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

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

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

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

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

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

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. The preoperative markings, careful attention to the suction area, and close postoperative follow-up are extremely important for liposuction of the legs and ankles.

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

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

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

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

Various types of anesthesia or anesthesia combinations are appropriate for liposuction, depending on the overall health of the patient, the estimated volume of the aspirate to be removed, and the postoperative discharge plan. Dr Michele Koo is extremely careful about her anesthesia provider and hand picks those that give anesthesia to her patients. Dr Koo is the patients’ best advocate and ensures that all precautions are taken for the safety and well being of her patients.

In smaller volume liposuction cases, anesthetic infiltrate solutions alone may provide adequate pain relief. Termed wetting solution, this anesthetic infiltration solution not only facilitates the procedure but also provides preemptive and prolonged postoperative local analgesia.

5 Doses of lidocaine up to 50 mg/kg have been used; however, it is important to note that plasma lidocaine levels can peak 10 to 12 hours after infiltration when epinephrine is present in the wetting solution. Lidocaine toxicity has been implicated in a series of liposuction-related deaths. Signs and symptoms of lidocaine toxicity can be seen at plasma levels between 3 and 6 μg/ml. Initially, patients may experience lightheadedness, drowsiness, tinnitus, a metallic taste in the mouth, slurred speech, and numbness of the lips and tongue. At higher plasma concentrations, shivering, muscle twitching, tremors, convulsions, central nervous system depression, and coma may result. Respiratory depression and cardiac arrest can also occur with higher doses. Marcaine is rapidly absorbed, poorly reversed, and has a long half-life, making it a less suitable agent for subcutaneous infiltration in liposuction procedures.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

So you’re thinking that you don’t like the way your butt looks, well don’t sit home and cry about it. You know we don’t have to always be stuck with what nature gave us.

Dr Michele Koo, MD, Board Certified Plastic Surgeon, St Louis, Missouri, can offer you numerous ways to enhance and improve your sad sagging butt. Or is it that you feel that your butt is too big or too small. Let’s start with one issue at a time.

BUTT TOO BIG: the options for the big butt problem is to perform liposuction and/or a GLUTEOPLASTY meaning removing excess skin that hangs down and touches your thighs.  If you feel that you have too much junk in the trunk and just want less of the J Lo good thing then DR MICHELE KOO can perform ultrasonic liposuction and remove the bulk (too much roundedness) and make your overall butt look smaller and less round.  If you have too much on the sides of your buttock, then DR KOO would also taper and liposculpt your outer thighs and posterior thighs making your buttock appear round from behind instead of square with the appearance of lifting the butt off your posterior thighs.
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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.

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 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

Let Dr Michele Koo, MD, FACS (314) 984-8331 of St Louis, MO change your life and remove all that excess skin, fat, and surgical scars on your abdomen and make your tummy flat and your thighs slimmer.

You have been on and off diets all your life and now after children, you can’t remove that excess skin and fat from your mid-section. Everytime you lose some weight, you look down at your tummy and become depressed and frustrated with yourself and you fall off the wagon and your weight bounces back up.

If you’re tired of not being able to stay on a healthy eating regimen and exercise plan because you’re not getting the results you want, let Dr Michele Koo, MD, FACS, St Louis, MO, Board Certified Plastic Surgeon, Member of the Aesthetic Society, change your life with a tummy tuck (abdominoplasty) or a liposuction that will keep you motivated and take you to the next step. You’ll finally see the results and rewards of all your hard work with a flat belly, a slimmer waist and thighs.

This photograph is of a mid 50 year old Missouri woman who was frustrated with her large abdomen after three children and c-sections.  No matter how much weight she lost, she was unable to get rid of her large belly.  Prior to her surgery of a tummy tuck (abdominoplasty) and ultrasonic liposuction of her upper abdomen, waist, hips, and inner and outer thighs, she reports wearing size 14 clothes.  At 4 months after her surgery, she fits into a size 6.  She is able to tuck in her shirts, wear low cut jeans, and wore a 2 piece bikini on her vacation with her husband.  At the time of her surgery, she also underwent a breast lift, completing her entire body makeover.  She has kept her weight off now 2 years after the surgery and continues her healthy lifestyle which she was never able to stay on prior to her surgery, because nothing she ever did previously worked!

Dr Koo performs ultrasonic liposuction at the same time as the tummy tuck (abdominoplasty) and contours the entire trunk and legs to make you look like a new person. She feels that this tummy tuck and liposuction combination is extremely safe and can achieve amazing results all in one surgery and one recovery time. Dr Koo also repairs the split in your rectus abdominus muscles which have become lax with age, weight gain, and possibly children and surgeries. This will cinch in your waist and entire circumference of your trunk, reducing your clothes size!

Do not be discouraged and depressed with your shape and inability to change your waist and abdomen, Dr Michele Koo, MD, will take you the rest of the way to being what you want to be with a tummy tuck, abdominoplasty, and liposuction. 

Call Dr Michele D. Koo, MD, FACS, St Louis, Missouri, Board Certified Plastic Surgeon, 314-984-8331, and talk to many others who have had this and similar tummy tuck (abdominoplasty) and liposuction surgeries and find out how that has changed their lives.