A question we are often asked by our patients is about insurance payment for extra skin removal.  In general, insurance companies consider the medical problems from obesity are covered, but the excess skin is a non-covered cosmetic defect.  This is in keeping with their attitude that the premature wrinkles and aging of the face experienced by smokers is a non-covered cosmetic defect while lung cancer and heart disease are covered.  Exceptions to the rule revolve around the skin excess causing a medical situation.  Frequent rashes , skin breakdown or ulcers are medical complications of excess skin which should be treated by doctor and patient alike.  In extreme cases, this situation may warrant excess skin removal surgery.  Good documentation by the treating physician will help the insurance company decide on reimbursement in these unusual situations.  It is our aim to advocate for your medical care.  At the same time, we must help you to have realistic expectations regarding your health insurance coverage.

A tummy tuck, or abdominoplasty, is, in my opinion, the most dramatic body contouring procedure.  A tummy tuck can refuvenate the adomen.  The abdomen’s muscle, fat, and skin layers are made tighter and more defined.  Over the years, many techniques have been developed to improve the procedure.  Previously, that improvement was limited to the front of the abdomen.  Each technique has enhanced the result.  Liposuction of the hips, the thigh lateral tension suturing, and central abdominal liposuction with minimal undermining, all have thier advocates.

Startign in the mid-90’s, we noticed something about our major weight loss patients.  Those who had lost 50-100 pounds or more from surgery or medically controlled diet and exercise, were complaining not only of skin excess on the abdomen, but also the sides and buttocks.  Some of these patients had such an excess, that we felt obligated to extend the abdominal incision all the way around the patient to remove the excess.  What we began to notice was that the thighs and buttocks looked so much better after this more extended type of tummy tuck.  A lifting of the thighs and buttocks had occurred.

Trying to learn from this experience, we began to offer to other patients a more extensive, or extended, tummy tuck.  Not necessarily all the way around the patient in every case, the incision did extend around to the posterior hip area just above the buttocks.  Removing skin in this area lifted the thighs and buttocks.  This extension has, in my opinion, revolutionized the tummy tuck operation.  Now a patient’s appearance can be improved in the back as well as the front, obtaining a buttock-thigh lift at the same time as the abdominal improvement. 

The extended operation does leave a longer scar.  We mark it before surgery so that it may come to lie underneath the underwear or bathing suit line.  It does not add much to the healing time, but does add about two hours to the operation. 

While not everyone wants to trade a scar for an improvement in the thights and buttocks, those that have made this decision have been glad that they elected the extended tummy tuck.

In the 80’s, there was a renaissance in plastic surgery of a reconstructive nature.  New operations and techniques were invented which benefited patients greatly.  This period of innovation and learning led to the next wave, a renaissance of cosmetic surgery.  Other factors, of course, contributed to this.  Other medical and surgical specialists began using various types of fiber optic scopes and video cameras and created the wave of minimally invasive surgery through small incisions. 

Out of this era arose a technique which, because of the learning curve, remains relatively uncommon.  An attitude shift is required that the surgeon must accept using an endoscope. 

Starting as a novel way to hide the augmentation scar away from the breast, the logic has evolved.  The technique produces, in my opinion, better visualization of the tissues by magnifying the surgical field and placing it onto a large video screen for all to see.  I believe that I can see better.  Just as important to the operation, everyone in the operating room can now follow the progress of the operation.  I believe that assistants who can follow the procedure do their jobs much better.

Previously limited to saline implants placed into the pocket then inflated with saline, recent modification allows us to use silicone gel implants if desired by the patient. 

I do not believe that any one technique is best for all patients.  However, I have come to believe that endoscopic breast augmentation is not only an excellent way to hide the scars of augmentation, but remains an excellent new alternative to obtain much better visualization of the operation.

