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

          

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.