• Liposuction and Fat Grafting

• Eyelid and Facelifting Information

• Tummy Tucks (Abdominoplasty)

• Arm lifting and Thigh-Buttock Contouring

• Dermal Remodeling, Acne Treatment and Spider Vein RX

Liposuction and Fat Grafting:

How are the areas to be treated decided?

We divide the areas into three distinct types:

a.  Primary Deposit Sites:     These are the first places weight is gained, and the last places lost with diet and exercise.  These are sites that diet and exercise cannot seem to provide correction without extreme reduction in body fat percentage.  Being genetically determined, these are the most frustrating and difficult “problem areas” for most patients.  Fortunately, these are the most important sites treated with liposuction, particularly since once these storage cells are reduced, no new fat cells are developed to replace them.

b.  Secondary Deposit Sites:              These are sites that have fat cells that can either store fat for future use, or, provide fat breakdown for energy delivery for the body.  These sites fill when the Primary Deposit Sites have substantial stores, but are termed “metabolically available” based on the fact that diet and exercise are usually effective at reduction of these areas.  It is the Secondary areas that you can realize good contour changes by diet and exercise alone.  These sites may also be treated with liposuction, particularly as our metabolism slows with aging and the changes associated with middle age makes diet-exercise less effective for most people.

d. Tertiary Deposit Sites:  These sites are not considered for liposuction, as these are specifically where fat is routinely broken down (metabolized) for release of energy for our body demands.  Remember, fat breakdown yields 9 calories per gram (versus carbohydrates and proteins which yield 4 calories per gram).  For many years, the actual amount of energy delivery credited to fat breakdown was not considered to be very large.  In the last few years, metabolic research has revealed a much larger importance of energy derived from fat on a daily basis.  These sites are not considered for liposuction, but are provided for the sake of completeness.

Is liposuction safe?

Yes, particularly when performed by experienced lipocontouring surgeons.  The overall complication rate has dramatically decreased over the past 20+ years.  Today, using either modern anesthesia techniques, the estimated complication rates range between 2-3%.  Whenever patients consider any elective procedure, it is important to determine the gain versus risks before proceeding.  In general, liposuction is considered a high gain with reasonably low risk group of procedures.  As in any surgical procedure, some degree of risk is always potential, making surgeon selection very important.

How does liposuction work?

In the late 1980’s, bioengineers discovered that the mechanism by which liposuction worked related to the use of the cannula (tubes) moving through the fatty tissues caused a breaking up into small fragments.  Since the use of the tumescent technique, bleeding has become substantially less, since now surgeons provide the liquid medium for those fragments to enter into a suspension, and the fat containing suspension comes out with less injury and bleeding.  This discovery led to the reduction in size of cannula, and was an integral part of the patenting of the Tulip Syringe System.

Why is the Syringe System more gentle and effective than using a vacuum machine? 

The best way to explain this would be to consider an analogy.  If you have ever used a vacuum cleaner, and moved it from a smooth (wood, linoleum, etc.) surface onto a heavy pile carpet area, you will hear and feel the increased resistance.  This rise and fall of pressure and vacuum produces a “cavitation effect”, resulting in more damage to the underlying tissues (fat, skin, muscle, etc.).  The syringe is different, in that, it uses fluid to displace the air in the system prior to placement of the cannula.  Now incisions are replaced by small puncture openings (3 mm), followed by insertion of the small cannula into position before drawing back the syringe plunger to apply any vacuum.  Since the syringe does not allow any air to be involved in the system, there are no pressure changes at the opening tip of the cannulas.  This major advance has resulted in less swelling, less bruising, increased volumes able to be safely removed in a single stage, shortened recovery, decreased pain medication needs, and shortened the duration of wearing compression garments.

When can I return to exercise and activities following liposuction?

