An abdominoplasty or “tummy tuck” does require general anesthesia and can take up to several hours in the operating room. The length of time for the operation depends on the amount of skin that needs to be removed and how large a tummy you have.

If you are of “good health,” that is, if you do not have health problems with your heart and lungs, and have been cleared of any previous heart and lung problems, then you are a candidate for a tummy tuck or what I call a MOMMY MAKEOVER.

You also MUST be cigarette smoke free for at least 2 weeks before and for 2 weeks after the surgery. In fact, better results are had by those who don’t smoke at all in terms of better incision healing and fewer wound healing complications.

During a tummy tuck, I repair the rectus muscles that have become split as a result of pregnancy or perhaps were split even from birth. The result is a trimmer shape and waistline!

It is misleading to think that you will be able to sustain your new shape and size after plastic surgery if you are not willing to change your eating habit and/or exercise habits. While I will change your body absolutely remarkably in a way that you couldn’t have with diet and exercise alone, your shape will not be maintained if you don’t watch what you eat afterward.

My suggestion then is to get into the habit of at least walking 2-3 times a week to begin with for 10-15 minutes at a time. Once you get used to that level of activity then you should progress to at least 30 minutes 3 times a week then to everyday.

When I speak of changing eating and lifestyle habits, it can be as simple as portion control and giving up regular soda and skipping dessert 2-3 days a week and limiting the amount of carbohydrate intake without giving it up entirely.

A tummy tuck is an absolutely EXCELLENT way of getting rid of all your excess skin, stretch marks and fat that overhangs your midriff after children or weight fluctuations. In fact, it is the ONLY way to get rid of all that excess skin. You can lose the weight and tone up the abdomen with exercise and diet but  become extremely frustrated and discouraged when you see that torso has not changed one bit and in fact may look worse with the weight loss, when the skin looks even more saggy and flaccid.

Many of my patients such as yourself will come for a consultation when their weight loss or shape change plateaus with the exercise and diet and want to know what more can be done. This is an extremely important time not to “fall off the wagon, become discouraged” and bounce back to your previous  destructive eating binges and habits.

This is an ideal time to intervene with plastic surgery which can take you to the next level of a healthier lifestyle and new body. The tummy tuck is the “kick in the rear” that you need to stay on track and to maintain your healthier lifestyle.

When you can actually SEE the results of all your hard work with an incredible new body shape, you are much more willing and likely to maintain this new lifestyle permanently.

I hope this is encouraging and helpful and I will write more on the costs and recovery in my next MOMMY MAKEOVER BLOG.

If you are sick and tired of being trapped by your saggy, lifeless, flat breasts and hanging skin with stretch marks after pregnancy and breast feeding there is something you can do about it.

Plastic surgery to remove all that excess skin and fat and lift your breasts to their original position with fullness on top can be achieved safely.

If you are looking for a MOMMY MAKEOVER, you have found the right person in Dr Michele Koo, MD, FACS, St Louis, MO, who is a Board Certified Plastic Surgeon. She will listen to exactly what you want and be able to get rid of that frustrating hanging large belly that has made you depressed for years with liposuction and a tummy tuck (abdominoplasty). At the same time you can address your breasts which may have lost most of the nice sexy full volume and is now hanging on your abdomen. She will examine you and determine if you need a breast lift alone or a breast lift along with a breast implant (breast augmentation) to achieve that full, firm, sexy and lifted breast that you used to have.

MOMMY MAKEOVERS addressing the breasts and tummy in one operation is very safe and Dr Koo will let you know how much can be done at one time safely, and whether you can achieve what you are looking for with only a breast augmentation and liposuction or if you need more contouring by removing skin with a breast lift and tummy tuck.

One of the most important aspects in the success of any surgical procedure is the physical condition of the patient at the time of surgery. Even though liposuction, breast augmentation and a tummy tuck are elective procedures, Dr Koo assesses you using the same standards as those used for anyone who is undergoing any type of surgery. This is very important for your safety and well being. Dr Koo emphasizes your safety above all and ensures that you will have an excellent outcome safely.

Dr Koo specializes in contouring the body after pregnancy and weight loss. She obtains a thorough medical history from all patients who are to undergo a MOMMY MAKEOVER and a diligent physical examination is performed. Surgical history, including previous procedures is obtained for the YOUR safety.

Patients with comorbid conditions such as tobacco use, hypertension, coronary artery disease, chronic obstructive pulmonary disease, diabetes mellitus, hepatitis C, and human immunodeficiency virus are screened carefully. Patients with a history of pulmonary embolism, deep vein thrombosis, or blood clotting disorders require added precautions, such as chemoprophylaxis and sequential compression devices.

Dr Koo uses sequential compression devices in the majority of liposuction, tummy tuck, and breast lift and breast augmentation procedures. Conditions that may increase the risk for deep venous thrombosis include chronic venous insufficiency, family history of thrombotic syndromes, obesity, trauma, severe infection, polycythemia, central nervous system disease, malignancy, homocystinemia, a history of pelvic or lower extremity radiation therapy, and use of birth control pills or hormone replacement therapy.

