Medications that the patient may be taking is reviewed, as many common prescribed and over-the-counter medications may affect wound healing and blood clotting. Medications such as aspirin, nonsteroidal antiinflammatory agents, birth control pills, vitamin E, and herbal preparations such as St. John’s wort are recognized to interfere with the coagulation mechanism.   Dr Koo recommends avoidance of such agents before surgery. Some medications may also interact with medications used during surgery.

The body mass index, calculated from the patient’s height and weight in metric units of kilograms per meter squared, is a good method with which to assess the patient’s relative risk-to-benefit ratio for the procedure. Although liposuction may reduce cardiovascular risk, blood pressure, and fasting insulin levels, it should not be considered a treatment for obesity. Patients with inherent risks including those with poor wound healing, infection, deep venous thrombosis, sleep apnea, or a body mass index greater than 30 would benefit from additional counseling, and lifestyle modification should be considered before a body-contouring procedure.

Dr Koo performs a thorough physical examination which includes documentation of the patient’s height, weight, and circumferences of all pertinent body areas. Dr Koo will look at all previous surgical scars including, of course, a possible previous C Section scar and will attempt to remove all possible scars and stretch marks that are within the area that can be removed with an abdominoplasty.

Typically, Dr Koo recommends waiting a minimum of 6 months after childbirth prior to considering any plastic surgery to reshape the breasts and body. This allows time to lose the water weight gain, establish good eating and exercise habits, and allows the skin to retract. With weight and skin tone stabilization, the breasts and abdomen will revert to as mich of the pre-pregancy condition that is possible. For some women, depending on activity level, eating habits, and genetics, this could take up to one or more years.

Dr Koo also recommends waiting until the patient is not considering any more children before major skin resection such as a tummy tuck (abdominoplasty) to prevent relapse of stretch and split of the abdominal muscles again with recurrent pregnancies.

The saggy, flat breasts and lax, loose abdomen and hanging skin can all be removed and abdominal muscles tightened completely to a pre-pregnancy state.  The maintenance of the shape and appearance is then up to the patient to continue to eat healthy with regular activity levels which Dr Koo encourages and helps with suggested excercise classes and trainers.  If the patient is looking for firm, lifted breasts that are full and round, then a breast implant along with the breast lift may be necessary. She will discuss all the possibilities and let the patient know what surgery is in her best interest for long term results.

Lipodystrophy can be located in the following areas: abdomen, flanks, thighs, arms, neck, knees, back, buttocks, and breasts. Careful physical examination entails site-specific evaluation. Dr Michele Koo examines patients for the presence of occult hernias. Men who present for abdominal liposuction should be examined with particular care, as abdominal prominence may often be attributed to intraabdominal fat, which is not addressed by liposuction. In men interested in body contouring of the anterior chest, the examination of those with gynecomastia may direct the method of surgical treatment. Ultrasound-assisted liposuction or direct excision of skin and breast tissue may be necessary in those with additional fibrous tissue.

Skin evaluation is pertinent in the evaluation of any patient seeking body-contouring procedures. For those seeking liposuction, adequate skin elasticity should be present to allow for skin retraction after surgery. Particular attention should be given to associated wrinkles, laxity, and surface irregularities, including dimpling. Scars should be noted.

Cellulite is a term that is used to describe the lipomatous deposits under the skin that outwardly give the skin a lumpy or orange peel-like appearance. Cellulite is often noted in areas such as the hips, buttocks, or thighs. Cellulite is predetermined by genetics, so even thin women can develop the appearance. Factors such as hormones, pregnancy, and aging may all attribute to the appearance of cellulite. Patients should be aware that liposuction procedures do not address cellulite and may in fact worsen its appearance. In contrast, dimpling is usually considered to be a more isolated area of concavity that may be secondary to underlying scar or fascial attachments and may be improved by the liposuction process.

Any asymmetry or contour irregularities is noted and brought to the patient’s attention. Dr Koo makes additional effort to correct any dimpling or asymmetry intraoperatively; however, this is frequently difficult to achieve. The patient should be aware of possible persistent asymmetry, depressions, and dimpling after the liposuction procedure.

Society of Anesthesiologists status of a patient before scheduling liposuction because it is an important factor in determining the most appropriate location for the procedure to be performed safely.

Lidocaine is used most commonly as the anesthetic agent for subcutaneous infiltration. It has a wider range of safety than Marcaine (AstraZeneca, Söodertälje, Sweden) and is more easily reversed. Historically, the recommended dose of lidocaine is less than 7 mg/kg; however, in liposuction procedures, there are several factors that allow for increased administration. The risk of systemic toxicity with lidocaine and epinephrine-containing anesthetic infiltrate solutions is diminished with the slow absorption of anesthetic from fat, the persistent vasoconstriction from epinephrine, and lidocaine removed in the liposuction aspirate. Lidocaine doses up to 35 mg/kg have been generally accepted for solutions containing epinephrine injected into the subcutaneous fat.5 Doses of lidocaine up to 50 mg/kg have been used; however, it is important to note that plasma lidocaine levels can peak 10 to 12 hours after infiltration when epinephrine is present in the wetting solution. Lidocaine toxicity has been implicated in a series of liposuction-related deaths. Signs and symptoms of lidocaine toxicity can be seen at plasma levels between 3 and 6 μg/ml. Initially, patients may experience lightheadedness, drowsiness, tinnitus, a metallic taste in the mouth, slurred speech, and numbness of the lips and tongue. At higher plasma concentrations, shivering, muscle twitching, tremors, convulsions, central nervous system depression, and coma may result. Respiratory depression and cardiac arrest can also occur with higher doses. Marcaine is rapidly absorbed, poorly reversed, and has a long half-life, making it a less suitable agent for subcutaneous infiltration in liposuction procedures.

Epinephrine is a critical additive in the infiltrate solution. It is recommended that doses of epinephrine not exceed 0.07 mg/kg, although doses as high as 10 mg/kg have been used safely.

Moderate sedation or analgesia, termed conscious sedation, is defined as purposeful responsiveness, with response to verbal or tactile stimulation evident. No airway intervention is required; however, supplemental oxygen may be administered as indicated. Patients demonstrate adequate spontaneous ventilation, with maintenance of cardiovascular function. Although numerous agents can be administered to achieve this level of sedation, it is imperative that the physician be adequately trained in anesthetic medications and airway management if intravenous sedation is planned without the presence of an anesthesia professional. In limited, smaller volume liposuction cases, intravenous sedation may be administered to maintain patient comfort.

In general anesthesia, the patient is unarousable, even with repeated painful stimulation, and independent ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive-pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function.  As with any surgical procedure, medication is titrated to effect, and a certified anesthetic provider is present for any procedure under general anesthesia.

The physician is primarily responsible for providing and supervising anesthesia and analgesia. A certified registered nurse anesthetist or other qualified health care provider may administer anesthesia, but only under direct physician supervision, unless state law specifically provides otherwise. Dr Koo has a core staff that she works with that is completely trained and familiar with her methods, techniques, and preferences and only that staff is allowed in her operating room. Dr Koo and all operating room and key facility personnel are fully trained to recognize emergencies and complications.

The dry technique was the first method developed. It was performed under general anesthesia without the infiltration of subcutaneous solutions before insertion of the liposuction cannula. Substantial swelling and discoloration is a common consequence of the dry technique. This technique is also associated with a large amount of blood loss, with suction aspirate consisting of 20 to 45 percent blood. These sequelae sharply limited the amount of fat that could be removed without transfusion or hospitalization, which resulted in the abandonment of this approach, except in limited applications. The dry technique is not recommended for suction volumes greater than 1000 ml because of the amount of blood loss incurred. The dry technique should never be used in conjunction with ultrasound-assisted liposuction.

The wet technique entails injecting 200 to 300 ml of infiltrate or wetting solution, with or without additives, into the operative field before insertion of the liposuction cannula. Small doses of the vasoconstrictor epinephrine were added to the infiltrate, which significantly decreased the blood loss to 4 to 30 percent of the aspirate. The wet technique was the method of choice in the early 1980s.

The superwet technique, developed in the mid-1980s, uses 1 ml of solution for each 1 ml of fat to be removed. The surgeon’s preoperative estimate of the suction aspirate is considered in this technique. The infiltrate solution consists of saline or lactated Ringer’s solution with epinephrine and, in some cases, lidocaine. Using larger volumes of subcutaneous infiltrate, blood loss generally decreases to less than 1 percent of the aspirate volume.

The tumescent technique was introduced in 1985. It uses the largest volume of infiltrate and involves infusing 3 to 4 ml of the infiltrate solution for each planned milliliter of aspirate. Drug concentrations in the tumescent infiltrate solution vary, but typically they consist of a range of 0.025% to 0.1% lidocaine and epinephrine 1:1,000,000 in a lactated Ringer’s or normal saline solution. Estimated blood loss with the tumescent technique is approximately 1 percent of the aspirate, comparable to the superwet technique.

Since the advent of epinephrine-containing wetting solutions and sophisticated fluid management techniques, increasingly larger volumes of liposuction aspiration have been reported. Large-volume liposuction, defined as a total aspirate of 5000 ml or greater, can be a safe and effective procedure when patients are carefully selected and when anesthetic and surgical techniques are properly performed. Meticulous fluid balance calculations are necessary to avoid volume abnormalities, as metabolic alterations and fluid shifts result from medication effect, hypodermoclysis, and surgical technique. General practice guidelines recommend overnight observation postoperatively for patients undergoing large-volume liposuction.