In other countries, a buttock augmentation involves soft implants beneath the gluteus muscle.  We cannot currently obtain these implants in this country.  There is, in addition, a higher infection and extrusion rate than that of breast implants.  The most successfult buttock augmentation in this country currently appears to be an auto-augmentation using one’s own fat to obtain extra volume.  Liposuction done very gently with syringes can harvest healthy fat cells for transplantation into the buttocks.  The limitation is that individual volumes of successfully transplanted fat appear to be on the order of 1/100 of a ml, or 1/3,000 of fluid ounce at a time.  This means that to obtain an augmentaion of 10 ounces, or 300 ml of fat for the entire buttocks, a small to modest increase in volume would take around 30,000 individual passes of the liposculpture syringe.   Injected individual volumes of fat much larger than 1/100 of a ml seem not to survive in the long run.  Therefore, such a buttock auto-augmentation takes many hours if done properly.  The other type of auto-augmentation is done while doing a buttock lift.  The extra fat normally removed from the upper buttock is instead left attached to deeper tissues, folded down, and allowed to fill the lifted buttock space.  A potential drawback is the relatively unpredictable survival of the fatty tissue.  In my opinion, this is a very difficult operation in which to obtain symmetrical results.  In addition, this type appears to me to have a rather male looking result, the augmentation being a little too much toward the center.  Luckily, I find that the majority of female burrocks I have been asked to evaluate, seem to have a greater problem with dropping or sagging of the tissues rather than an absolute loss or absense.  Lifting the tissues up appears to restore the colume where it needs to be.  A buttock lift involves the careful placement of a curved incision at the top of the buttocks to lift up the tissues to their original position.  If one looks in the mirrow and places her hand on the hip, just above the buttocks, and pulls upsward, she will see a demonstration of what a lift can do.  This lift is often done at the same time as an abdominoplasty or tummy tuck.  Although it can be done as a separate procedure, when doing the two at the same time is is called an extended abdominoplasty.  They result is improvement all the way around the patient.  After all, a healthier looking backside seems to go very well with a healthier looking abdomen.

There is a saying that if there is more than one way to do something, then either all of the ways work, or none of them work.  With facelifting, all work to some extent, but none provides an ideal approach.  Here are a few observations.  First, facial rejuvenation involves the observer patient, and the artist plastic surgeon.  No one technique is suitable for all patients.  No scientific study will narrow the options to one for all.  Second, in our efforts to constantly improve, plastic surgeons sometimes fall prey to egoes.  Not only do we sometimes name a new technique we have developed after ourselves, we might then promote it as the new best thing.  Sometimes the rest believe that for awhile.  We try to learn what works, and to keep it, discarding the hype eventually.  Third, all facial rejuvenation techniques work to some extent on everyone.  No technique is permanently rejuvenative on anyone.  Fourth, the spectrum of techniques that a given plastic surgeon uses is likely the safest one for that sugeon to use.  Therefore, in my opinion, please choose your plastic surgeon well.  The technique will then reveal itself to both of you.

But what does the sun have to do with all this?  Well, during this remodeling process, the skin is repopulating the injured area with cells it deems necessary.  These include pigment cells.  If the healed wound or scar detects sufficient sunlight during this time, it will send more pigment cells to live in this scar.  This will result in a darker shade than the surrounding skin. 

Do I have to go out only at night for a year after surery?  Do I have to wear impervious, opaque clothing?  No.  Just wear waterproof sunscreen SPF 18 or higher on your scar and be reasonable about your sun exposure.  You should be just fine if you are careful about sunscreen.

Well, nearly 30 years later, I know that it does work to some extent.  As it is one of the most frequent operations in the country, I am glad of that.  Suction removal of fat, ultrasound assisted, or laser-assisted removal can remove a reasonable amount of fat from under someone’s skin.  For those people who happen to have an abnormal deposit of fat, say one where it seems to run in the family, liposuction may help.  Notice I said “reasonable” amount.  If one removes a large amount of fat, liposuction becomes a bigger and different operation.  One must be aware that fat removal becomes a less benign operation as the volume of fat being removed goes up.  For it to be successful in most people’s opinion, liposuction requires relatively elastic skin.  Contrary to many ads and claims I have seen, liposuction does not appear, to me, to tighten skin.  An aged person, a person who has lost lots of weight, or one whose skin is loose,  are poor candidates for liposuction.  Good candidates are relatively healthy people near their ideal weight who have discreet fatty deposits.

In February of 2009, Dr. Harlan Pollock gave a talk on drainless tummy tuck.  He demonstrated a technique of additional suturing of the abdomen which tightened and obliterated the space in which we normally put drains.  He implored us to have a little faith and some courage to try to make this operation better for our patients.  Fifteen months into this new experience, we now have patients who will never know what drains are like.  They deal with healing from surgery without having to trail drains along with them.  They get to enjoy their new abdomen a few weeks earlier.  The emotional healing is now much better, in my opinion. 

On behalf of our patients, thank you, Dr. Pollock.