Pregnancy has an effect on the female’s body that is unriveled in men. Stretching of the abdominal muscles and skin and enlargement of the breasts followed by an overall deflation with delivery usually causes irreversible tissue changes. Many of these tissues pass the elastic deformation stage from which there is no snapback or return to normal tissue integrity and tightness. When the process is repeated more than once, such tissue changes become even more pronounced.

As a result, plastic surgeons have addressed these breast and abdominal changes for a long time through a variety of procedures. Breast implants combined with lifts and various forms of tummy tucks with liposuction are used to help reverse the pregnancy-induced changes. While major body improvements can be achieved, some women end up with even better body contours than before the pregnancy process began.

This combination of breast and abdominal surgeries after a woman has finished having children has become known as Mommy Makeover. This term does not necessarily describe any specific operation(s) but is a marketing concept that implies combined multiple body site surgery. Striking a nerve for pregnancy reversal, it is a concept that many women have come to embrace. More and more women are having combined breast and abdominal procedures than ever before if their finances make it possible. This can be seen in the substantial increase in the number of breast lifts/implants and tummy tucks done every year over the past decade.  Some of this increase is the increased awareness and desire to comprehensively address the post-pregnancy body, a  very effective strategy to improve a woman’s self-esteem and operative satisfaction.

When breast and abdominal reshaping procedures are done separately, they are simpler with less recovery and risk of complications. But when combined, additional considerations need to be taken. The amount of recovery is going to be more substantial. While every women is different, it may be four to six weeks until one can return to work and be back to most normal activities. It is more stressful on the body and issues of good nutrition and cessation of smoking before the procedure is crucial. Surgery is going to take longer and one might be advised to stay overnite in the surgical facility.

Operating on two body areas simultaneously also increases the overall risk of complications such as bleeding, infection and minor wound healing issues. But even more relevantly is that the risk of aesthetic concerns and the potential desire for revisional surgery is increased. While one’s body shape will definitely be improved, multiple site surgery induces many factors that make the exact final body result unpredictable. A perfect result is very difficult to achieve in a single breast or abdominal reshaping procedure, but is impossible in multiple site surgery. Most women come to accept the minor asymmetries and scars that result from a Mommy Makeover.

As Mommy Makeover surgery continues to grow in popularity and numbers of procedures performed, it is important to appreciate that it is more than just a catchy phrase. The end result can be very satisfying but it is substantial surgery that requires adequate time for recovery and awareness that revisional surgery may be needed to obtain the best result possible.  

Dr. Barry Eppley

Indianapolis, Indiana   

Background: Liposuction is a well known surgical method of fat removal that has been available in the U.S. since 1981. It has gone through numerous technologic advancements, particularly in how the fat is mobilized prior to vacuum extraction. From ultrasonic to Smartlipo to Waterjet techniques, fat is being removed in an expanding variety of ways. But no matter what technology is used, liposuction is still am invasive procedure that is relatively traumatic procedure, particularly if you are a fat cell!

The most common body area of liposuction is the stomach and surrounding areas. Whether it be a man or a woman, this is the most frequent area of fat deposition that is genetically predisposed as an intrinsic method of energy storage, organ protection and temperature control. The only location of this fat that is accessible, however, is in the subcutaneous layer between the skin and the abdominal muscles. This must be carefully assessed prior to surgery, particularly in men, to be certain enough exists at this level to justify an invasive liposuction surgery.

The extent of abdominal liposuction rarely stops at just the front or the stomach area. The expanded fat contours extends around the waistline into the back and in women even includes the bra line or bra rolls. This makes abdominal liposuction a much larger treatable area than just the stomach. When all areas are put together, this is the largest surface area on the body that liposuction can treat.

Case Study: This 40 year-old female wanted to improve her fat stomach and round waistline. She had lost 30 lbs on her own but felt she had just hit the wall and could make no other changes on her own. She was 5’ 5” tall and weighed 185 lbs. She worked in the restaurant industry which involved a lot of physical activity and walking.