Dr Koo is very precise and accurate with the preoperative marking and discusses the areas of liposuction during the preoperative consultation several times prior to the surgery and again on the day of surgery to ensure that the patient understands completely the areas to be contoured and they coincide with the areas of concern for the patient. This is essential to satisfactory results. Patients are marked with a fiber-tip marking pen in the upright position or standing. Areas to be avoided, such as the zones of adherence, is noted carefully.

Dr Michele Koo uses multiple-access incisions for almost all areas because removing all fat from a single access incision may lead to depressions around the access site and contour deformity. Incisions are placed in natural skin folds and asymmetrically to limit visibility of the resultant scars.

Dr Koo places the patient in the appropriate position for access to the treatment site. If multiple areas are to be treated during a single operation, it is convenient to prepare the patient circumferentially so that all areas of the trunk and extremities may be treated without repeated preparation and repositioning. Dr Koo feels that she is able to achieve the most optimal results with circumferential liposuction along with the tummy tuck (abdominoplasty) repositions the patient intraoperatively to better treat and evaluate surgical progress and symmetry. 

A thorough operative record includes documentation of each stage of the liposuction procedure. The infiltration solution mixture should be documented and the volume of subcutaneous infiltrate used should be noted as well. Oftentimes, surgeons will note the amount of infiltrate and volume of aspirate by body area and record the total volumes for the entire procedure. This information, along with intravenous fluid administration and monitoring of vital signs and urine output, are important factors for maintaining adequate fluid management intraoperatively and postoperatively. A diligent fluid management strategy between the surgeon and anesthesia provider is important for avoiding volume overload sequelae.

Sequential compression devices should be in place before a general anesthetic is used in most liposuction procedures. Patients who undergo other types of anesthesia or minor procedures may do so without sequential compression devices.

The use of postoperative compression for 6 weeks is usually indicated after liposuction procedures to minimize edema and support the soft tissues. The various compression modalities and garments available for each area can be extremely useful but must be tailored to the area of treatment. The use of a foam material underneath the compression garment to increase compression and protect areas of irritation is frequently beneficial.

No single liposuction technique is best suited for all patients in all circumstances. Factors such as the patient’s overall health, body mass index, the estimated volume of aspirate to be removed, the number of sites to be addressed, and any other concomitant procedures to be performed should be considered by the surgeon to determine the best technique for the individual patient.

Suction-assisted lipoplasty. Suction-assisted lipoplasty is the most commonly performed aesthetic procedure in the United States. Suction-assisted lipoplasty procedures use an external source of suction to facilitate the removal of fatty tissue.

Power-assisted lipoplasty. Power-assisted lipoplasty is an approach in which the system that drives the cannula is a power source other than the surgeon’s arm. Systems are either electrically driven or gas-driven by nitrogen or compressed air tanks. A small motor moves the 2- to 4-mm cannula tip in a forward and backward motion, replicating the motion of the surgeon and decreasing physician fatigue. The cannulas are small and flexible and are comparable in length and diameter to standard suction-assisted liposuction cannulas. Power-assisted liposuction is effective for large-volume removals, fibrous areas, and revisions. It is typically used in conjunction with the tumescent or superwet technique. The excessive vibration of the cannula and the noise of the power system are the two main disadvantages of this technique.

Combination ultrasound-assisted lipoplasty and suction-assisted lipoplasty. A combination of techniques may be used for treatment of various areas of lipodystrophy.

Other. Syringe aspiration of fat has been used for addressing superficial irregularities independently or in conjunction with another liposuction modality. This method for aspiration may result in less blood loss and has been reported to be a more precise and accurate mode of fat removal. The main disadvantage of syringe aspiration is prolonged operating time. This technique is effective for sensitive and smaller volume areas, such as the neck. It also is commonly used for harvesting fat for transfer, as less mechanical damage to the fat cells allows for a greater percentage of viable cells for transfer.

Embolism may occur from fat or venous thrombosis. The signs of pulmonary embolism may be shortness of breath or difficulty breathing. Deep venous thrombosis may be present with calf or leg pain, Homan’s sign, swelling or erythema of the lower extremity, persistent tachycardia, and/ or mild pyrexia. The thrombus is not usually palpable. Treatment of deep venous thrombosis may entail anticoagulation or placement of a venous filter. Patients who develop a pulmonary embolus may undergo thrombectomy or thrombolysis as well. Although the exact pathophysiology of fat embolism syndrome remains somewhat controversial, signs or symptoms of fat emboli after liposuction require emergency medical care, as permanent disability or fatality may result.

Advances in the understanding of fluid management in the care of the patient undergoing liposuction has increased the margin of safety of this procedure. Firm guidelines for the appropriate amount of fluid resuscitation have yet to be established; however, there are multiple formulas and fluid balance calculations for determining the appropriate balance of intravenous fluid administration and subcutaneous infiltration. The key to appropriate perioperative fluid homeostasis is proper patient selection and consistent communication between the surgeon and the anesthesiologist with regard to perioperative fluid replacement and urine output. The surgeon should be cognizant of all fluid administered and removed with aspirate and excreted as urine output to avoid problems with hypovolemia or fluid overload.

Fatal complications secondary to liposuction may be attributed to anesthetic cardiopulmonary complications, necrotizing fasciitis with overwhelming infection, hypovolemic shock, fat embolism, pulmonary embolism, disseminated intravascular coagulopathy, or intraperitoneal and bowel perforation. Less common reports of death resulting from liposuction procedures have also included toxic shock syndrome, acute respiratory distress, and hypersensitivity to medications or instruments used during the procedure.

Intestinal or organ perforation from the liposuction cannula, though rare, usually occurs with a preexisting abdominal scar. The abdomen, thorax, retroperitoneum, and major vessels in the subcutaneous space are all potential areas into which a cannula can be misdirected and potentially result in major injury. Kidney perforation has been reported. Symptoms of organ perforation may not become apparent for several days. When internal organs are violated, patients may present for follow-up with symptoms of an acute abdomen, and an emergent laparotomy may be indicated to assess the extent of damage and to repair injury, as visceral perforations and their associated infections may be fatal. Gentle technique and awareness of the possibility of misdirection of the cannula in the presence of a scar will prevent this complication.

The total blood loss involved in suction-assisted lipectomy is principally dependent on (1) the amount of blood present in each milliliter of aspirate and (2) the absolute amount of aspirate. Total blood loss can be estimated as the percentage of blood in the aspirate multiplied by the total amount suctioned. Clinically, the blood loss is rarely a limiting or significant factor in cases in which total aspirate is less than 1000 ml, regardless of the infiltration method used. The dry technique results in a suction aspirate containing 20 to 45 percent blood.

Any of the complications described in the previous section can also occur in the later postoperative period. Surgeons should recognize additional complications that may present as convalescence continues.

Patients with a higher body mass index have been found to have a significantly increased risk for developing postoperative seromas. Ultrasound-assisted liposuction has also been associated with a slightly increased risk of seroma formation. Suggestions for decreasing the incidence of seroma include expressing any remaining fluid before closure; using a single suture to close incisions, allowing for fluid egress; applying a well-fitting compression garment; and encouraging the patient to ambulate soon after surgery. Simple aspiration is the most common treatment for a seroma. An implantable catheter or drain can be used to avoid repeated aspiration.

Although large areas of skin loss is rare, ulceration or friction injury is more commonly noted at the entrance site from incorrect use of the cannula, tension on skin margins, or an incision that is too small for the instruments used. Burns have also been associated with ultrasound-assisted liposuction, as the ultrasound cannula can become very hot, and prolonged contact with the skin may result in skin damage.

Infections can occur and have been known to progress to serious and life-threatening conditions if not appropriately attended to. Many surgeons will prescribe perioperative antibiotics to minimize the risk of infection. Physicians who perform liposuction should be familiar with the signs and symptoms of conditions such as toxic shock syndrome and necrotizing fasciitis.

The most common postoperative sequelae of liposuction are contour irregularities; these may be considered complications if they persist for over 6 months. Because contour irregularities may be secondary to postoperative swelling and skin elasticity, they may be treated conservatively for at least 6 months after the initial operation. However, for areas of excessive fat removal or insufficient fat removal, secondary liposuction, fat grafting, and dermolipectomy can be considered to address the persistent area(s) of concern. Nonsurgical treatments for early contour irregularities include manual lymphatic massage and Endermologie (LPG Systems, Valence, France). Long-term swelling may be noted in a small number of liposuction patients.

Skin hyperpigmentation may be attributed to several factors. Hemosiderin deposition by ecchymosis, external pressure from bandages applied, and possible friction from the inlet holes of the cannula have been suspected of increasing the likelihood of hyperpigmentation postoperatively. Several areas are known to be prone to hyperpigmentation (e.g., the medial thigh). This effect is more often attributed to ultrasound-assisted liposuction and extended treatment time to a single area (>10 minutes). Patients should also be cautioned that oral iron therapy, exogenous drug administration (particularly estrogen), and sun exposure may contribute to the development of hyperpigmentation after liposuction.

Patients may experience paresthesias after surgery. Patients have reported hypersensitivity and numbness after surgery that may persist for weeks or months. In a small number of patients, these paresthesias may be permanent.