In the days of using the vacuum suction machines, recuperation could take from 4-6 weeks, with garment wear and limited activity recommended for that period.  Now we return most patients to physical exercise by day 3-4, and full exercise within 7-10 days.  It is no longer recommended for you to remain in bed or with very limited activity levels.  Clinical experience shows clearly that the more active (within reasonable limits) following liposuction, the shorter the period of stiffness and more rapid the full recovery of activity.  Many patients return to full work schedule within the first 5-7 days following.  We will attempt to estimate that return on an individual basis, varying with pre-treatment physical condition, overall health, and the volumes removed.  In general, it is our experience that patients with small volumes (such as 1,500 cc or less) often return to work and activities within the first 3-4 days without significant limitations.

Can liposuction replace the need for tummy tuck?

Liposuction has significantly changed both the indications for tummy tucking, and improved the final result realized by combination of both techniques.  Fifteen to twenty years ago, tummy tuck was recommended on all patients with prominent abdomens, hanging skin (pannus), weak abdominal muscle wall, and fat deposits.  Today the prime indications for abdominoplasty (tummy tuck) are flaccid, hanging skin excesses with minimal fat and muscle wall defects (hernias, post-pregnancy stretching (diastasis), etc.).  Due to limitations of blood supply to the abdominal area, it is typically recommended that extensive liposuction should not be performed at the same time as abdominoplasty.  To do so raises the risks without materially increasing the final result.  Today, it is common to perform “serial” or staged liposuction aimed at doing large fat volume reduction prior to the resection and removal of excess skin tissue.  This permits substantial volume shrinkage resulting in a smaller amount of skin incision lengths and surgery extension to accomplish a successful tummy tuck and recontouring.  By reducing the requirement for long incisions, and limiting the extent of dissection to remove excess skin, the recuperation can be shorter, less risks of open surgery, and a better final result. The common use of both liposuction and tummy tucking is to do the liposuction of the abdominal and upper hip (flank) areas, followed in a few months with the excess skin removal.  We will have to examine you do recommend the appropriate sequence best for your case.

When should I be able to see results of my liposuction?

Results can often be seen within the first 2-3 weeks, representing the change produced by the actual volumes of fat removed.  Over the next 8-12 months, continued changes result from the gradual healing and reduction of swelling in the tissues.  Many patients have remarked within the first month, that “I am very happy, even if it doesn’t change much more than this”.  All patients should be reminded to be patient, carefully follow the instructions regarding aftercare, diet and exercise programs.  Up to one-half of your final result may be determined by faithful and proper diet-exercise programs.

Are fat grafts safe and effective?

Yes, since the invention of the Tulip Closed Syringe System, gentle extraction of live fat cells have become a predictable and effective graft.  The ability to use low pressures, minimal damage is sustained by the cells resulting in a more healthy and successful transfer to areas needing plumping and filling.  Before the early 1990’s, fat grafts were considered occasionally effective and somewhat unpredictable.  The Syringe System plus the use of Platelet Rich Plasma (PRP) have resulted in marked improvement in the fat grafting process and success.  Since the fat cells are removed from the “Primary” sites (storage problem areas) from you, there is no problem with rejection or reaction to the graft cells.  Further, it is believed that the fat cells from these problem areas retain “donor site memory” much like the grafts of hair in male pattern baldness.  This means the graft thinks it is still where it came from, not where it was placed.  This concept is very important, since areas needing augmentation and fullness are often areas from where fat is very easily lost.  Since PRP has been actively included, both small and large volume fat grafts have become more effective.

Where can fat grafts be placed?

Small volume fat grafts have become very popular in the areas of the face, including cheeks, lips, folds, and depressions.  Large volume grafts have proven effective in filling of larger body and extremity depressions, augmenting retro-glandular breast volumes, and improving large asymmetries associated with polio and unilateral wasting problems.

Fat has proven to be most effective when transferred (grafted) to areas normally having fat present.  Simply stated, fat grafts do best where fat normally resides.  Placement of fat grafts is recommended in the subdermal skin areas, as compared to known fillers (collagen, radiance, etc) of wrinkles place within the dermis itself.  Confusion sometimes exists that fat grafts can fully replace the need for the dermal fillers.  This is clearly not correct, as the placement at each level (i.e. in the subdermal area and within the dermis) is often useful and needed to realize the contour changes desired.

