Reverse Tummy Tuck

Does this procedure really exist?

Yes, there is actually a procedure called "reverse tummy tuck" or "reverse abdominoplasty". We actually included a separate chapter on it in The Atlas of Abdominoplasty.

The reverse tummy tuck is a unique procedure designed to improve the shape and contour of the upper abdomen while hidding the final scar location in the breast fold.

Who is candidate for the reverse tummy tuck?

Good candidates for the reverse tummy tuck are usually not significantly overweight, have excess skin and soft-tissue laxity primarily above the belly button, and may also be planning on a breast procedure that will result in a breast at the breast fold. The last part is not a requirement since the scar is well concealed but certainly allows performing both the breast procedure and the reverse tummy tuck without additional scars.

Can muscle tightening be performed with reverse tummy tuck?

Yes. Most candidates for reverse tummy tuck are not in great need for muscle tightening, however, if it is deemed beneficial it can be performed. The process of muscle tightening with reverse tummy tuck is very similar to that performed with endoscopic tummy tuck (see earlier post on endoscopic tummy tuck).

Can liposuction be performed with reverse tummy tuck?

Yes. Liposuction can and is often used in combination with all of the tummy tuck procedures.

What about the belly button?

The belly button is usually not released during the reverse tummy tuck and therefore there is no scar around or inside the belly button. The upward pull of the reverse tummy tuck procedure has a natural rejuvenating effect.

Drains?

Although not manditory, drains are still highly recommended.

Look for posts on circumferential abdominoplasty in the near future.

All the best,

Dr. Remus Repta

Phoenix/Scottsdale Plastic Surgeon

Buttocks Fat Grafting

What is buttocks fat grafting?

Buttocks fat grafting is a procedure designed to augment or increase the size of, as well as to improve the shape of the buttocks by using fat from other areas of the body.

The buttocks is a very important part of human sensuality. It is represented throughout different cultures past and present in art and fashion. Just as there are different procedures to improve the shape and appearence of breasts, so too are there a range of prcedures designed to shape and improve the size, shape, and appearence of the buttocks.

The procedure available to improve the size of the buttocks include implants, autologous flap (more on this procedure in later posts), and fat grafting.

How is buttocks fat grafting done?

Buttocks fat grafting is performed by removing fat from one area(s) of the body and using that fat to increase the volume and improve the shape of the buttocks. The fat is obtained through liposuction in a special manner. Any of the area of the body is a potential source for fat, with the abdomen, hips, thighs, flank, and back being the most common sources. Through liposuction fat is removed and the area being liposuctions is contoured to the desired effect. The fat is prepared in the operating room and reinjected into the buttocks through tiny incisions that are less than a few millimeters long.

Does buttocks fat grafting last?

Yes. Fat grafting has been around for some time now and it has been clearly shown that fat grafting does last. There is some debate about how much of the graft "takes" and how much gets absorbed, however, the fat that does take stays forever. Most plastic surgeons agree that at least 50% of the fat graft usually takes. In my experience, the percentage of fat that takes is more like 75%. This fat then increases or decreases with weight gain and weight loss respectively just like the rest of your body....since it actually is your body.

What can I expect after surgery?

The recovery for buttocks fat grafting is similar to most liposuction procedures. You'll have garments on the areas where liposuction has been performed, there will be some soreness but nothing too remarkable, you can do most activities as long as they are not strenuous, heavy, or prolonged. With regards to sitting, if the patient is comfortable and able, I recommend resting some of the time on your stomach since this will help with the swelling, otherwise when sitting it is important to have plenty of padding and to relieve some pressure periodically. Brusing and swelling will be present as expected.

Summary

I believe buttocks fat grafting is a wondeful procedure for patients that do not have enough volume in their buttocks. It works well, lasts the rest of your life if you mantain your weight and health status, and most importantly it feels real because it is real.