The analysis of the sequelae of liposuction and tummy tucks does not provide specific percentages of complications associated with liposuction. Seromas, infection, and tissue irregularities are the most common minor problems. Deep venous thrombosis, associated with pulmonary embolism and death, is the most frequent serious complication of liposuction. Thus, the prevention and, if necessary, the expeditious diagnosis and treatment of deep venous thrombosis are integral to the care of the liposuction patient.

Dr Koo examines patients who may desire  secondary surgery to correct contour irregularities carefully and counsels them to ascertain their realistic goals for surgery. Previous surgical procedures are considered and careful notation is made to document the site of secondary surgery and the anticipated amount of secondary lipoaspirate or augmentation with dermal fat grafts of lipotransfer. Skin resection may be necessary for areas of inadequate skin retraction.

Physical outcome and ease of recovery are not the only factors that define patient and physician satisfaction, as successful body contouring surgery requires a patient to embrace positive lifestyle habits. Dr Koo recognizes the importance of patient education on postoperative alternatives in diet and exercise and will help the patient establish a connection with nutritionists as well as exercise trainers. This will ultimately help the patient maintain successes achieved with the liposuction and  tummy tuck procedures. 

Dr Michele Koo always maintains a relationship with her patients seeing them post operatively indefinitely thereby making sure that they “check in” for annual breast examinations as well as keeping track of their weight and exercise maintenance. Dr Koo wants to change and enhance the patients life and lifestyle and continues to take care of her patients years after any procedures at no further follow-up charges.

 

 

 

 

 

DR MICHELE KOO, MD, FACS, ST LOUIS, MISSOURI, 314-984-8331.

Dr Michele Koo, MD, Board Certified Plastic Surgeon, Member of the Aesthetic Society can create beautiful augmented breasts for you with saline or silicone breast implants. Your breasts can be enhanced to full, round, sexy breasts that still look and feel completey soft and natural. Dr Koo can create the breast cleavage that you have always wanted with breast enlargement using breast implants. 

Dr Koo performs the breast enhancement with either an incision under your breasts or around your areola. She places the implants in one of two positions, either under your muscle or under your breasts. Dr Koo will decide the pocket for your breast implants after she examines you and determine which is the perfect surgery for you depending on what you want your breasts to look like.  The surgery is an outpatient procedure under general anesthesia and you will be able to drive the next day and return to an office type occupation after 1 or 2 days.

You will be able to do light exercising in 2 weeks and full cardio exercising in 4 weeks. You will look awesome in a swim suit in 4 weeks and be ready for any social event with low cut dresses and tops in 2-4 weeks.

The breast implants that are available now are silicone and saline implants and both are perfectly safe. Dr Koo will use either MENTOR or ALLERGAN NATRELLE breast implants depending on the shape and size of your own breasts and what she feels she needs in order to make your breasts the best that they can be.

The surgery takes less than one hour and you will go home that day and feel fine by that afternoon. There is only some minor discomfort and pressure from the tight surgical bra that Dr Koo gives you. Dr Koo then sees you in the office 4 days after the surgery when you will be able to see your beautiful full augmented breasts.

The breast implants whether it is saline or silicone will need to eventually be replaced in 15-20 years. the replacement surgery is relatively minor and takes even less time than the original surgery if you do not need a breast lift or other procedures with your breast implant replacement. You will be able to still undergo mammograms with breast implants in place. Dr Koo’s office, St Louis, Missouri, 314-984-8331, will make sure that you are seen every year in follow-up with Dr Koo for a professional breast examination and that you will have regular mammograms according to recommendations depending on your age.

At the time of your breast augmentation, Dr Koo can also perform a breast lift if necessary or other procedures to correct any breast asymmetry.

Call DR MICHELE KOO, MD, FACS, 314-984-8331, ST LOUIS, MO, to begin your journey to feeling more confident and sexy with your very natural looking and feeling, full, round, sexy breasts after BREAST ENHANCEMENT - BREAST AUGMENTATION WITH BREAST IMPLANTS.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

null

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dr Michele Koo, MD, FACS, Board Certified Plastic Surgeon, St Louis, Missouri, 314-984-8331.

 

The patient is a 47 year old Missouri woman who started her journey of weight loss at 230 lbs and a size 22.  On the day of her surgery, she weighed 185 lbs and was a size 16.

 

Dr Michele Koo performed a tummy tuck (abdominoplasty) and ultrasonic liposuction of her hips, waist, and thighs. She is shown in her after pictures at four months at 155lbs and a size 8.  She couldn’t be more thrilled. The surgery performed by Dr Koo changed her life.

 

When the patient started dieting and losing weight, she consulted Dr Koo. The patient felt trapped and frustrated by her loose hanging skin, stretch marks and did not feel that she could continue her dieting and exercise without some type of plastic surgery procedure such as an abdominoplasty or tummy tuck and some type of liposuction. She needed help to continue to take charge of her life and her body.

 

Dr Koo was very encouraging and understanding and stressed the fact that the patient had already done the bulk of the hard work losing the weight and should not feel discouraged by the appearance of her trunk and belly (midriff) area. So many patients bounce up and down with their weight because they hit a plateau and can’t go any further with their appearance after working for so long exercising and restricting their diet. They feel completely exasperated that they cannot further change their tummy and get rid of the loose hanging skin.

 

Enter Dr Michele Koo, St Louis, Missouri, 314-984-8331, Board Certified Plastic Surgeon and a Member of the Aesthetic Society. She can and will safely take you the rest of the journey toward a flat tummy and a skinny waist. She will encourage you to continue your activity level and healthy diet without using supplements or crazy ultra restrictive diets. She might suggest a gastric bypass or a gastric banding first if you are extremely obese prior to any body contouring and liposuction procedures.

 

Dr Koo will be very honest with you that this is a long process and lifestyle change that she wants for you. After the tummy tuck (abdominoplasty) and liposuction, you will need time to recover over 2-4 weeks and more than likely will need even 6 weeks to full recovery of returning to strenuous work. However, Dr Koo will tighten your abdominal muscles stretched from pregnancy and remove all the excess loose hanging skin of your belly and make you look like a totally new person with the tummy tuck and liposuction. 

 

Dr Michele Koo  wants you to be well informed and the following exerpt from Heller, et al, Yale Medical Center should provide some background information. Functional abdominoplasty was first described by Kelly in 1899 and popularized for cosmetic purposes in 1967 by Pitanguy, who introduced the low transverse (i.e., bikini line) incision that could remove lower abdominal scars. Since this time, abdominoplasty procedures have rapidly gained popularity, with 102,497 being performed in 2004, an increase of 510 percent from 1992 levels and an increase of 24 percent from 2002 levels.

During this period, surgeons focused increased attention on reducing complications. Local complications such as hematoma, seroma, wound dehiscence, and skin necrosis occur in up to 32 percent of nonsmokers and as many as 52 percent of smokers. As such, greater effort has been set forth to define the vasculature of the abdomen to limit these complications. Huger described three vascular territories of the abdominal wall: zone 1 ranges from the xiphoid to the pubis between the lateral borders of the rectus abdominis and is supplied by the superior and inferior epigastric arteries; zone 2 is the trapezoidal area defined by anterosuperior iliac spine superiorly and by the groin inferiorly-its blood supply is from the superficial inferior epigastric, superficial circumflex iliac, and external pudendal arteries (superficial system) and from the deep inferior epigastric vessels (deep system); zone 3 is the area of the lateral abdomen and flanks and is supplied by the segmental lumbar, subcostal, and intercostal arteries. Traditional formal abdominoplasty with its low transverse incision and wide undermining to the costal margin sacrifices zone 1, zone 2, and to a limited extent zone 3. Furthermore, the skin of zone 1 experiences additional vascular compromise caused by tension on the suture line and thinning of the abdominal flap. Thus, many surgeons have proposed less extensive approaches to abdominoplasty in an attempt to maintain adequate vascularity, but the best aesthetic outcomes remain with the classic abdominoplasty.

To improve contour, liposuction has been offered to abdominoplasty patients, but previously as two independent procedures separated in time by at least 6 months. Caution concerning the advisability of such an approach was based on the belief that the traumatic forces of liposuction would limit the vascularity of the flap and thereby increase complications. Matarasso studied the safety areas for lipoplasty combined with abdominoplasty and recommended limited and cautious liposuction of the epigastric and mesogastric areas (zone 1) with full type 4 abdominoplasty. With advances in superficial liposuction, Saldanha et al.  performed lipoplasty of the abdomen, sparing the epigastric and mesogastric areas, followed by an abdominoplasty with rectus muscle plicature, and found a complication rate no higher than that of a formal abdominoplasty. In a study performed by Lockwood, patients who underwent high lateral tension abdominoplasty and superficial fascial system repair with and without liposuction experienced complications that did not exceed historical controls. In 2006, the most recent survey of 497 surgeons reveals that 56 percent of surgeons perform some sort of liposuction with a full abdominoplasty but also stresses the need to differentiate complication rates in patients who received liposuction with their abdominoplasty versus those who did not.  

Dr Koo believes that liposuction of the abdomen to achieve the “finished look” of a smooth flat tummy can be performed simultaneously with minimal complications. She takes extra precautions with her unique surgical procedure of a refined high lateral tension abdominoplasty that achieves amazing results as seen in the featured before and after picture.