Does Breast Augmentation with Fat Transfers work?

Yes, The use of fat transfer provides us with an alternative method of breast augmentation that uses no foreign implant materials. See the web article which references an interview in Cosmetic Surgery Times. Please click on the clipboard image on the left, this will bring up a new window.

 

What is PRP, and where is it used?

Platelet Rich Plasma (PRP) is derived from a small volume of your own blood drawn at the time of IV start, spun in a centrifuge to divide into layers, and extracting the platelet rich layer.  Platelets are very important to the early clotting and healing processes, helping create the original closure to small capillaries and delivering chemical agents critical to starting the normal inflammatory-healing cycle.  Research has shown that delivery of concentrated platelets directly to a site offers a major acceleration of the wound healing processes, both in form of chemical agents and platelet derived growth factors to speed the process of healing.  It is used both in fat grafting, bone grafting and all open incision soft tissue procedures.  In each case, rapid resolution of healing is noted, making it a very important aid to nature’s own processes without the required delay for gradual inflammatory response to arrive. 

Eyelid and Facelifting Information

Have there been any recent changes to the techniques and results?

In eyelids, the major changes involve use of PRP (Platelet Rich Plasma) and ability to approach the lower eyelids without an external scar (in select cases).  PRP is now well established as a major advance in both bone and soft tissue surgery, as a means to significantly accelerate wound healing mechanisms and promote rapid recovery.  Use of a transconjunctival approach (from the inside aspect of the lower eyelid) allows reduction of the fat pads (bags) and is often usedwith or without laser surface or chemical surface peeling for fine wrinkles.  The main limitation of this approach is that excessive skin excesses and overdeveloped eyelid muscle bulging cannot be addressed.  Transconjunctival approaches are often utilized in the younger group of patients, where large skin excesses are not a prominent.

In facelifting, the most significant changes include use of PRP, and the use of gentle, closed syringe system liposuction of the jowl and neck areas as part of the face and neck lifting.  In addition, there are different options available which address suspension of the SMAS (submuscular aponeurotic system), lifting of the sagging neck muscles, and lifting in the mid and deep planes of the face.  By reduction of the weight contributed by the fatty layer, lifting is improved and the length of time it lasts is increased.  Most surgeons today include this as part of, not as a addition, of face and neck lifting procedures.

 How long does the surgery take, and what is the recuperation time?

In eyelids, the surgery usually takes between 1-1.5 hours for both upper and lower lids.  The recuperation, particularly with use of PRP, is now reduced to less than one week in most cases.  Important instructions on care after surgery are provided prior to any surgery.

 In face and neck lifting, the surgery usually takes between 2-3 hours including the time needed for performing liposuction.  There is typically a wrap dressing which is usually removed the next day, and replaced by a less compressive elastic garment.  Recuperation with use of PRP is now reduced to one week or less in most cases, based on less swelling, bruising and complications associated with its use.  You typically can wear makeup the day of your stitch removal (usually 3-6 days).  Important and detailed instructions will be provided prior to your procedures.

 How do I determine when the eyelids or face and neck lifting needs to be done?

The best way to answer this question for yourself is to consider two things.  First, are you able to effectively cover up the sagging or bagging of the eyelid, cheek or neck skin?  Second, is it something you begin to notice more than once or twice a week when looking in mirror or at photos of yourself.  If these changes have occurred, it is worth looking into your options for either conservative or more aggressive treatment.

 Are there more than one way to do the eyelid and face/neck lifting surgeries?  Which would be best for me?

Options are now available which are determined during your evaluation appointment.  Some of these are discussed above in the “recent changes”.  Neck and cheek lifting  is now offered in limited lifting (standard), mid-plane facelifting, and deep-plane facelifting choices.  The selection of the best choice for you is determined between you and the doctor.  Often patients seek more conservative changes, wanting to avoid the “over-tightened” look sometime seen.  These typically select the standard and more limiting type surgery, which can improve their look dramatically, but avoid the more noticeable effect produced with more aggressive surgery.  Some patients have very flaccid and non-elastic skin producing marked sagging and hanging of skin.  These often are better served with a lifting of both the skin, SMAS, and deeper structures to accomplish their goals.

