Body Procedures

Liposuction

The removal of fat using a suction cannula was popularized by a Frenchman, Dr. Illouze in the early 80's and shunned by North American surgeons for a number of years. Nevertheless, it went on to become the most popular aesthetic procedure in the United States.

The liposuction cannula is a hollow metal tube up to six millimeters in diameter with a handle at one end and a hole at the other. Suction is applied at the handle end. The end with the hole looks like an organ pipe: the opening is on the side and the tip is sealed off. When the surgeon moves the cannula back and forth through the tissues, fat bulges into the opening and is broken off by its metal edge. Suction then removes the fat from the cannula. Blood vessels and nerves are pushed out of the way so there is less bleeding and numbness than one would expect. Because the cannula is narrow, only small incisions are required. Consequently scars are minimal.

To minimize blood loss even more, the tissues are pre-treated with injections of large quantities of fluid containing epinephrine (adrenaline). Epinephrine causes the blood vessels to constrict and thereby reduces bleeding. It also makes the fat easier to aspirate. This is known as the 'wet' or 'super-wet' technique. Up to five liters of fat may be removed from a patient at one sitting for safe day case surgery. More than five liters is an indication for overnight admission.

Advances in technology have more recently given us ultrasonic liposuction (e.g., the 'Vaser'). This device consists of a cannula that transmits ultrasonic energy to emulsify the fat and thereby facilitate its removal. However, the initial tide of enthusiasm for ultrasonic liposuction has now receded through the eddies of peer evaluation. Suffice it to say that although it makes liposuction quicker and less tiring for the surgeon, there are more complications for the patient than with conventional methods. To the 'artists' in the plastic surgery community, the difference between the Vaser and a traditional cannula is the difference between a high power machine tool and Michelangelo's hammer and chisel. Personally, I use the ultrasonic method only in places where fat is hard to extract: the breast and the back. Which would you prefer?

Liposuction has become so popular that many different medical specialists have selflessly taken up the cannula in the endless battle against bulging flesh. Most of these are not actually Plastic Surgeons: many are not surgeons at all. Caveat emptor! Misadventures in aesthetic surgery have resulted from excessive amounts of fluid being removed during liposuction coupled with insufficient intravenous replacement. Injury from the cannula can result from poor knowledge of anatomy and ignorance about the general management of the surgical patient.

The ideal patient for liposuction is of normal or slim build with excellent skin tone, but has atypical bulges of fat in localized areas: for example, the hips, the abdomen, the back, the knees and the thighs. A person who is evenly overweight with loose skin is a poor candidate; however it is fair to say that there is a whole spectrum between these extremes, and everybody has to be judged individually. Because of this, not every individual will have an outstanding result, but many will be improved. Others will need body contouring by other methods.

Liposuction is usually performed under either general anesthesia, or - for very small areas - local anesthesia with intravenous sedation. A five liter liposuction may comfortably be carried out on a day surgery basis, but greater volumes or the addition of other procedures would lead me to recommend an overnight stay.

At your initial consultation, I shall take a detailed history and perform a thorough examination with the object of defining the esthetic problem, establishing your goals, formulating a treatment plan and ensuring that any pre-existing medical conditions may be appropriately managed to minimize risk at the time of surgery. You will have ample time to ask questions and discuss your options in a professional yet friendly setting. The surgery itself will be carried out in a safe environment (a hospital or an accredited ambulatory surgery center) and you will have a board certified anesthesiologist giving the anesthetic. You should be able to return to work in about one week and you will have to wear a compressive garment for 30 days.

Body Contouring

The term: 'body contouring' gives the impression of the human body as a lump of clay that the 'artistic' plastic surgeon sculpts it into a work of fine art - like Michelangelo's David, perhaps. Very few plastic surgeons are artists in the generally accepted meaning of the word - despite self-indulgent posturing, marketing hype and the occasional art creation. The sad truth is that we are dealing with a pre-existing musculoskeletal structure and skin envelope that we can only alter in well-defined and limited ways. We do not have a free-handed liberty to shape the body into whatever form the patient desires. (However, we can make improvements. Read on!)

Body contouring is therefore a misleading term that includes such procedures as liposuction (foolishly and even more misleadingly rendered 'liposculpture' by those with artistic pretensions); excisional surgery after weight loss; body, leg, breast and arm lifts; abdominoplasty and fat injection.

Liposuction (suction assisted lipectomy, liposculpture, suction lipectomy) can remove unsightly bulges of fat from areas where there is a disproportionate amount of it. It has become the most common aesthetic surgery procedure performed in the United States, and is highly effective in the right circumstances. The surgery itself leaves tiny scars. However, if large amounts of fat require removal and if the skin tone is poor - for example, after massive weight loss - the results are frequently disappointing. The loose skin, now unsupported by fat, becomes looser, taking on ripples at best; and, at worst, hanging in folds.

Body contouring involves dealing with the loose skin by removing it and thereby tightening that which remains. Since long incisions are necessary, the scars are more prominent than with liposuction, but are hidden - as far as possible - in inconspicuous places. For example, in arm reductions (batwing correction, brachioplasty) the scar is placed in the armpit or down the inside of the upper arm; in thigh lifts, the scar is located in the groin crease or down the inside of the thigh; in lower body lifts, the scar is sited within the bikini line, and with breast lifts, the scar is positioned around the nipple-areola complex and on the undersurface of the breast.

People who experience massive weight loss, be it from gastric bypass, banding or dieting alone, experience wildly different patterns of skin redundancy. Like all sensible plastic surgery, the techniques used, their combination and their staging have to be individualized to the patient and his or her physical condition. At your initial consultation, I will take a detailed history and perform a thorough examination with the object of finding out your aims, determining what combination of procedures would best satisfy them and ensuring that any pre-existing medical conditions may be appropriately managed to minimize risk at the time of surgery. You will have ample time to ask questions and discuss your options in a professional yet friendly environment.

Finally, if you are ever sitting in a plastic surgery office and you glimpse a bronze cast of the 'artist's' hands, take my advice and head for the door.

Abdominoplasty (Tummy Tuck)

Abdominoplasty is synonymous with 'tummy tuck,' but the modern abdominoplasty involves more than that simple descriptive implies.

People seek aesthetic surgery of the abdomen for different problems: some have stretch marks from pregnancy; others have a loose fold of skin due to a significant weight loss; still others have fatty accumulations on their tummies and flanks. In some individuals there is a weakness or separation of their rectus muscles contributing to a 'pot belly' appearance.

Clearly it is important that the surgery be individualized since no two patients are the same and the surgical options do vary. Some patients come to see me for abdominoplasty when all they really need is simple liposuction alone. Oddly, it is far more common the other way around!

In the operation, a transverse ellipse of fat and skin is removed from the lower abdomen and the remaining upper abdominal skin is drawn downwards to close the defect left by its excision. This results in significant tightening of the tummy, particularly when the muscles are plicated (tightened) at the same time. The belly button is preserved and repositioned in its correct location, and liposuction is performed in select areas. The final result is a firm, contoured abdomen with a transverse scar in the bikini-line.

At your initial consultation, I will take a detailed history and perform a thorough examination with the object of finding out your aims, determining what combination of procedures would best satisfy them and ensuring that any pre-existing medical conditions may be appropriately managed to minimize risk at the time of surgery. You will have ample time to ask questions and discuss your options in a professional yet friendly environment. Generally, abdominoplasties are performed under general anesthesia in a same day surgery setting. However, if combined with another procedure such as breast lift or augmentation (the so-called 'mommy makeover'), then an overnight stay in the facility is recommended. You should be back to work in two to four weeks.

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