 

 

 

 

          

Whether you have undergone a gastric banding or gastric bypass and have had massive weight loss or have too much skin and fat or you feel trapped by your large fat belly and overhanging skin of your abdomen, DR MICHELE KOO, MD, FACS, BOARD CERTIFIED PLASTIC SURGEON, ST LOUIS, MISSOURI, can help you get out of your own way and get rid of all that skin and fat that you have never been able to do for yourself.

If you’ve never had a skinny waist or waist and want a flat tummy and want to get rid of all that fat around your midriff or just want to be able to wear clothes normally, you can achieve a flat stomach with an abdominoplasty and body contouring by Dr Michele Koo, MD, FACS, Board Certified Plastic Surgeon, St Louis, MO, 314-984-8331.

Dr Michele Koo wants you to know that this is possible for you and is not just a dream. Dr Koo makes sure that her office helps you uphold your end of the bargain which is that you must eat sensibly and start on a regular walking routine. You do not need to feel frustrated if you can’t jog or lift weights or have the time or money to go to exercise classes or hire a trainer or a cook. What you must do are common sense tasks of cutting your portions that you eat and walking at least 3 times a week. You should not deny yourself the kinds of food you like to eat but you must not eat as much of it.

Eating sensibly and increasing your activity level an essential part of achieving weight loss and maintaining shape after a tummy tuck - abdominoplasty and body contouring (liposuction).  While Dr Koo does not require you to lose weight prior to your surgery, she does encourage you to start good habits prior to your surgery so that they will become second nature after the surgery thereby changing your lifestyle for the long term. You will then be able to maintain a much healthier life after the surgery when she removes all the skin and fat that you couldn’t possibly do for yourself.

Dr Koo wants you to understand some of the techniques that she uses for your body contouring. According to Dr Daniel Brauman of Cornell University, liposuction abdominoplasty-liposuction of abdominal subcutaneous tissue deep and superficial to Scarpa’s fascia, with excision of excess abdominal skin and, when indicated, plication of the anterior rectus sheath without undermining-is an effective, low-risk approach to minimizing abdominal flap undermining. The technique allows aggressive thinning and sculpting of full-thickness abdominal subcutaneous tissue and achieves a natural (not featureless) abdominal contour. It minimizes the creation of dead space, which often leads to postoperative complications, as well as preserves sensory nerve and blood supply to the abdominal skin. The operation may be performed with the patient under local anesthesia, which probably diminishes the risk for deep vein thrombosis. Moreover, additional procedures can be conducted safely and the postoperative course is short, uneventful, and without restrictions; patients return to normal activity within a week or so. New evaluation criteria for abdominoplasty are discussed in this article, the most important of which is the assessment of intraabdominal fat content and its impact on surgical outcome and the decision to perform anterior rectus sheath plication. The concept of a sliding, mobile, sensate abdominal flap, created by liposuction and sustained by multiple neurovascular mesenteries, is also offered.

Traditional abdominoplasty is associated with the potential for several problems. The procedure has been identified as a specific risk factor for deep vein thrombosis by Daane and Rockwell, Reinisch et al., and Stuzin et al. Dillerud  found that wide undermining causes skin necrosis. In addition, undermining necessitates prolonged postoperative suction drainage to avoid seroma, which is the most frequent complication of abdominoplasty. It has also been reported by van Uchelen et al. to produce sensory changes of the abdomen and thigh. Further, incisions are often long and geometrically designed, and tension may cause excessive scarring. In contrast, limited abdominal flap undermining, which has resulted in less morbidity, fewer complications, and shorter scars than the classic procedure, has been advocated for appropriate cases by Wilkinson and Swartz, Greminger, Eaves et al., Zukowski et al., Shestak, and Lockwood. 

Liposuction abdominoplasty is a safe and highly effective alternative to traditional abdominoplasty in appropriate patients. Dr Koo feels that the procedure has consistently and significantly reduced many of the problems that have been associated with classic abdominoplasty. Other related concepts are also offered: The successful outcome of abdominal wall surgery appears to depend on the preoperative evaluation of the intraabdominal fat content, and a sliding abdominal flap, created by liposuction, is mobile and has unique advantages in comparison with undermining.

Dr Koo almost always repairs the lax abdomen by repairing the split between the abdominus recti muscles that can be a result of weight gain, pregnancy, or simply present congenitally (at birth).  She will determine if your anatomy will allow her to be able to tighten the abdominal musculature and help tighten the rib cage even more.

Liposuction creates sliding flaps by dissecting free their fibrous/neurovascular mesenteries.  Abdominal flap mobility is obtained by fat removal, the transection of the cutaneous ligaments, and the stretching of the neurovascular mesenteries. The concept of a sliding flap, tethered by a subcutaneous pedicle, is not new; these flaps are used extensively in reconstructive surgery. Liposuction sliding flaps possess a rich blood supply, evident by the rarity of skin necrosis in the procedure; however, they are not safer than undermined traditional flaps. Clinical judgment should be exercised regarding the extent of liposuction, the thickness of the flap, and the degree of tension. Sliding flaps possess several advantages: they eliminate dead space, can be contoured, and are sensate. 

Anterior abdominal wall-tightening procedures such as rectus plication are performed to achieve a flat, nonprotuberant abdominal appearance. The intraabdominal contents consist of intraabdominal fat and organs; the fat includes both visceral fat and a substantial amount of retroperitoneal fat.  Normally, there are marked variations in the volume and position of the abdominal contents. Visceral position is affected by posture, respiratory excursions, and body build. Therefore, a postural increase in lumbar lordosis predisposes to a protruding abdomen even in a thin person.

With the exception of the anterior abdominal wall and the diaphragm/rib cage, most of the abdominal cavity has rigid and nonyielding boundaries. The superior boundary of the abdominal cavity is the diaphragm/rib cage; the inferior boundary is the pelvis. Lateral boundaries are the fleshy parts of obliqui, transverses, and the ilium and iliacus. The anterior boundary is the recti and aponeuroses of obliqui and transversi abdominis, and the posterior boundary is the lumbar vertebrae, crura of the diaphragm, psoas, and quadrati lumborum.  Thus, only the anterior abdominal wall and diaphragm/rib cage-and to a much lesser extent the waist between L-3 and L-5-are pliable and can accommodate an increase in the intraabdominal volume.  Furthermore, the abdominal cavity encloses a finite intraabdominal volume. Tightening of the pliable anterior wall pushes the intraabdominal contents (volume) against the only other pliable boundary, the diaphragm.

Dr Michele Koo, MD, FACS, St Louis, Missouri, 314-984-8331, is a Board Certified Plastic Surgeon and a Member of the Aesthetic Society. She wants you to know all the possibilties of body contouring to remove all that skin and junk hanging over your pants that has made you so depressed and uncomfortable for so long. She is extremely concerned with what it is YOU want and makes sure that you receive that result SAFELY.

The more you understand about the possibilities and risks of LIPOSUCTION, TUMMY TUCKS - ABDOMINOPLASTIES, the more Dr Koo feels that you will be prepared for the after care as well as understand your participation in the process to change your lifestyle, improve your mental outlook, and ultimately your quality of life.

The following is an exerpt from the Plastic and Reconstructive Surgery Journal, Vol 12 (4), April 2008, pp 1-11 by Jack Friedland, MD, et al.

Modern abdominoplasty techniques were developed during the last 40 years of the last century. Standard abdominoplasties include a transverse lower abdominal incision, wide undermining of the skin and subcutaneous tissue to the costal margins, tightening of the abdominal musculature with correction of rectus muscle diastasis, resection of redundant abdominal skin and subcutaneous tissue, umbilical repositioning, and skin closure. The introduction of liposuction has revolutionized the treatment of aesthetic deformities of the trunk and the extremities, but it only deals with the element of excess subcutaneous adipose tissue and does not confront the laxity of the skin or the irregularities of contour. Concentrating on aesthetic deformities of the trunk without considering their circumferential aspects (and those of the lower extremities) may lead to asymmetry and imbalance of the body aesthetic unit. Therefore, it is necessary to consider lateral and posterior truncal deformities and the deformities of the buttocks, hips, and thighs to obtain a successful result from body contour surgery.

An accurate assessment of the patient’s deformities and the technical expertise of the surgeon are essential components of successful body contour surgery. The surgeon must take into consideration all aspects of the patient’s medical history to determine the ideal course of treatment. Most patients requesting body contour improvement will be women who have given birth and are multiparous. Knowledge of the number of children and whether the woman has a history of caesarean section is important. The effects of smoking cigarettes on wound healing are well known and should be explained to the patient. Patients should abstain from smoking for a significant period before and after surgery. Significant medical problems that may affect the outcome of surgery include a history of hypertension, coronary artery disease, chronic obstructive pulmonary disease, diabetes mellitus, hepatitis C, and human immunodeficiency virus. A history of abdominal hernia and a thorough gastrointestinal history, such as irritable bowel syndrome or inflammatory bowel disease, should be covered. The female patient who has had more than one pregnancy is certainly more likely to have developed rectus muscle diastasis. Any woman requesting surgery should be questioned regarding her desire for future pregnancies. Most surgeons advise their patients to wait until their family has been completed before proceeding with definitive abdominal body contour improvement. An additional factor that is of significance is a history of intraabdominal operations. The location of scars is important in determining the plan of correction. In addition, a tall, lean individual will undoubtedly have an easier postoperative course and a different appearance than an obese, short individual, who may require more procedures than an abdominoplasty for body contour improvement. The patient’s weight should be stable for at least 3 months, and if he or she is overweight, it is advisable that they lose weight down to a desired goal before proceeding with surgery. This makes the operation easier for the patient to undergo and for the surgeon to perform (physical activities and exercises should be encouraged before surgery). It is extremely important that the physician knows about a personal and/or family history of deep vein thrombophlebitis, in addition to any other hemostatic problem. Knowledge of the intake of medications, whether prescribed or over-the-counter, and the ingestion of herbs and other products that may adversely affect the coagulation mechanism is important so that the patient may be instructed to discontinue them for an appropriate period before undergoing surgery.

