring, then body contouring surgery may not be for you. Body contouring surgery is unique from pure cosmetic body contouring in that the goals are to make you look good in clothes…not to be critically judged out of them.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

With the tremendous increase in the number of bariatric surgeries performed in the past five years, to no surprise there has been a near equal increase in the number of post-bariatric body contouring procedures performed to deal with the resultant excessive hanging skin. These bariatric plastic surgery procedures include arm lifts, breast lifts, abdominoplasties, thigh lifts, buttock lifts, and the circumferential body lift.

The circumferential body lift, while an ‘old’ procedure per se, has been reborn in great numbers as a result of massive weight loss patients. The circumferential body lift, or a 360 degree tightening and lift, is really a combination of a frontal abdominoplasty and posterior hip and buttock lifts. In bariatric patients, many will have a frontal overhang of skin (with a sagging pubis) but with a buttock and thigh droop on the backside. The circumferential body lift works so well because it removes excessive overhanging abdominal skin (with a pubic lift) and lifts sagging buttocks, hips and thighs. In the properly selected patient, the resultant circumferential scar around the waistline is worth it. And, surprisingly, it is not a painful procedure to go through unlike what many would think.

If the patient has a midline vertical scar from an open gastric bypass procedure, then the body lift is combined with a ‘vertical wedge’ cut out along this midline scar. This helps produce some horizontal waistline tightening which, without it being done, would not happen as much. If the patient doesn’t have a vertical midline scar then I rarely do this as part of the body lift so as to not make more scar than the patient will already have.

One thing the body lift can not do is to increase the size of the buttocks. Most massive weight loss patients will develop a very flat buttock appearance. While there have been some variations of the body lift touted as taking the excess skin and fat from the back and using it as a ‘buttock implant’, this rarely produces enough bulk in the right place of the buttocks to make it worthwhile. And there are some risks in doing this as part of the body lift procedure. I tell my patients to think about buttock augmentation as a later procedure. It is likely that this concern will fall off the list for many patients over time.

The most significant complications that I have seen in body lift patients are fluid collections (seromas) and wound separations (in the front at the inverted T if a midline wedge is cut out and at the back just above the gluteal cleft). I tell every patient that the likelihood of these issues is very high and most patients will develop some variations of one or both of them. Fortunately, they are managed not by further surgery but by needle aspirations and dressing changes until they heal themselves. These issues always occur, not early, but between 2 to 4 weeks after surgery. If you reach a month after surgery without any of these common problems, then they are not likely to occur.

Dr Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

In the most recent issue of our prestiguous journal, Plastic and Reconstructive Surgery (April), I read an article on evaluating the effectiveness of mesotherapy on body contouring. This was a study out of Seoul, Korea on 20 women who had mesotherapy injections on their inner thighs on one side and not the other over a 12 week period. The results showed, not surprisingly, that no measureable improvement could be seen.
This study highlights several important points on aesthetic treatments that are frequently confused. Mesotherapy is the injection of a mixture of different compounds into the skin. (the study cited above used aminophylline, buflomedil, and lidocaine) This is different than LipoDissolve therapies where one specific compound, phosphatidylcholine, is injected into the underlying fat. Mesotherapy (meso = mesium or skin) and LipoDissolve are terms that are often used interchangeably but they really signify completely different types of treatments. Just because both come out of a small needle, like Botox and injectable fillers, doesn’t mean they all do the same thing. I have always questioned the effectiveness of mesotherapy approaches for fat removal or cellulite treatment. It is difficult to see how injecting chemicals into the skin can effect the underlying fat. Perhaps cellulite may have some improvement with mesotherapy since this problem has a skin component to it. But I have yet to see well-controlled studies that have provided convincing evidence to date. But the removal of fat requires agents that directly contact it such as what happens in LipoDissolve. While LipoDissolve requires more study and better analysis, given the large number of patients that are being treated (it is NOT an FDA-approved procedure), but I have first-hand experience with its outcomes and there clearly is some benefit to its use. The issue with LipoDissolve is not its effectiveness but in choosing the right patients for treatment and analyzing for each patient the cost-benefit analysis versus other treatment options, most typically that of liposuction.
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

As a plastic surgeon, I get the ‘oportunity’ to see lots of fat-related concerns and, in the new world of bariatric plastic surgery, get to see patients who either still are or were obese prior to their bariatric bypass surgery. Looking at fat excesses, and I have to assume that the average U.S. citizen is fatter today than 10 or 20 years ago (that is what every report I have read on the subject says), it appear overly simplistic to assume that the problem is one as basic as too much in, too little out…..or to put it another way….someone’s weight problem is merely a function of greed and sloth.

This probability is fairly well recognized today as much greater credence is given presently to the concept that I grew up with known as a ‘glandular’ problem. Today we refer to it as a genetic predisposition or a familial tendency towards weight gain. But even accepting that premise (which I believe has a lot of truth) still does not seem to explain the great diversity of body types one sees and how they respond to their lifestyle. I see lots of hospital employees , for example. who carry a gallon of water with them every day and purportedly eat very little but never lose much weight. And then there are others who pretty much eat what they want and yet remain fairly trim.
In reading Michael Hanlon’s book, ‘10 Questions Science Can’t Answer (Yet)’, he reports a fascinating study as a spin-off to the movie Supersize Me in which the journalist Morgan Spurlock ate nothing but from a McDonald’s menu for several weeks. His weight gain and other ailments are well chronicled including the onset of incipient liver disease. In 2006, that ‘experiment’ was repeated in Sweden under more controlled circumstances using 18 volunteers. While all subjects gained weight, they did it in surprising variable amounts and some gained very little. Some subjects cholesterol levels actually dropped! And none developed the elevated liver enzymes until much later in the study. (one month in duration) What does this prove? At the least it suggests that increased fatness, if you will, is more than just calories. It is a complex interaction of diet, genetics, intestinal absorption capacity, and probably something in the fat cells themselves that has yet to be described.
As I look at the tremendous variability in body types that I see everyday, and listen to the complaints of patients who have valiantly tried to reduce body areas they do not like (contrary to popular belief, we really don’t see a lot of tremendously overweight people for body contouring surgery), I have come to realize that for many of them their ‘problem’ is really a surgical one. Nothing short of sucking out or cutting off of the excess can really make a difference for them. Diet and exercise certainly helps but is not a dramatic solution for many.

Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medcal Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
‘Indianapolis