Under general anesthesia she underwent traditional liposuction using an initial tumescent infiltration technique. Her full abdomen, flanks, and bra rolls were treated and a total of 4,400cc of fat aspirate was extracted. Total operative time was 2 hours and she was sent home in compression garments as an outpatient.

Her postoperative course was noteworthy for several typical events that occur through the recovery process. In weighing herself in the first week after surgery (which I do not recommend), she actually weighed 5 to 7 lbs more than prior to surgery due to fluid retention. By three weeks after surgery, she was down 8 lbs from her initial weight as all retained fluids had released and some of the weight of the fat extracted was being seen. By six weeks after surgery her total weight was down 15 lbs, a reflection of what was removed surgically and some weight from the catabolism of the recovery process.

Her course of postoperative swelling was common and one in which similar patients should be aware. Despite wearing compression garments, she had a lot of swelling of her pubic area and even her labia as the garments and gravity push swelling down south. This can be quite surprising to patients if they are aware that it will happen. She also had a lot of swelling throughout her legs and even down to her feet which took up to a month after surgery to completely go away. There were also many trunk areas of irregularities and lumps and bumps of the stomach and flanks that took months to completely resolve.

From a work standpoint, she returned after two weeks. But by her own admission it was difficult and she felt weak. She could only work ½ days the first week back. She felt better by three weeks after surgery but never felt close to normal until six weeks after the procedure.

Case Highlights:

1) Liposuction is an effective fat removal procedure but is very traumatic to the body. For the sake of patient recovery, volumes extracted should be kept under five to six liters of aspirate.

2) Liposuction of the stomach and waistline into the back can make a big difference in the shape of the trunk and can result in significant weight loss as well.

3) The recovery from major trunk liposuction is not insignificant and can take several months for a full recovery. Patients should allow for sufficient time and limited activities for an adequate recovery process.

Dr. Barry Eppley

Indianapolis, Indiana

Abdominal contouring through either liposuction alone or combined with some form of a tummy tuck are very common and popular body contouring procedures. Whether it is done to help with fat removal alone from weight gain and aging, pregnancy-induced abdominal changes or abdominal deformities from massive weight loss, these procedures provide very effective changes that can be long-lasting.

While they are commonly done, does this mean that patients are usually satisfied with them? As a plastic surgeon, I would tell you that they are tremendously satisfying for patients based on observations of results and comments from patients. But such anectodal evidence may seem self-serving as it is not objectively collected and sometimes one only hears or sees what they want to be true. Patients are also concerned about complications and recovery and these can understandably give one pause when considering these abdominal shaping surgeries.

In the May 2012 issue of Plastic and Reconstructive Surgery, this exact question was studied. A published paper from a private practice in Kansas studied  the effects on the quality of life in 360 liposuction or combined lipoabdominoplasty patients. One of the objectives of the study was to compare liposuction and tummy tucks parameters from the patient’ viewpoint. These included the results, recovery, complications and psychological effects from the surgeries. The patient numbers broke down into 219 liposuction, 13 tummy tuck alone patients and 128 patients who had a combined tummy tuck and liposuction procedure.

To no surprise, liposuction patients had less pain and quicker recoveries than the tummy tuck patients. The average time off work was 6 days for liposuction and 16 days for tummy tucks. Conversely, tummy tucks with or without liposuction reported more significant results and improvement in abdominal contours than liposuction alone. Half of the liposuction patients felt that the procedure did not provide enough results. Overall nearly 86% of patients reported improved self-esteem  and nearly 70% reported an improved quality of life. Collectively, high levels of patient satisfaction were reported at near 89%.

The complication rate for any clinical series of a procedure is always of interest. In this study, it was close to 11%. Tummy tucks had more complications than liposuction with infection and delayed healing being the predominant issues.

For patients, this study has several relevant findings. Better results come from tummy tuck-based abdominal contouring procedures than just liposuction alone. Thus if in doubt between choosing between these two procedures, be aware that higher levels of disappointment occur with liposuction alone. After surgery scar concerns from having a tummy tuck is very uncommon. But to achieve this better result from a tummy tuck comes the price of more pain and recovery, having at least double the time until one can return to work. Nearly 100% of tummy tuck patients say they would undergo the operation again and would recommend it to others based on their experience.     