The patient’s general appearance-especially the appearance of the abdomen, including the location of scars-should be documented, measured, and photographed. Although most infraumbilical scars are removed during abdominoplasty, supraumbilical scars can present certain problems, such as impaired blood supply of the superior flap, difficult dissection in the scar area, or patient dissatisfaction with the scar still visible postoperatively. The most common complication is fat necrosis under the scar, and possibly skin necrosis, dehiscence, or infection.

Adhesions of the skin at the level of the waist are not uncommon, and these bands can essentially divide the abdominal excess skin into superior and inferior segments. There is a significant risk of ischemia of the abdominal flap if extensive release of these adhesions is attempted; discontinuous undermining is preferable. If any herniae are present, their concurrent repair is essential for aesthetic improvement. This can be accomplished by either the operating surgeon or another surgical consultant.

Large herniae, such as ventral, umbilical, or incisional, may require complex repair before the performance of an abdominoplasty for aesthetic improvement, which would then subsequently be performed at a later date. Diastasis of the rectus abdominis muscles, whether mild, moderate, or severe, is usually corrected at the time of the abdominoplasty. All patients are concerned with stretch marks, most of which occur during one or more pregnancies and are located in the lower half of the abdomen, extending laterally to the flanks. Many of these will be removed along with the skin and subcutaneous tissue flap. There are some physicians who feel that they can be removed with external lasers, but the efficacy of that procedure has yet to be proven. The flaccidity and laxity of skin of the abdomen above the umbilicus is treated by redraping of the abdominal flap, although in severe cases, it may require a staged reverse abdominoplasty. Below the umbilicus, it is treated by redraping with excision of the excess skin and soft tissue along the inferior margin. Laxity of the adjacent areas of the flanks and thighs can be treated with liposuction, but in more severe cases, high-lateral-tension abdominoplasty procedures along with extension of the incision laterally should be considered.

An abdominoplasty, with or without suction-assisted lipectomy, is considered a major surgical procedure and must be approached systematically to avoid complications. Before surgery, the anesthesiologist will assign an aesthetic risk scale to the patient, but the surgeon should be aware of the guidelines that determine the American Society of Anesthesiologists classification of physical status. The scale is divided into four categories, depending on severity, as follows: American Society of Anesthesiologists class I, no risk factors; class II, minor risk factors; class III, serious risk factors; and class IV, life-threatening risk factors. A local anesthetic and/or local anesthetic with simple intravenous sedation is usually not satisfactory for the performance of an abdominoplasty. It is advisable to have the procedure performed under general anesthesia with an anesthesiologist in attendance to ensure patient comfort and safety. Use of wetting solution containing local anesthetics and epinephrine injected into the subcutaneous adipose tissue has significantly decreased blood loss and provided a more pain-free postoperative environment. Muscle relaxation during the procedure is essential if musculofascial tightening procedures are to be performed. All forms of anesthesia are associated with a relatively low incidence of complications, but the surgeon must be aware of all of them. The best prevention of complications is for the physician to be informed of the patient’s medical history, especially regarding drug allergies and experience with anesthetics. Postoperative nausea and vomiting is the most common complication after general anesthesia, which can be extremely debilitating for the patient and may have an adverse effect on fascial sutures if extreme vomiting occurs. In addition to routine antiemetics, propofol and dexamethasone have antiemetic properties that may be beneficial. Clinicians must be prepared with monitors, emergency drugs, and airway supplies to facilitate treatment of laryngospasm, intraoperative hypotension or hypertension, oxygen desaturation, bradycardia or other cardiac arrhythmias, seizures, and cardiac standstill to reduce the risk of long-term sequelae should a severe or toxic reaction occur during or after surgery.

Abdominoplasties can be performed on an inpatient or an outpatient basis. If performed in an outpatient facility, that facility should be accredited by the Joint Commission on Accreditation of Healthcare Organizations or the American Association for Accreditation of Ambulatory Surgical Facilities. Patients should be admitted for postoperative care to an accredited facility for observation, monitoring of vital signs, and pain control.

The time it takes to perform the operation depends on the extent of the procedure, including the performance of ancillary suction-assisted lipectomy and the treatment of other areas in addition to the trunk. There are no data to support a definite time limit in surgery; however, 6 to 7 hours appears to be the maximum surgical time for any one operation.

Proper preoperative planning is essential to avoid intraoperative and postoperative complications. Hypothermia is not an uncommon problem, especially when liposuction is performed in conjunction with abdominoplasty. The vasodilatation associated with general anesthesia, the large skin surface area, and the infiltration of cold solutions can all contribute to hypothermia. Care should be taken to warm the operating room and intravenous and wetting solutions and to use forced warmed air devices liberally. It is of paramount importance to address venous thromboembolism, a term referring to a spectrum of diseases that includes deep venous thrombosis and pulmonary embolism, in these patients.

Unfortunately, the patient’s first symptom is often fatal; therefore, prevention is the key to reducing the incidence of deep venous thrombosis and pulmonary embolism. Demographic risk factors include the following: a previous history of deep venous thrombosis or pulmonary embolism, history of malignancy, inherited or acquired thrombophilia disorders, obesity, heart failure, use of oral contraceptives, history of spontaneous miscarriages, pregnancy within the past 3 months, age older than 40 years, presence of varicose veins in the lower extremities, and recent surgery with use of general anesthesia.

It is important to educate the patient and provide informed consent about the risk of deep venous thrombosis and pulmonary embolism. Multiple methods have been studied and recommended for venous thromboembolism prophylaxis. Early ambulation and proper patient positioning are perhaps the simplest and most logical measures. Studies have demonstrated techniques to position the patient in such a way as to maximize venous flow through the legs and avoid external pressure. Aspirin has been used in the past; however, it has been felt that because of lower efficacy and high-risk profile (gastrointestinal and wound-related bleeding), is should not be recommended for the prophylaxis of venous thromboembolism. Graded elastic compression stockings have been shown to reduce the incidence of deep venous thrombosis by increasing venous return as a result of the constant pressure to the lower extremities. Studies show that their efficacy is greatly improved when combined with other modalities, such as low-dose unfractionated heparin or intermittent pneumatic compression stockings, and therefore they are not currently recommended for monotherapy. The use of intermittent pneumatic compression stockings on the lower extremities is essential. These devices reduce stasis by increasing venous blood flow, improving valve function, and reducing the distention of the vein walls. They also have a poorly understood mechanism of reducing the level of plasminogen activator-1, which in turn increases fibrinolytic activity.  Studies of general surgical procedures have demonstrated a 50 to 60 percent reduction in deep venous thrombosis with their use. The devices should be applied to all patients undergoing general anesthesia or procedures longer than 1 hour in duration. It is important to apply them 30 to 60 minutes before induction of anesthesia (because general anesthesia itself is associated with higher rates of venous thromboembolism) and should be continued postoperatively until the patient is fully ambulatory. Low-molecular-weight heparin and low doses of unfractionated heparin have been shown to reduce 65 percent of deep venous thrombosis and 50 percent of pulmonary embolism in abdominal surgery. Both forms work through inactivating two factors in the coagulation cascade-factor Xa and factor IIa (thrombin). The advantage of low-molecular-weight heparin is that it is dosed once daily, does not require coagulation monitoring, and has a lower rate of bleeding complications. In addition, because it does not bind to platelets, it is less likely to create heparin-induced thrombocytopenia. It is important to begin therapy 2 hours before or 12 hours after surgery to reduce the risk of bleeding complications. Several studies have shown that administering low-molecular-weight heparin preoperatively provides a protective effect during surgery and in the immediate postoperative period. There is a slightly higher risk of bleeding with preoperative dosing; therefore, the decision on when to give the first dose should be based on the patient’s individual risk-to-benefit ratio. Therapy is usually continued for at least a few days after active ambulation. Warfarin sodium (Coumadin; Bristol-Myers Squibb, Princeton, N.J.) is only recommended for patients with the highest risk factors. It is seldom used in plastic surgical patients because of its several drawbacks, which include a delayed onset of action, multiple drug interactions, and an increased bleeding and hematoma rate. The American College of Chest Physicians has devised a classification scheme that divides patients into one of four risk categories based on age, clinical setting, and known risk factors. Davidson et al. combined these recommendations with the risk assessment model of Caprini et al. to create an algorithm for venous thromboembolic prevention in plastic surgery patients.

