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.