Dr. Barry Eppley

Indianapolis, Indiana   

Liposuction causes the fat that is removed to boil…or at least so it seems. The bubbling seen in the collection canister into which the suctioned fat goes can often be seen to be boiling even though it is not hot. This is actually the vaporization of water in the fat which is caused by the negative pressure (- 1 atmosphere) by the vacuum machine. This is also why it is easier or takes less suction pressure to do liposuction at high altitudes, the atmospheric pressure is less and the vaporization pressure of water is reached more quickly.  

According to the American Society of Aesthetic Plastic surgery, who has compiled statistics on cosmetic surgery for years, the most common cosmetic surgery in 2011 was liposuction. This is not surprising given that liposuction has a large number of treatable sites on the body from the neck to the ankle. This is unlike, for example, the nose (one) or breasts (two) where each patient has a more limited number of surgical sites.

An improved neck shape is a desire for many aging men and women. With time, loose skin and sagging fat develop that create a full neck with a more obtuse angle. When seeing patients who seek a better neck and jawline, they are usually surprised when the concept of a facelift is presented. They may have come in for a ‘necklift’ or some other limited operation but they most certainly didn’t think they needed a facelift.

For some, the issue of a facelift vs a necklift is a matter of misunderstanding terminology. It is common that most people believe that a facelift alters everything from the forehead down to the neck, not just an isolated neck and jawline change. Once explained properly they are ready to proceed with what they called a necklift. But for others a facelift is simply more than they want to do even though it is the ideal procedure for their aging neck and jowls.

Besides a facelift, they are a variety of other smaller or less extensive procedures that can be used to reshape the neck. These include the options of liposuction, submentoplasty, chin implants and the direct necklift. Often putting together two of these procedures is done to optimize their effects. But none of these procedures should be confused with creating the same effect as a facelift in the aging neck and it is important to realize their limitations.

Liposuction of fat can be very effective in reducing neck fullness. But that is dependent on how much fat actually exists in the neck and, most importantly, the quantity of neck skin and its tone. Loose neck skin will not respond to liposuction the way many older patients would like. The neck may indeed get less full but the skin may retract poorly and leave more visible folds and irregularities. Even with liposuction technology such as Smartlipo, which aids the fat removal process by a heating effect, significant loose skin will not be dramatically tightened. While I have seen some surprisingly good results with its use in the older neck, it is not a replacement for an excisional or lifting procedure for loose skin. When using it patients have to be willing to accept these skin issues or be ready to have a facelift later if they want further improvement.

The submentoplasty procedure is another method of neck fat removal but does not rely on liposuction at all. It is the removal of fat from underneath the platysma muscle and is often done as part of a facelift. Through an incision under the chin, the fat is seen through the separated platysma muscles in the midline. When done in a facelift, I use a ‘kelly clamp’ technique to remove the upper portion of the fat pad and then close the muscles over it. For those fuller necks with a lot of subplatysmal fat, a submentoplasty can make a dramatic change in the neck angle in side view. But like liposuction, its success as an isolated procedure depends on how well the skin retracts, which is why it works best in younger patients. In older necks, such fat removal can create skin dimpling and a central neck indentation.

Skin removal in the neck can be done without a traditional facelift. It is not commonly done as one might expect due to the scars that are created. But for the right patient who is fully educated, the scar may be a worthwhile trade-off. The direct necklift uses a vertical removal of skin from the chin down to the lowest horizontal neck skin crease. But skin alone is not just removed. All of the fat underneath this skin and even subplatysmal fat can be removed. The platysma muscle is then sewn together in the most dramatic form of neck muscle tightening due to the visual exposure that the surgeon has. The direct necklift produces the most significant neck angle change, even compared to the traditional facelift. Other types of neck excision or lifts exist, such as a submental tuck or a necklift that uses incisions behind the ears only, but their effects are very limited.

A chin implant is often a surprising suggestion to many older patients when discussing their neck concerns. It is a complementary procedure that increases the prominence of the jaw and by so doing lengthens the upper neck. While not enough alone to change a neck as much as a patient would like, it is a common component of many facelift procedures. It can be used with any of the non-facelift neck procedures and is conveniently done through a submental incision.