The placement of the abdominoplasty incision depends on the type of abdominoplasty to be performed, whether it is limited or full, and whether the umbilicus is left in place or allowed to float. Traditional abdominoplasty is appropriate for patients with excess skin above and below the umbilicus, periumbilical hooding, excess fat, and diastasis recti. The basic steps include direct skin flap undermining from the xiphoid process to the symphysis pubis, with midline musculoaponeurotic fascial plication, translocation of the umbilicus, and dermolipectomy of the lower half of the flap to remove excess skin and fat in a vertical vector. Limited abdominoplasty, or miniabdominoplasty, is reserved for patients with excess skin below the umbilicus and moderate skin elasticity and tone. The technique was first described in 1986 by Wilkinson and Swartz and further refined 1 year later by Greminger. This group described a shorter incision compared with the traditional technique and limited undermining to the level of the umbilicus. Limited plication of the fascia can be performed up to the level of the umbilicus, and liposuction may be used above and below the umbilicus to help improve contour. An extension of the limited abdominoplasty is to float the umbilicus. This technique is used when the patient has minor to moderate skin and soft-tissue excess above the umbilicus that would not be addressed with the miniabdominoplasty yet is not severe enough to require a traditional abdominoplasty. Wilkinson described the technique in which undermining at the fascial level and release of the stalk allows the umbilicus to descend approximately 2 cm. This allows more pull on the abdominoplasty flap, which eliminates the laxity in the upper abdomen. If the distance between the dropped umbilicus and a high mons is too short, a mons reduction may be indicated to lengthen the hairless abdominal flap and place the scar within the pubic hair. High-lateral-tension abdominoplasty was described by Lockwood in 1995. This technique is used for those with excess skin at the lateral abdomen, lateral hip and thigh, and pubis, and also addresses the anteromedial thighs. The key principle that differentiates this technique from the traditional approach is to shift more of the skin resection from the central region to the lateral region. A more limited resection of central skin decreases tension on the suprapubic portion of the incision. When redraping the abdominoplasty flap, the vertical vector is directed inferolaterally, allowing more extensive resection of skin laterally and directing most of the incision tension toward the lateral aspects, which in turn is supported by the superficial fascial system closure. Direct undermining is limited, with more emphasis on extensive discontinuous undermining, which allows for wider use of liposuction.  Fleur-de-lis abdominoplasty was first popularized by Dellon in 1985. This pattern of resection incorporates Castanares and Goethel’s vertical wedge incision in the upper abdominal midline with Regnault’s shallow-W excision. More specifically, the approach addresses resection of not only the vertical but also the horizontal abdominal excess, leaving both a midline and traditional abdominoplasty scar. When combined with the high-lateral-tension procedure, the results can be even more effective. Reverse abdominoplasty was first described in the Brazilian literature by Rebello and Franco in 1972 and further in 1978 by Baroudi. This procedure is usually reserved to address residual redundant tissue in the superior abdomen after any type of lower abdominoplasty has already been performed. The procedure can easily be combined with a mastopexy or breast reduction because both techniques use the same inframammary incision. Endoscopic abdominoplasty is reserved for those patients with good skin elasticity, true diastasis recti, and little or no excess skin or subcutaneous tissue.

Dr Koo feels there are very few applications for true endoscopic abdominoplasty as the majority of patients require some amount of skin removal and not just the repair of the rectus muscles.

Musculofascial repair is performed in almost all types of abdominoplasty techniques. Although the incidence of true diastasis recti has been reported to be quite low, most women have laxity secondary to prior pregnancies.  Plication of the fascia is typically in a midline fashion; however, a combination of vertical, horizontal, and/or oblique plication has been advocated based on the musculoaponeurotic deformity.

Umbilicoplasty is important to manage correctly. Multiple techniques have been described to produce an aesthetically pleasing navel, which includes a pronounced dimple, invagination of surrounding tissue, and slight superior hooding. Underlying fat is usually resected from the chosen site and a skin incision is made, varying from a single slit, ellipse, diamond, or teardrop shape. Various flaps have also been described to create the new umbilicus. The umbilicus should be placed approximately 9 to 12 cm above the superior margin of the mons pubis, located slightly above a line connecting the anterior and superior iliac spines.

Dr Koo usually always places subcutaneous suction drains during abdominoplasties to prevent the formation of seromata. Most prefer to place at least two drains, with their orientation and exit points varying, depending on surgeon preference. The drains are usually removed when there is less than 30 cc of aspirate collected in each drain over a 24-hour period.

Routine wound dressings vary from the placement of Steri-Strips (3M, St. Paul, Minn.), gauze over the incision, and a bolus and stent over the umbilicus, to circumferential compression by an elastic abdominal binder or an appropriately sized elastic compression girdle (with lower extremity extensions if additional contour procedures have been performed). Some feel that the use of compression garments does not affect long-term outcome but believe they produce beneficial effects in the immediate postoperative period. Care must be taken to not place abdominal binders too tight, because they can compromise perfusion to the skin flap and/or increase intraabdominal pressure.

Liposuction in combination with abdominoplasty has long been a controversial topic. Combining both procedures has been reported to magnify the potential for thrombotic or fat embolic problems. It has also been associated with increased complications if performed in patients identified as having high-risk factors, such as obesity, smoking, and diabetes mellitus. If direct undermining is performed and the abdominal wall is liposuctioned, one risks further impingement of the vascular supply, with increased potential of skin or soft-tissue necrosis. For this reason, some advocate liposuction of the hips only and refrain from epigastric and saddlebag area suctioning. The blood supply of the abdominal wall is divided into three zones: zone I, in the midabdomen and supplied by the deep epigastric arcade; zone II, in the lower abdomen and supplied by the external iliac artery; and zone III, consisting of the flanks and lateral abdomen and supplied by intercostal, subcostal, and lumbar arteries. Abdominoplasty sacrifices the blood supply in zones I and II, leaving the flap perfused by perforators in zone III and from collateral flow from the superficial circumflex iliac artery in zone II. Safe zones for liposuction in combination with abdominoplasty on the basis of this blood supply have been described. Safe areas are considered lateral and superior, whereas the central medial flap should be suctioned with caution.  When liposuction is performed, it is recommended that the superficial fat compartment be avoided and that one stays below Scarpa’s fascia to limit vascular compromise and contour irregularities.  The introduction of Lockwood’s high-lateral-tension technique, which limits direct undermining and preserves blood supply to the abdominal wall flap, has enabled surgeons to use liposuction more liberally in conjunction with abdominoplasty.

Early complications include infection, skin necrosis, umbilical necrosis, seroma, and prolonged edema. The order of occurrence varies in the literature, but the most commonly reported complications are wound infection, dehiscence, hematoma/seroma, and skin loss. Not surprisingly, the incidence of these complications is higher in smokers, patients with diabetes or hypertension, and obese patients. Some have reported an alarmingly high incidence of injury to the lateral femoral cutaneous nerve. The frequency of most complications appears to be inversely related to the surgeon’s experience. Most surgeons place patients on prophylactic antibiotics, administered intravenously before and during the surgical procedure, and oral supplements during the immediate postoperative period. The high level of methicillin-resistant Staphylococcus aureus infections encountered in some surgical facilities indicates the need for prophylactic antibiotic administration in these locations. Skin necrosis occurs as a result of decreased blood supply caused by increased tension, excessive thinning of subcutaneous tissues, or the presence of obesity-related comorbidities. Seromata can best be prevented by the placement of postoperative drains. Some surgeons place quilting sutures, attaching the undersurface of the adipose tissue of the abdominal flap to the anterior surface of the underlying muscular fascia in an attempt to decrease the empty space.  Preserving a thin layer of adipose tissue on the fascia in an effort to preserve some lymphatic drainage has also been reported. Seromas can be treated with percutaneous aspirations, placement of a subsequent drain, or open surgical evacuation. Protocols for the use of medications, such as doxycycline, used to sclerose seromas has also been discussed.

Uneventful healing and a good cosmetic result is almost always the case, but occasionally reoperation to correct hypertrophic scarring, suprapubic deformity, umbilical deformity, excision of excess residual abdominal skin or subcutaneous adipose tissue, secondary correction of rectus diastasis, or additional lipoplasty to improve a contour irregularity of the abdominal wall may be necessary. It is useful to establish parameters of success and to discuss these with the patient before surgery. A realistic date for return to work and physical activities should be established and ideally agreed on before surgery. If the patient is satisfied with the result of surgery, the physician is almost always satisfied as well. However, self-evaluation for improvement by the physician should be considered if it is felt that a second operation is necessary to further manage and improve the patient’s residual deformities.

DR MICHELE KOO, MD, FACS, hopes that the above information is helpful in understanding the risks and complications that are involved with a liposuction and an abdominoplasty and feels it is therefore extrememly important that you as a consumer be aware of who your plastic surgeon is and their qualifications. It is important to be a Board Certified Plastic Surgeon.

She feels it is important that you are totally informed of all your options and that the procedures are extremely safe and can be so very beneficial for reshaping and changing your entire body, but that it is a process and sometimes a lengthy recovery and that you may even require several surgeries.

BEGIN YOUR NEW LIFE, LET DR MICHELE D KOO, MD, FACS, SHOW YOU THAT THE POSSIBILITIES ARE ENDLESS IN CHANGING YOUR SHAPE AND SIZE!!!  314-984-8331 ST LOUIS, MISSOURI.