All the best,

Dr. Remus Repta

Extended Tummy Tuck

Extended Tummy Tuck

What is the extended tummy tuck procedure?
The extended tummy tuck also referred to as extended abdominoplasty, is an abdominal cotouring procedure that is designed to remove a maximum amount of extra skin and soft-tissue laxity without a scar that goes all the way around the waist (circumferential tummy tuck or body lift). Most patients that have a significant amount of extra skin and soft-tissue laxity around the waist are best served by a body lift also known as a circumferential abdominoplasty. However, for various reasons, patients may either not want a body lift or may not be an ideal candidate to undergo the body lift procedure. In these cases the extended tummy tuck is a great procedure that will allow maximum improvement of the extra skin and soft-tissue laxity.

How long is the incision?
The short answer is that it is as long as your body needs it to be to remove the extra tissue without creating folds of tissue at the ends of the incision which may be seen when too short of an incision is used. By definition, the incision used for the extended tummy tuck is longer that a full tummy tuck procedure but shorter than a circumferential tummy tuck. As a general rule the extended tummy tuck incision spans from about one palm witdh beyond each hip bone on both sides or about 3-5 inches longer on both sides than a full tummy tuck.

What else is involved in the extended tummy tuck procedure?
The goal of the extended tummy tuck procedure is the same as any other tummy tuck procedure, namely to thin, to flatten, and to tighten. To accomplish this, liposuction of the abdomen, hips, and flanks is performed when needed/or deemed beneficial to the overall result. In addition, muscle tightening or muscle repair is also performed to help flatten the abdominal wall. Finally, the extra skin and soft-tissue is removed, allowing the tummy to be tighter in profile and shape.

Next up. The body lift or circumferential abdominoplasty.

All the best,
Dr. Remus Repta

Phoenix/Scottsdale Plastic Surgeon

Drains: Annoying but Necessary.

Whats the deal with the drains?

The lowly drain must be one of the least appreciated and liked components of the tummy tuck procedure. They are nuisance to deal with early on, they get in the way, they require extra work to take care of and to record the output, and when you can't stand them anymore there is the hesitation or fear of having pulled out.

So are drains necessary following the tummy tuck procedure.

The simple answer is yes. Although there is a tummy tuck technique that does not require drains, lets call it the "French Method" since it got its start in France, the procedure in my opinion takes longer and gives a less powerful result than the tummy tuck techniques that do not require a drain.

The body naturally creates "healing" fluid whenever surgery is performed. When there is a large elevated or undermined area such as in the tummy tuck procedure, the amount of healing fluid is fairly large and there is a large space for it to accumulate if left alone. Some of this fluid will naturally result in scar tissue and/or pseudobursa (see previous post) if not properly managed. To prevent this, we place a drain(s) and use the compression of an abdominal binder to decrease its production, expedited its removal, and allow the abdominal soft-tissue to adhere to the underlying abdominal wall. The vast majority of the tummy tuck procedures including endoscopic, mini, full, extended, reverse, and circumfrential tummy tucks require both a drain and an abdominal binder.

How long is the drain(s) going to stay in?

I always like to answer this question with: "as long as your body needs it and not a day longer". This is an accurate answer since the length of time varies from individual to individual. I prefer to see about less than 25-30 ml of drain output per 24 hours. This usually takes about one week to ten days to achieve.

Doe it hurt to have the drain removed?

Again, it varies on the individual, type of drain, how its placed, etc. I honestly cannot remember the last time a patient did not remark how easy and painless drain removal actually was. I use a flutted or tapered drain, make sure the drain passes easily through the skin during surgery, place numbing medication at the skin site, and usually bring the drain out through the incision or just below it. This not only avoids an additional scar but this area is usually numb in the few weeks following surgery.

In summary, the drain, although annoying at times is necessary to get a great result. We want your tummy to be thin and flat and the extra scar tissue that would build up without a drain is just not acceptable in my opinion.

All the best,

Dr. Remus Repta

What is a Pseudo-bursa?