While there are a variety of surgical options for neck rejuvenation in older patients, their effects are limited. What they can do should not be confused with that of a facelift (with the exception of a direct necklift) and should be chosen only because one is more interested in less cost and recovery. For the neck with a lot of sag and droop, none of these more limited procedures may be a good option.

Dr. Barry Eppley

Indianapolis, Indiana

There is no more significant surgical procedure for reshaping one’s stomach area than that of a tummy tuck. For those women whose unsightly stomach is due to a combination of loose skin, excess fat and lax rectus muscles, a tummy tuck has the best chance to make it flat again. While the permanent physical price is that of a low horizontal scar and a small circumferential belly button scar, this is a relatively minor cosmetic trade-off for those women who are unhappy with the current state of their abdomen.

While a tummy tuck has the best chance for making one’s stomach flat, this does not mean that everyone will end up so. There are numerous factors which control how flat a stomach can become including one’s inherent body shape, the amount of intraperitoneal fat and the thickness of the upper abdominal skin flap. This last one, abdominal skin flap thickness, influences the chance of stomach flatness after a tummy tuck more than any other factor.

When a tummy tuck is done, a horizontal ellipse of skin and fat is taken from the lower abdomen. This newly created defect is eventually covered by the remaining upper abdominal skin being pulled down and stretched over it. This upper abdominal flap is composed of both skin and fat which moves downward through a combination of undermining and tissue stretch. The largest part of this tissue flap is composed of fat. Like an accordion, when the abdominal flap is pulled down to cover what was removed is does become less thick. The fat component of the flap, by necessity, must become thinner to cover a larger surface area.

The closure line of a tummy tuck brings together the upper abdominal skin flap and the inferior pubic skin flap. While in theory and in drawings the upper abdominal flap does all of the movement downward, this is not exactly so. There is some upper movement of the pubic area since it is not a fixed structure. Its skin and fat can stretch also. It simply does not move as much as it is smaller and more attached to the pubic bone and upper thigh area.

More relevantly, however, is that the skin flap thickness between the upper abdominal skin flap and the pubic flap is usually different in almost all patients. The abdominal skin flap is always thicker. While it may thin out as it is brought downward and the two skin flaps may look level across the incision line closure, it may not later. As the abdominal skin relaxes after surgery and with the patient in the standing position, the lower edge of the abdominal skin flap may appear fuller and create a ledge above the scar line. I call this the abdominal shelf deformity after a tummy tuck. It is there because of the inherent differences in the thickness of the two joined skin flaps.

While some defatting of the lower edge of the abdominal skin flap may be done during surgery to prevent a shelfing deformity, it must be done conservatively to prevent devascularizing the skin edges and developing  wound healing problems later. The same applies to thinning our the abdominal skin flap with liposuction.

The tummy tuck abdominal shelf deformity can be treated secondarily through either liposuction or skin flap resection. Liposuction can be used to thin out the thickness of the lower half of the lower abdominal skin flap. If the tummy tuck scar is thin and there is no loose skin above the incision, liposuction is the preferred treatment. If the tummy tuck scar is wide or otherwise not ideal and there is some amount of residual loose skin above the scar, then a wide scar revision approach would be better. Using a resection of the scar and an inch or two of skin and fat above it, a leveling of the two skin flaps across the new tummy tuck scar line can be achieved.

Dr. Barry Eppley

Indianapolis, Indiana   

Liposuction is a very popular and successful method of removing unwanted fat. While it removes fat, the real underlying intent of liposuction is body contouring. Reducing or removing bulges and undesired body protrusions is almost always a fat problem with only the abdomen and arms often have an excess skin problem as well. Since body contouring is the real goal of liposuction, the smoothness or evenness of the skin that makes up the outer aspect of the body contours is equally important.

If you read message boards, patient commentaries and various plastic surgery sites, it becomes clear that the most common concern after liposuction are ‘lumps and bumps’. Skin irregularities, unevenness and asymmetry are not rare liposuction problems and concerns. Whether it is in the first few weeks after surgery or months later, how the skin looks and feels over treated areas raises lots of questions. Some of these concerns will only be temporary while others will go on to be a persistent aesthetic distraction.