Is there a charge for cosmetic consultations?

We offer all cosmetic consultations at no obligation or cost to our patients.  The philosophy of offering an “information resource” is very important to us.  This allows you the opportunity to obtain needed information, to eliminate confusing and conflicting media advertising, and to be able to ask your questions in a private and professional setting.

 

Tummy Tucks (Abdominoplasty)

What are the reasons that I would need a tummy tuck versus liposuction?

Since the development of modern liposuction techniques, the combination of tummy tuck and lipo-reduction are often employed to maximize the results.   Patients having tummy muscle wall defects (hernias, diastasis, ventral wall defects, etc.) and/or extensive hanging skin of the lower abdomen (without large fat deposits) are mandatory candidates for tummy tuck surgery only.  Most patients fall into another group, however.  Most patients also have substantial fatty deposits of the abdomen and hip areas, and need/want to correct these areas as well.  Today, it is common for such patients to undergo a “volume reduction” liposuction procedure prior to actual tummy tuck.  In some cases, these patients actually eliminate the need for surgical skin removal and the more complicated tummy tuck recuperation.  In others, removal of large fat deposits in advance, makes the actual length of tummy tuck scar to less than one-half of that required if tummy tuck is done first.  By reduction of the thickness of fat deposited on the abdomen wall, the procedures are less complicated, and often result in better results than tummy tuck alone.

Extensive stretch marks and skin laxity pose a challenge for the final appearance.  When stretch marks extend above the belly button area, it is often difficult or impossible to completely remove all evidence of them. 

Why can’t tummy tuck and liposuction be done at the same time?

Although limited liposuction can be performed in the area of the hips and back, use in the front abdomen area may interfere with the circulation to the front and lower abdomen.  This significantly increases the risks of skin loss or bleeding following the surgery.  In addition, it has been found that doing the procedures about 6 months apart often allows a more effective contouring than either tummy tuck or liposuction alone can produce. 

 Must I lose weight prior to having my tummy tuck?

It is now considered less important to have patients achieve large weight loss prior to having a tummy tuck procedure.  The primary reason relates to the ability to perform large volume reduction of the fat deposits prior to skin excess removal via use of liposuction techniques.  It is, however, strongly recommended that patients follow diet and isolation exercise instructions to prepare for tummy tuck or liposuction surgeries.  Final results are enhanced when patients develop quality diet habits, and couple those with good exercise programs.

 What are stretch marks, and will they be eliminated by tummy tuck?

Stretch marks are typically a hereditary characteristic where there is a separation of the skin cell to skin cell attachments associated with major weight increases, muscle development and pregnancy.  As the bridges between skin cells separate a wide, flat irregular defect is noted on the skin surface.  Although technically not a scar, it is a type of “skin scar” which often is unsightly and undesirable.  Usually, elimination of stretch marks near or above the umbilicus is not practical.  There is only so much skin that can be safely removed at one time.

 What is the recuperation period, and when will I be able to return to work?

Most patients are able to return to work within 7-10 days from the day of surgery.  This is considerably shorter than the recuperation needed prior to PRP use.  Return to limited active exercise is now recommended (on a case by case basis) to be about 7-14 days.

 Why is PRP (platelet rich plasma) an advantage in tummy tuck procedures?

Use of PRP (platelet rich plasma) has become very important in reducing the swelling, bruising and recovery from tummy tuck procedures.  As in other soft tissue surgeries, extraction a small amount of platelet rich fraction from your own blood, and its placement in the areas of open surgery accelerates the wound healing processes.  As late as 5 years ago, it was not uncommon for recuperation to be measured in weeks (up to 4-8) and the need for use of external drains after surgery for several days.  Since utilization of PRP, use of drains have been virtually eliminated, and the rate of activity return shorted to 1-2 weeks. 