Recently I have had a few questions about bulging or fullness following tummy tuck. While there are a handful of reasons for fullness to be noticed some time following the tummy tuck procedure I think the presence of pseudobursa is often under reported or underdiagnosed.

So what is a pseudobursa?

Simply put a pseudobursa is a pocket of extra thick scar tissue. Remember those drains that you had after the tummy tuck? They were necessary to prevent a seroma, or collection of "healing" fluid. Despite the use of drains, however, seroma can still ocurr. It is not hard to imagine that some seroma fluid accumulates after the drains are removed. Of course, the majority of the time the body keeps up with absorption of the seroma fluid and any extra fluid that may be under the abdominal soft-tissue is not noticed. The body naturally wants to isolate any free fluid between the abdominal soft tissue and the abdominal wall. The body knows that it does not belong there so it sends in cells to create scar tissue around the fluid. This scar tissue surrounding a fluid pocket is called a pseudobursa. If the wall of the pseudobursa is thin enough then they usually go undetected. Occasionaly a previously undetectable pseudobursa gets infected. When this ocurrs usually there is some tunneling and drainage at the nearest incision, either the lower incision in the midline or the belly button scar. If the pseudobursa contains a lot of fluid or the scar tissue is very thick it can be noticeable as a bulge or fullness.

The most common areas for pseudobursa formation is just above the waistline incision in the middle. This is the most gravity dependant area so it is naturally the most likely area for pseudobursa formation. Pseudobursa can also be seen just above the belly button. The presence of the belly button stalk and the surrounding tissue can form an area for a seroma to accumulate and for a pseudobursa to form.

How do you treat pseudobursa?

Although the pseudobursa can be injected with medicine to scar the two parts together and reduce the overall size, this is usually not that effective. If the pseudobursa is detected either by the development of infection or because it can be felt or seen as a bulge or fullness then it should be removed. The prior incision scar must be used to access the pseudobursa. The scar tissue is then removed, sutures are placed to obliterate the space where the pseudobursa was located, and drains as well as an abdominal binder are used similar to the original tummy tuck procedure. The recovery process is usually much easier than the original tummy tuck procedure with the exception of the drains and the abdominal binder.

Below is a photo of a pseudobursa excision.  Extra skin and soft tissue with the underying pseudobursa was removed.  When present on top of the abdominal wall the size of the pseudobursa is actually large and more spread out.  Once it is detached from the surrounding tissue it shrinks up.  This contractile property is likely related to some of the symptoms patients experience when a pseudobursa is present.

Feel free to ask any questions that I may not have covered. Look for an extended tummy tuck post next.

All the best,

Dr. Remus Repta
Phoenix/Scottsdale, AZ

Liposuction and the Tummy Tuck

What is Liposuction?

Liposuction is the process of removing fat by using small cannulas that are inserted through tiny incisions in the skin. It is one of the most powerful discoveries in body contouring. Liposuction goes by many names these days including laser assisted lipo (LAL), ultrasound assisted lipo (UAL), power assisted lipo (PAL), etc. All of these modalities have differences and similarities, the final component, however, is always the use of tiny incisions to access fat underneath the skin.

Is there a role for Liposuction in Tummy Tucks?

Liposuction is an almost indispensible tool for giving the very best results possible for the tummy tuck procedure. Although not every tummy tuck candidate benefits from liposuction during the tummy tuck procedure, I would estimate that 90+ percent do.

How is Liposuction beneficial in Tummy Tucks?

In three different ways:

1) To thin the abdominal soft-tissue apron. Remenber, part of the primary goal of the tummy tuck procedure is to "Thin". Despite the fact that tissue will be removed with the tummy tuck procedure, the remaining tissue may and frequently is still relatively thick from an ideal cosmetic result standpoint. Liposuction can be used to uniformily thin the fat of the abdomen.