The process of liposuction is, by its very nature, somewhat imprecise and not always predictable. It is basically a blind procedure in which the amount of fat and, equally importantly, the evenness of its removal is done by the look and feel of the treated area. This leaves a lot of judgment to the treating physician and the influence of skill and experience is huge in getting optimal results. There is also the effect of how fat that is left behind, and you always have to leave some to prevent skin contractures and indentations, survives from the trauma of the surgery. Uneveness of the skin can occur, even if an even layer is left underneath the skin, if some fat dies or resorbs in the after surgery healing period.

The lumps and bumps from liposuction should be viewed and understood as three types or phases, early middle and late. Early skin irregularities after liposuction is the norm right after the procedure. This is due to swelling, bruising, collections of fluid (blood, liquid fat, tumescent fluid), and lack of skin healing and contraction. Some patients will have a lot of these irregularities while others will have far fewer. It is somewhat dependent on the anatomic location and the quality of the skin over the treated area. These early lumps and bumps will be evident during the first month after surgery and this phase can be considered over when there is no longer any bruising or grossly evident swelling. Numbness of the skin is still prevalent over much of the treated area.

The middle or intermediate phase of liposuction contouring effects ranges from between one and three months after surgery. Blood and  fluid collections under the skin are largely gone by this time and most of the major amounts of swelling are gone. Some irregularities that were initially seen have either gone away or have greatly diminished. The skin begins to feel softer and less firm. Some of the skin numbness has gone away and normal feeling is beginning to return. A lot of healing is occurring underneath the skin and this is a very active phase of collagen formation and the reuniting of disrupted tissues.

The last phase of liposuction skin reshaping occurs between three and six months after surgery. By this point the skin is soft again as the final remnants have swelling have resolved. The treated areas are no longer uncomfortable to deep pressure and squeezing. Completely normal skin feeling has returned. The skin has contracted down to show the evenness of the subcutaneous fat removal. Any additional fat that was not removed but would go on to resorption has done so by this point in time.

Understanding these phases of skin reshaping and the time course of irregularities after liposuction should help patients with their expectations and concerns. What may seem like a skin problem early on my gone on to resolve itself as part of the natural process of healing. If skin irregularities and asymmetries persist beyond six months after surgery, these are not likely to resolve on their own as the healing process is complete. This is when revision of these liposuction results would not be premature.     

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

The removal of unwanted fat through liposuction techniques is effective but has as its main complications that of irregularities and asymmetries of body contours. While taking down the size of fat collections, it does not always result in the desired body contours or a show of the underlying muscular detail. This has lead to a liposuction concept known as sculpting or liposculpture. What is liposculpture and is it really different? Is it a better at achieving natural body contours and a more attractive body shape? Who is it best used on?

Liposculpture moves beyond the removal of just localized areas of too much body fat to a more artistic approach to fat removal. Instead of using large bore cannulas which can indiscriminately remove fat rapidly and creates large diameter internal tunnels through the fat, smaller size cannulas are used. These tools are more selective about how much and where fat is removed. Smaller cannulas may also be combined powered liposuction equipment such as oscillating, ultrasonic and laser-assisted devices. Whether these energy-driven devices are more effective at liposculpture is a matter of debate.

But the most important element in effective liposculpture is that of the surgeon. There has to be an appreciation of what makes up natural and pleasing body contours. The tools used are only as good as the hands that are directing them in shaping new contours. There also has to be an understanding of what the structure of fat looks like underneath. In some areas there may only be a thin fat layer which can reveal an improved body contour through superficial cannula extraction. Such aggressive right-under-the skin fat removal must be applied carefully to avoid scarring and undesireable skin retractions. Areas such as the inner knee, neck, back rolls, axillary breast and flanks are good examples of where superficial liposculpture must be used to get good contouring results as there are not deeper fat layers.