BEFORE BREAST AUGMENTATION 34A

AFTER BREAST AUGMENTATION 34D

DR.  MICHELE KOO, MD, FACS MISSOURI, ILLINOIS, KANSAS, 314-984-8331

Dr Koo feels that there are certain facts that you should know about breast augmentation and breast implants and she wants you to be well informed. The better informed you are, the better your results will be as she will be able to communicate with you as to what your possibilities are. Her time is your time and she wants your surgery to be as perfect as it can be and that the size, shape, and look of your breasts will be exactly what you picture in your mind.

The following is an article in the Plastic and Reconstructive Journal that Dr Koo wants you to have access to by Dr William Adams of University of Texas Southwestern Medical University, December 2008. Dr Koo has her own techniques that are variants what is mentioned in the article but wants you to understand the preparation and techniques that go into determining your ultimate choice of implants, size, position, shape, and look of your breasts.

A process is defined as a group of practices that are completed successively to reach a goal. For 45 years, breast augmentation has been thought of as an isolated surgical procedure; however, well-documented elevated reoperation rates of 15 to 24 percent over 6 years in successive premarket approval studies have resulted in a critical analysis of this procedure. Factors that impact outcomes have been identified and practice recommendations have been established.

Background: Breast augmentation has been an integral part of plastic surgeons’ practices for over 40 years. Although devices have evolved, patient outcomes are still not ideal, as documented in multiple premarket approval clinical trials. Unlike many other areas of surgery, the practice of breast augmentation has suffered from the lack of a defined process for patient management. The purpose of this study was to clinically define and evaluate the process of breast augmentation and analyze patient outcomes using these practices compared with existing premarket approval trial data.

Methods: Three hundred consecutive primary breast augmentations from 2001 to 2005 were followed prospectively. Each patient underwent a defined process of breast augmentation including structured patient education and informed consent; tissue-based preoperative planning consultation; refined surgical technique; and structured postoperative instructions, management, and follow-up.

Results: The mean follow-up was 2.1 years. The most common complications were rippling and palpability, soft-tissue stretch, and hypersensitivity. The overall reoperation rate was 3.7 percent for the entire group and 4.7 percent and 2.9 percent for saline and form-stable cohesive gel implants, respectively.

Conclusions: Optimizing patient outcomes in breast augmentation requires defining the overall process to allow for enhanced patient outcomes. This is the first report that defines and integrates the entire process comprehensively that is validated by outcomes data. This process is transferable to other surgeons and, using this algorithm, patient outcomes in this study were superior to premarket approval clinical trial data. In summary, approaching this procedure with a global process produces superior patient outcomes in breast augmentation.

Dr Michele Koo, MD, Board Certified Plastic Surgeon, St Louis, Missouri, 314-984-8331.

Breast augmentation is an extremely popular and safe surgical procedure that 100’s of thousands of woman have undergone without any complications. The majority of these woman are extremely happy and would choose to have to surgery again if given the choice to do over again. In 2007, the FDA again allowed the use of silicone gel implants for elective breast augmentation for cosmetic reasons.

However, with time and aging of the implant, the breasts may change and the implant become encapsulated (scar formation around the implant). The breasts may become hard and misshapened and painful. The breasts may become too saggy and heavy and extremely uncomfortable for the woman.

Breast implant removal and replacement along with a breast lift is very safe and often a normal sequelae to breast augmentation that is over 15-20 years old. The recommended life of a saline or silicone implant is approximately 15-20 years. Whether a breasts starts to show the changes of encapsulation (hardening) and pain depends on where the original breast implants were placed, the original type of implant, and, of course, the patient herself.

The surgery that needs to be performed to change the breast implants is largely dependent on what was done at the time of the original surgery, whether the implant was placed under the breast or under the muscle, what type of implant was used, and what the breasts look and feel like in its current condition.

A breast implant exchange or a complete breast implant removal without an implant replacement can be performed. If the breasts have become saggy and have fallen so that they are too low on the chest, a breast lift may have to be performed at the same time as the breast implant replacement or removal. All of the above procedures can be performed very safely in one procedure by DR MICHELE KOO, MD of St Louis, MISSOURI, 314-984-8331.

There are a few points that Dr Koo wants you to understand about breast implants and breast augmentation according to an article by John B Tebbets in the Journal of Plastic and Reconstructive Surgery.

Factors That Affect Responses to a Breast Implant

Every medical device implanted into the human body is placed in an environment where certain factors cannot be predicted or controlled by the surgeon or the patient, especially factors related to a patient’s individual wound-healing characteristics and the genetic characteristics of each individual patient’s tissues.

A breast implant has a range of effects when placed into the body, effects that continue for the entire time the device is implanted. Short- and long-term effects of a breast implant in the body depend on three different sets of factors: device-related factors, surgery-related factors, and factors related to the patient’s wound-healing and genetic tissue characteristics. Surgeons and patients have some level of control over device-related and surgery-related factors, including implant type and size, maximal soft-tissue coverage over the implant, and optimal surgical techniques to minimize tissue trauma and bleeding. Neither surgeons nor patients, however, can predict or control patient wound-healing and genetic tissue characteristics.

Factors That No Surgeon or Patient Can Predict or Control

No surgeon or patient can predict or control a patient’s wound-healing characteristics or a patient’s genetic tissue characteristics, factors that can affect outcomes following breast augmentation. Each patient has unique, individual wound-healing and genetic tissue characteristics that influence the interaction between a breast implant and the surrounding tissues. Individual wound-healing characteristics influence the characteristics of the capsule or lining that forms around every breast implant and affect the degree to which that capsule tightens or contracts, which in turn determines whether capsular contracture will cause excessive firmness of the breast or other deformities. A patient’s wound-healing characteristics may also affect the quality of incision scars, the risks of infection or fluid production around an implant, and other factors that can affect the aesthetic result. Genetic and hormonal effects of pregnancy and nursing vary from patient to patient and can affect aesthetic results and outcomes.

A patient’s genetically determined tissue characteristics can affect the response of the patient’s tissue to the implant, including how much the skin will stretch and thin in response to a specific size implant and how the breast tissue overlying the implant will respond. Surgeons and patients can avoid selecting excessively large implants, but even an appropriate-size implant for a patient’s visible tissue characteristics may cause excessive stretch of the breast skin envelope in patients whose tissues do not adequately support the weight. Unfortunately, surgeons have no tests available to predict a patient’s wound-healing or tissue responses to a breast implant. As a result, no surgeon can predict or control the occurrence or severity of capsular contracture, infection, tissue stretch deformities, or other conditions relating to patient wound-healing and tissue characteristics.

Reoperations: The Risks, the Tradeoffs, and the Logic

Every additional reoperation that is required following placement of breast implants imposes additional risks, costs, and tradeoffs to the patient. Some reoperations are medically necessary, but others are not. Severe capsular contracture, infection, and fluid accumulation around an implant are medical reasons to perform an additional operation. A patient’s request for a size change to a larger or smaller implant, though desirable to the patient, is not medically necessary and imposes risks and costs that may not be logical medically. For example, although the risk of infection with implant exchange is small, it is not zero, and for the patient who experiences such a complication, the incidence is 100 percent and may require implant removal without replacement or may produce an uncorrectable deformity.

Every reoperation causes additional surgical trauma and bleeding, and healing after each additional surgery produces more scar tissue, the effects of which are uncontrollable. Seemingly simple operations such as a minor revision for implant malposition or excessive stretch, though usually safe, invoke healing mechanisms that are uncontrollable and can result in exchanging one deformity for another. Logically, reoperations should not be performed for reasons that have no medical necessity or to address relatively mild aesthetic conditions where the risks and effects of the surgery might possibly produce a change that is worse or different compared with the existing condition.

Implant Removal without Replacement: The Logic

Breast implants are not medically necessary devices. Regardless of the efforts and costs to place breast implants, if certain conditions or complications occur, continuing to attempt to salvage the implants or leaving implants in place can cause permanent damage to a patient’s tissues, producing deformities that are uncorrectable.

Once a patient has breast implants, virtually every surgeon and patient wants to keep the implants in place. The positive effects of implants make some patients unwilling to even consider removal without replacement under any circumstances. Removal without replacement must be a joint decision of the patient and surgeon, both of whom must recognize and acknowledge that the aesthetic consequences of removing implants may be far more preferable to possible permanent, uncorrectable deformities and additional reoperations with additional costs and risks if the implants are left in place. Surgeons and patients should define criteria for removal without replacement before the patient has a breast augmentation, and the patient should understand and document her acceptance of these conditions in informed consent documents. A surgeon’s willingness to adhere to stringent criteria for reoperations directly influences reoperation rates, risks, tradeoffs, and costs to the patient.

Unilateral versus Bilateral Implant Removal

When a condition requiring implant removal occurs unilaterally, removal of one implant creates a deformity (asymmetry) that virtually guarantees at least one reoperation to replace the implant. Unilateral implant removal encourages patients and surgeons to prioritize implant replacement, often sooner than is medically optimal. Unilateral implant removal can compromise future decisions and the timing of those decisions. When removal is indicated, bilateral implant removal totally avoids these compromises and eliminates a demand for reoperation based on asymmetry.

Implant Removal without Replacement: The Criteria

Every surgeon must define personal criteria for implant removal without replacement, based on clinical experience, medical indications, and logic. On the basis of more than two decades of experience, I recommend breast implant removal without replacement for the following clinical conditions or situations, and I require that every patient accept and acknowledge these criteria in informed consent documents before the primary augmentation

* Recurrence of capsular contracture after having performed a complete capsulectomy and implant replacement with a new (textured saline if the primary was silicone gel filled) implant for a first capsular contracture of grade III or IV (limits total reoperations for capsular contracture to two).

* Recurrence of stretch deformity (bottoming, lateral malposition) after having performed a previous capsulorrhaphy, partial capsulectomy (if indicated), and exchange to a smaller implant (limits total reoperations for stretch to two).

* Traction rippling or visible implant edges medially when there is no additional tissue coverage available locally (e.g., conversion of submammary to subpectoral), or when pectoralis coverage has been previously compromised by division of medial pectoralis origins.

* Culture-documented contamination or infection of the periprosthetic pocket, regardless of implant type or pocket location (any occurrence of documented infection). This approach optimizes rapid resolution and minimizes inflammatory effects on tissues that occur with prolonged salvage efforts, effects that may produce significant and sometimes uncorrectable tissue deformities over time. Further, this approach minimizes the risks and costs of future reoperations attempting reimplantation, and it eliminates reoperations for recurrent infection or capsular contracture that can occur after attempted reimplantation.

* Recurrent seroma, regardless of negative cultures, after treatment of an initial seroma with exploration, capsulectomy (if indicated), and prolonged drainage.

* Inadequate soft-tissue coverage, when pinch thickness of tissues covering any area of the implant is less than 0.5 cm (except when coverage deficit is medial or superior and can be improved by dual plane or retropectoral implant placement).

* In any situation where two previous reoperations have been performed, for any reason (limits reoperations to three, including removal without replacement).

Criteria to Limit Reoperations

The following criteria have evolved over more than two decades to limit reoperations with their inevitable risks, tradeoffs, and costs:

* No reoperations for implant size exchange if not medically necessary (e.g., a slightly larger implant after performing a capsulectomy, provided adequate soft-tissue coverage is available).

* No reoperations for grade II capsular contracture.

* No reoperations for minor stretch deformities [<3 cm of additional widening of the intermammary distance due to lateral envelope stretch, <2 cm of elongation of nipple-to-inframammary fold distance (bottoming) 6 months or more postoperatively regardless of emptying of upper breast or slight excess volume in lower breast].

* No reoperations to adjust nipple-areola position if sternal notch-to-nipple distances are within 1.5 cm bilaterally (for either primary or secondary procedures).

* No implant replacement if patient has previously required bilateral implant removal for any condition or suspected condition, including replacement of saline-filled implants following removal of silicone gel-filled implants to address concerns of connective tissue disease or other undefined symptom complexes or psychological conditions.

* No reoperations if patient is unwilling to sign detailed informed consent documents acknowledging that she understands and accepts that every reoperation involves additional risks, tradeoffs, and costs, that correction of any condition by reoperation is not guaranteed, and that with any reoperation, we may exchange one set of problems or compromises for a different and not necessarily better set of conditions.

Results

The above-described criteria, combined with implant selection based on quantifiable tissue characteristics and more detailed patient education and informed consent were applied in 1662 reported cases using textured, saline-filled breast implants with up to 7 years of follow-up. The resulting overall reoperation rate was 3 percent. Acknowledging the limitations of comparing the studies, this 3 percent overall reoperation rate at up to 7 years compares favorably to the overall reoperation rates of 13 and 21 percent at 3 years in the saline premarket approval studies of Mentor and McGhan and to the 20 percent reoperation rate at 2 years in the most recent silicone gel premarket approval submission by Inamed Corporation.

Discussion

Factors such as the surgeon’s experience, the surgeon’s technical skill, the reasons for reoperations (device-related versus surgery-related), and other factors preclude direct, scientifically valid comparisons between our reoperation rates and those of the premarket approval studies. Nevertheless, the large clinical experience with long-term follow-up reported in our studies includes every reoperation for any reason, similar to the premarket approval study results. In the premarket approval study, capsular contracture was categorized as a device-related reason for reoperation when in fact surgical tissue trauma and bleeding are significant if not major stimuli for capsular contracture. A reoperation is a reoperation, regardless of whether the patient requests it for size change or an improvement in aesthetics. Selective categorizing and analysis to shade interpretation of results and causes is largely nonproductive, if reducing reoperation rates is a goal. By defining and implementing out points and decision and management algorithms, we have dramatically reduced reoperation rates in our practice over the past two decades.

Conclusion

To reduce the rate of reoperations, with their inevitable risks, tradeoffs, and costs to patients, and to reduce the incidence of tissue-compromising deformities resulting from multiple reoperations, surgeons must define strict criteria for reoperations following breast augmentation and for bilateral implant removal without replacement. The criteria described in this article resulted in overall reoperation rates that are substantially lower compared with overall reoperation rates in recent large premarket approval submissions to the Food and Drug Administration. Each surgeon must define criteria according to his or her individual surgical experience and practice characteristics, but current Food and Drug Administration rulings and guidance suggest that continued availability of breast implant devices for patients demands that patients experience lower reoperation rates.

Dr Michele Koo feels very strongly that her patients can benefit from primary breast augmentation for elective cosmetic reasons as well as from breast implant revisions should the need arise. However, as the article above emphasizes, re-operation for breast implants have certain risks and complications that are out of the control of the surgeon and the patient. Dr Koo wants the best outcome for her patients and she feels that the better informed one is when going into the initial surgery, the easier it will be for all subsequent surgeries.

Dr Koo wants her patients to understand that no matter how pleased you may be with the original breast augmentation or revision surgery that once a breast implant is used, that will then obligate you to subsequent surgeries whether it is for an implant replacement after many years, or whether it is due to your breasts changing shape and size after children or weight gain and loss.

Dr Michele D Koo, MD, FACS, St Louis, Missouri, 314-984-8331, Board Certified Plastic Surgeon, Member of the Aesthetic Society believes that weight loss after pregnancy can be achieved with sensible eating habits and increasing one’s activity level. She does not think that one should worry about the weight gain during the pregnancy as long as your OB-GYN is following your rate of weight gain and which trimester you gain the most weight.

Fat deposits and weight gain is a normal part of pregnancy and is necessary for the healthy development of normal birth weight newborn. Fat accumulates during pregnancy in the same areas that plague most women even when not pregnant. The most common female areas of fat accumulation are the abdomen, hips, waist, inner and outer thighs.  The areas of fat accumulation are genetically determined that cannot be altered with diet and exercise. These are the areas that increase in size first any time there is any weight gain regardless of pregnancy.

The fat that is accumulated with pregnancy is a rapid weight gain type of fat that increases the size of the fat cells over a short period of time. There usually is not enough weight gain of 75 lbs and up that might actually stimulate the body to trigger the cells to multiply and increase the actual number of fat cells.

Short term weight gain such as with pregnancy should actually be easier to lose than weight that has accumulated over a long period of time.  Fat that has accumulated over a long period of time of years may be a result of an increase in number of fat cells and even fat deposit in the composition of muscle and internal body fat gain.

The body’s physiology may also have been altered in terms of its insulin release and response patterns, fat storage, other endocrine functions, and possibly set points for “normal weight.� However, during the post partum period, the woman may be recovering and exhausted from a newborn and perhaps other small children and attempting to return to work, and, therefore, not really devoting time and energy into healthier eating and exercising habits.  The weight then seems to be extremely “stubborn� and resistant to exercise and weight loss, but in fact the fat is very readily reduced with the same diligent adherence to exercise and healthier eating.

It is my opinion that if after 1 to 2 years post partum, a woman has not lost all of her pregnancy weight, she will not be able to do it. More importantly, even if she achieves her pre-pregnancy weight, she will not look the same unless all of the skin has tightened which becomes less and less likely with each subsequent pregnancy.

My recommendation to my patients is that, they wait 6-12 months after they have stopped breast feeding or at least 6-12 months after delivery prior to undergoing any liposuction procedure as at that point, the post partum weight is relatively stable.

It has been my experience, however, that most women after pregnancy will need some type of skin removal procedure, i.e., tummy tuck, breast lift in addition to liposuction to achieve what they are looking for. The likelihood of needing a skin resection procedure increases with a C-section and increases with the number of children a woman has had.  I discuss this at length with my patients, the pros and cons of the permanency of the scar versus the great shape that can be achieved with the addition of the skin removal.

My patient’s ultimate goal of how flat she wants her abdomen or smooth her thighs will determine whether she would be better served with liposuction alone or liposuction with skin removal. The amount of time to recover after a liposuction is not any different for post partum patients; the amount of time to recover is dependent on the amount of fat removed and the number of areas liposuctioned.

With each pregnancy there will be weight gain and skin stretching; if one is considering any kind of plastic surgery for post partum changes for unwanted fat and skin, one might want to wait until they are completely finished with having children. The most important thing that one should always know is, “that there is nothing that pregnancy or weight gain can do that Dr Michele Koo can’t fix.�

DR MICHELE D KOO, MD, FACS, ST LOUIS, MISSOURI, 314-984-8331 for individualized personal care that will change your life and let you take charge of your own destiny.

BEFORE JUVEDERM ULTRA PLUS INJECTION

AFTER JUVEDERM ULTRA PLUS INJECTION

Introduction