2) To contour the areas near the abdomen. The tummy tuck procedure will improve the contour of.......the abdomen. Frequently, the areas of the flank, hips, thighs, and near the bra/breast area may appear in contrast to the now improved tummy tuck contour. Liposuction can be used to contour these areas so that not only does the abdominal contour and silhouette look great, but your whole trunk area looks thinner, uniform, and beautiful.

3) To scultp the abdominal surface. I frequently will emphasize the vertical groove in the middle of the abdomen by using liposuction. This groove is sometimes referred to as the "Champagne Groove". (Google it for a colorful explanation). This is a very important part of the attractiveness of the abdomen, so I strive to create or improve it's appearence.

Are there some patients who are not candidates for Liposuction during their Tummy Tuck?

The short answer is yes. Some patients are higher risk for healing following tummy tuck. Patients who are heavy smokers, certain abdominal scars that may interrupt the blood supply to the abdominal skin and soft-tissue, etc., may not be candidates for the use of liposuction of the abdominal soft-tissue itself. Of course, liposuction can still be used in the areas around the abdomen to improve the overall contour of the trunk, but liposuction of the abdominal soft-tissue itself at the same time of the tummy tuck should be used with caution in this group of patients that present with increased risk of healing issues.

All the best,

Dr. Remus Repta

Bra Line Back Lift

What is the Bra Line Back Lift?
The Bra Line Back Lift is a new procedure that helps correct the soft-tissue rolls and folds of the middle and upper back. There are a large number of women who complain about the presence of these soft-tissue folds. Many express the desire to wear form fitting clothes in the current fashions but hesitate to do so because of the appearance that these back rolls present. Until now, there was relatively little that could be offered to help these patients.The Bra Line Back Lift was co-authored by me and Dr. Hunstad. Scheduled to be published in the October 2008 issue of Plastic and Reconstructive Surgery Journal, the leading journal for the American Society of Plastic Surgery (ASPS), the Bra Line Back Lift procedure was designed to improve the appearance of the upper and middle back by correcting the presence of soft-tissue folds and rolls and allowing a smooth, even-flowing silhouette to be achieved. In recent weeks, there has been increasing media coverage of the procedure. Below are the details of the procedure including ideal candidates, recovery time, and additional information.
Who are candidates for the Bra Line Back lift?
There is actually a wide range of patients that could be good candidates for the Bra Line Back Lift procedure. We have noticed that the most frequent request is from patients that are in their 40’s or 50’s, are in relatively good shape, but because of either aging, excess sun exposure, or secondary to weight fluctuation, they have excess soft-tissue laxity in the upper and middle back that present as rolls and folds. It is important to note that skin and soft-tissue laxity cannot be exercised and therefore cannot be tightened. Liposuction alone has been used to treat these areas but this just improves the presence of fat and it does not correct the laxity of the skin and soft-tissue which is the main problem.
How long does it take and what is the recovery time?
The procedure takes about one hour. It is performed under general anesthesia and as an outpatient procedure. The recovery process is fairly easy as reported by many patients. There is often not a lot of discomfort and beside the restriction of heavy lifting and vigorous activity, the patients are usually allowed to increase their activity level as tolerated. Drains are usually not used and since all of the sutures are internal and dissolved by the body, there is no cumbersome dressing needed and patients are allowed to shower in 24-48 hours.
Are there any scars?
Yes. Scars are always created whenever surgery is performed। The Bra Line Back Lift has the benefit of placing the scar within the borders of the bra strap. In discussing the Bra Line Back lift procedure, I tell my patients that a visible scar will be present, that it will be hidden by the horizontal part of the bra strap, and that in the end, they are choosing between the presence of back rolls or a scar. The benefit of choosing to undergo the Bra Line Back Lift is that with all form fitting clothes, the folds are now gone and a smooth silhouette is present. With the exception of a backless dress or the very tiniest bikini top, the Bra Line Back Lift scar is usually well hidden.

Feel free to ask any questions that I might not have covered. Before and after photos can be seen in our office as well as in The Atlas of Abdominoplasty textbook.

All the best,
Dr. Remus Repta