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.

MOMMY MAKEOVER BLOG continues on next Blog

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.

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.

Dr Michele Koo, Board Certified Plastic Surgeon, in the St Louis, Missouri area specializes in body contouring and liposuction to remove excess skin and stretch marks that can occur after massive weight loss or pregnancies.

Dr Koo of St Louis, Missouri sees patients from all over Missouri, Kansas, Illinois and the United States for body contouring, liposuction, and specifically removing significant amounts of excess skin.

There has been tremendous growth in the number of patients seeking body contouring procedures after massive weight loss. Most patients desire improvement of the abdominotorso region first. After massive weight loss, there is enormous variability of body proportions, and therefore Dr Michele Koo will present many surgical options based on the quality of the skin, subcutaneous fat component, and location of the lax tissue. Each area needs to be assessed to see whether there is a significant lower abdominal component, an upper midline abdominal component, or contributions from the buttocks and flanks. 

Dr Koo is a Member of the Aesthetic Society, and will discuss all of the options available to the patient for removing the abdomen skin, thigh skin, entire lower body skin or whatever different combinations of liposuction and skin removal procedures are necessary to regain the shape to the patients’ torso, waist, and entire body.

Dr Michele Koo, MD, plastic surgeon, will repair the rectus abdominus muscles that may be separated in your abdominal area which adds to the laxity of your abdomen when she performs the tummy tuck (abdominoplasty). The roundedness of the abdomen and loss of the waist may be due to the complete loss of support in the entire abdomen area and a flat stomach can be regained with a tummy tuck (abdominoplasty) when the muscles are sutured back together in the midline thereby supporting the back and abdominal contents.

If the patient also has excess skin in the thigh and buttock regions, Dr Koo will stage and prioritize the body rejuvenation as to whether to address the abdomen first or the lower body first depending on which area aggravates the patient the most and where the most excess skin is.

As a result of the increasing popularity of bariatric surgery, plastic surgeons are treating greater numbers of massive weight loss patients. These patients typically lose more than 100 pounds and have significant skin laxity with varying amounts of subcutaneous tissue excess. Commonly, the abdominotorso region is treated first; it often gives patients the most grief. The overhanging pannus may predispose this region to rashes and can make it difficult for patients to wear properly fitted clothing.

It is rare for a massive weight loss patient to undergo just a full abdominoplasty; treatment of the flanks and buttocks has become common. Therefore, many patients require a more involved procedure such as a circumferential abdominoplasty or even one that uses a fleur-de-lis approach.

Dr Koo will have a discussion with the patient regarding their surgical goals, the various surgical treatment options, and the impact that their medical conditions can have on the surgical outcome. Surgery is usually delayed until the weight loss has plateaued; for a bariatric surgery patient, this is usually after at least a 100-pound weight loss or longer than 1 year after the gastric procedure. Sometimes, surgery is performed sooner for a patient who requires a panniculectomy to assist in the management of other conditions.

The patient is first examined in supine position and evaluated for hernias and the extent of rectus diastasis. A patient that has had an open abdominal procedure has an increased risk of hernia formation. A massive weight loss patient may have an excess subcutaneous fat component, which can make palpation of a hernia difficult. Therefore, the hernia can remain hidden (occult) until the time of surgery.

The patient is then examined in the standing position. The abdominal region is evaluated for skin laxity and the extent of the subcutaneous fat component. Often, the patient will have striae, poor skin elasticity, and recalcitrant rashes not amenable to conservative treatment. A pinch test is performed in a horizontal fashion to evaluate the amount of tissue that can be excised. The horizontal pinch is performed on the lower transverse abdominal tissue that would be excised commonly during a routine full abdominoplasty. The laxity and quality of the skin are evaluated in a vertical dimension in the supraumbilical region as well. Using the vertical upper abdominal midline as a reference point, a vertical pinch is performed pinching tissue from each side of the midline to evaluate the upper abdominal midline excess and laxity. If a vertical pinch improves the upper abdominal waistline and can eliminate supraumbilical fullness, the possibility of performing a vertical midline incision is discussed. The threshold for using this additional incision is lowered if the patient has a preexisting paramedian or midline vertical scar.

The patient is then examined for mons pubis ptosis. This is marked in accordance with Baroudi’s description, leaving a 5- to 7-cm length from the vulvar commissure to the top of the mons pubis.  The patient is evaluated in a right lateral, left lateral, and posterior standing position using the horizontal pinch test to evaluate the impact the pinch has on lateral and anterior thigh laxity and buttock ptosis.

Dr Michele Koo, MD, St Louis, MO believes that the preoperative examination is essential because there is tremendous variability of skin quality, amount of the subcutaneous fat, and distribution of tissue laxity in these patients. Furthermore, it is during this period when the risks, benefits, and alternatives of all procedure options can be discussed thoroughly with the patient. She feels it is very important that the patient fully understand the lenghthiness of the surgery, recovery period, and the overall risks that come with this body rejuvenation process. She feels that the surgeries can be very safe but wants the patient to understand the emotional and physical comittment that is required to undergo the procedures to remove the excess skin and fat after massive weight loss.

Please visit Dr Michele Koo’s website at www.drmkoo.com or call her office 314-984-8331 in St Louis, MO for more information.

DR MICHELE KOO, MD, FACS, BOARD CERTIFIED PLASTIC SURGEON

BODY CONTOURING

ST LOUIS, MISSOURI

314-984-8331

                                                                         

 

BEFORE TUMMY TUCK, LIPOSUCTION BY DR KOO

AFTER TUMMY TUCK, LIPOSUCTION BY DR KOO

                                                                                                                                                                                                         

Lipodystrophy is the term used to describe locations of fat that tend to accumulate in certain areas.  The areas on our body that tend to accumulate fat are genetically determined and is a source of frustration for most people.  No matter how much we exercise and diet, there are areas of our body that will accumulate fat disproportionately. 

We all accumulate fat in specific areas determined by our genetics. Women then to accumulate fat in the hips, thighs, abdomen and buttocks. Men tend to accumulate fat in the abdomen and midriff.  Fat, however can be located in all of the following areas: abdomen, flanks, thighs, arms, neck, knees, back, buttocks, and breasts.

Dr Michele Koo, St Louis, MO will give you a careful physical examination to detail all of the areas that bother you that can be remedied with liposuction. Liposuction is a very safe procedure which can often be achieved as an outpatient procedure.

Men who present for abdominal liposuction often times have intraabdominal fat, which is not addressed by liposuction. In men interested in body contouring of the anterior chest, in other words, gynecomastia, Dr Koo will 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.

Other anatomical areas that require special attention if liposuction is to be performed are the legs and ankles. Patient satisfaction is not as high with liposuction in these areas. Pain can be a prolonged problem and complications are more frequent than with liposuction of most other areas. It is important to understand the patterns of fat distribution and how they relate to the anatomy of the area.

Dr Michele Koo, MD, pays special attention to the preoperative markings, with careful attention to the suction area, and her office renders close postoperative follow-up to achieve the utmost optimal results that are possible with liposuction and tummy tucks (abdominoplasty).

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.  Previous abdominal scars and stretch marks can often be removed with the tummy tuck (abdominoplasty) procedure. Men also do well with the tummy tuck procedure if they want to remove the over hang of skin in the belly area.

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.

Dr Koo makes a special 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.

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 Michele Koo is very experienced in tumescent and large volume liposuction to achieve the most amazing results safely. She will advise you as to what procedures can be done at one time and will stage your entire body makeover to achieve the flat tummy and thin thighs and buttocks that you are looking for. 

Ultrasound-assisted lipoplasty. Introduced in the late 1980s, ultrasound-assisted liposuction uses a cannula or probe to deliver fat-liquefying ultrasound subcutaneously. This technique permits the removal of fat from fibrous areas such as the upper abdomen, back, and flanks with greater ease, especially during secondary procedures. To prevent thermal injuries while performing ultrasound-assisted liposuction, two technique rules are of critical importance. First, the ultrasound probe or cannula must be kept in motion. Second, the infiltrate solution is a required component of ultrasound-assisted liposuction because it plays a crucial role in the process of fat emulsification and cooling the heat generated in the process. The dry technique should never be used in ultrasound-assisted liposuction, regardless of the planned volume of aspirate.

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.

DR KOO will take an accurate assessment of your entire trunk deformities and DR KOO’S technical expertise are essential components of successful body contour surgery. DR KOO takes into consideration all aspects of the your 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.  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, is  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 is 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.

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-is 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.

DR KOO thinks it is important to educate the patient and provides 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.

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.

Most surgeons place 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.

Pain management is important to consider in the body contour patient. The use of a postoperative anesthetic pump has become increasingly popular and has been shown to offer benefit to some patients. Pain pumps may help decrease the need for postoperative narcotic analgesia, which has the benefit of decreasing the side effects associated with these medications. Although the pain pumps have been shown to be extremely effective, it is necessary to determine whether the cost and the inconvenience of wearing the pump is acceptable to the patient.

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.

Immediate complications of surgery can be catastrophic and include the development of deep vein thrombosis, pulmonary emboli, fat emboli, and hematoma. Fat embolism syndrome is a rare occurrence that is manifested by the clinical triad of respiratory distress, cerebral dysfunction, and petechial rash. The syndrome usually manifests itself within the first 2 postoperative days and is treated supportively with corticosteroids. Information regarding the risks of developing venous thromboembolism in plastic surgery patients is limited; however, Grazer and Goldwyn reported a deep venous thrombosis incidence of 1.1 percent and a pulmonary embolism incidence of 0.8 percent in abdominoplasty patients. Hester’s group found that when abdominoplasty was combined with other surgical procedures, the incidence of pulmonary embolism was significantly greater. There have been studies documenting a higher incidence of thromboembolic phenomena when combining abdominoplasty with gynecologic surgical procedures and contrasting data showing no statistical difference in the frequency of these complications when the two types of procedures are combined.

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, 314-984-8331, ST LOUIS, MISSOURI