 What is a “High-Low” tummy tuck?  What are the reasons this would be recommended for me?

Development of a “High-Low tummy tuck” is a relatively new option for re-contouring the abdominal wall.  In many patients, the excessive skin includes a major folding and skin accumulation occurring above the belly button.  When sitting or bending at the waist, hanging and folded skin results in an undesirable appearance – even following having excess skin removed from the lower abdomen area.  In these cases, it is often more valuable to lift the upper skin excess at the same time as removal of the lower portions.  The belly button is not distorted or shifted, leaving a center abdomen with a very natural appearance, and a more effective correction than possible when trying to remove all skin excess from the lower abdomen.  The doctor must examine you to determine if you are candidate for this type of procedure.  It appears that a shorter recuperation is most common than the extended dissection needed to do a tummy tuck from the lower abdomen only.  Many patients return to work within one week following surgery.

What are some of the risks to having a tummy tuck?

Tummy tucks are subject to the full variety of any open surgical skin approaches such as, infection, excessive scarring, asymmetry, incomplete masking of defect, collection of blood under the skin (hematoma), excessive blood loss, skin slough, and worsening of appearance.  Very rarely, injury to the abdomen wall or peritonitis can result from tummy tucking.  Since the advent of reduction of flap thickness by pre-tuck liposuction stage, the extent of incision in the lower abdomen area has been reduced.  In general, the more limited the length of incision and extent of dissection, the less frequent are the complications.

Can I have a tummy tuck without going into the hospital?

Tummy tucks may be provided as an inpatient Hospital procedure, or on an outpatient, ambulatory basis.  Hospitalization may be needed in more extensive muscle wall repair or complicated cases.  When the general medical health of a patient is compromised with chronic illness or systemic disease, we typically recommend hospitalization for performance of this type of procedure. 

 Arm lifting and Thigh-Buttock Contouring:

Can arm lifts correct the large size of my upper arms?

Excess in upper arm size (excluding muscle size) may be due to excess skin, excess fat, or a combination of both.  Selection of the best procedure in each case is determined by examination of the cause.  When there is lots of excess skin with minimal fat deposits, removal of a strip of that skin is performed on the inner aspect of the upper arms.  Every effort is made to attempt to hide the scar on the inside of the arm.  In some cases involving both skin excess and fat excess, it is often recommended that the patient have syringe liposuction performed prior to excess skin removal.   This permits the doctor to effectively reduce the volume of the arm dimension coming from the fat tissues, followed in several months by the removal of the actual hanging skin excess.

Why can’t arm lifts and arm liposuction procedures be done at the same time?

Due to the potential risks of circulation, it is commonly advised to separate these two procedures.  By performing the liposuction first, in some cases, the degree of change is so substantial that surgical removal of the skin is not required.  This is determined on a case by case basis.

Who is a candidate for thigh-buttock lifting?

Patients who have sagging or hanging skin developing in the lower buttocks areas or in the inside thigh area may improve by removal of that excess, and effectively tightening the lax skin.  By deep suturing of the skin to the underlying skeletal-muscular structures often helps the unsightly appearance.

What about use of buttock implants versus fat grafting?

Use of implants versus fat grafting is dictated by the position and extent of lack of buttocks contour.  In those cases lacking upper buttock fullness, implant of silastic or similar materials may augment the contours.  In those cases involving the central and lower buttocks lack of fullness, fat grafting is often the preferred choice.  By taking fat from undesirable deposits and relocating them into the buttock areas, a natural and effective filling can be provided which lasts indefinitely.  Since the advent of PRP with fat grafts, the degree of success has increased in large volume fat transfer.   Solid or semi-solid implants are placed via an incision in the upper buttock crease area, and placed near the underlying muscle area.  This is an effective means of augmenting the upper and upper-middle buttock fullness more than the entire buttock areas.

Dermal Remodeling, Acne Treatment and Spider Vein RX: