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

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

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

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

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

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

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

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

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

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

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

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

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

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