Superficial liposculpture has also become well known because of abdominal etching. This is the most aggressive application of this technique. It is the deliberate removal of all fat possible between the underside of the skin and the underlying muscle layer. When done over abdominal areas that lie over the muscular inscriptions and outlines, one can achieve a ‘six-pack’ look. While achieving this desired look for some, it is actually creating an anatomic result that is almost always to be avoided in liposuction, skin retraction and scarring. Abdominal etching is reserved for those that are near their ideal body weight and have a thin layer of abdominal fat.

While liposculpture sounds appealing, it is not a method that is best for many liposuction patients. The most common liposuction patient has larger amounts of fat on the abdomen, waistline, thighs and arms. In these areas there are two distinct fat layers, superficial and deep. Extraction from the deeper layers is needed and should be the first layer that the cannula enters. Treating the superficial layers as well, while improving the amount of contour reduction, will increase the risks exponentially of surface contour irregularities. The abdomen, arms and inner thighs are particularly at risk for this problem with superficial liposculpture. The quality of the skin, its thickness and elasticity must be assessed to determine if it is wise to attempt removal of fat right under the skin.

While slick marketing and pictures of models attempt to attract prospective patients for so-called liposculpture surgery, it is important to remember that traditional liposuction methods with solely deep fat removal will satisfy most patients. Liposculture techniques should be applied judiciously and applied to areas that are best served by them. It is a liposuction technique that takes into account the anatomy of the fat and the contouring goals and not a method that replaces traditional liposuction for many body areas.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Liposuction is one of the most common cosmetic surgeries performed and, by far and away, the largest procedure in body surface areas treated. Despite its wide usage and high-tech tools and devices available to perform the procedure, there is a significant occurrence of cosmetic complications (contour asymmetries and skin irregularities) and the need for secondary revisions.

Aesthetic complications in liposuction occur with some frequency for several reasons. Part of their occurrence is due to the inherent nature of the procedure. It is a blind operation that is done largely by feel and experience. You can’t really see on the inside what you are doing. One must rely on external indicators to get a gauge on how much fat has been removed and how even it is. Using a straight-shaped device probes and extraction cannulas on curved body surfaces also makes smooth and even fat removal unpredictable. Lastly, because it is easy to acquire equipment and seemingly simple to do, there are a large number of inexperience poorly trained physicians performing the procedure. Collectively, this makes it not infrequent that the cosmetic results from liposuction may fall short of a patient’s expectations.

While the initial or primary liposuction procedure is straightforward to perform, secondary or revisional liposuction is much more challenging. The asymmetric or contour irregularities that exist pose more significant challenges due to scar and a broad areas of subcutaneous fibrosis. Liposuction problems generally fall into three types; too much fat removed, too little fat removed, and combinations of both which are the most common.

The ‘simplest’ liposuction problem is that of inadequate fat removal. This appears as high spots on flat surfaces and asymmetries on curved ones. It is the most likely to be improved by further liposuction efforts as more fat can be selectively removed. Because there is residual fat they may also be less scar present. It is usually best to use small cannulas for extraction as the areas are often relatively small and direct access through an incision near it can prevent creating other problem areas in the path of the cannula.

Too much fat removed poses a more difficult liposuction revisional problem for two reasons. First, there is a need for more fat tissue to build the area back up. In small areas there is usually not a donor site problem. In larger areas that may be more relevant. Secondly, scar is now present in the subcutaneous tissues and the predictability of how the skin will redrape over a recontoured area is more uncertain. The combination of skin contracture release and interpositional fat injections placed underneath is the only way to improve indentations. While release alone may look adequate at the time of the procedure, the lack of underlying fat will reveal itself quite quickly later. After surgery massage and skin smoothing devices are also very beneficial. It is fair to say that liposuction-induced skin irregularities can never be made perfectly smooth but they can be improved.

There are well known body areas that are prone to skin irregularity problems after liposuction and include the abdomen, inner thighs, back of the arms and upper knee regions. These occur because these are also areas that have more skin elasticity problems and it is always best to leave more superficial fat under the skin to guard against these irregularities. While every patient wants the maximum amount of fat removed in every liposuction procedure, conservative extraction in many areas is a wise choice.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana