Traditional abdominoplasty procedures have always involved the placement of drains to prevent abnormal fluid collection beneath the recently moved skin to prevent fluid collection.  These are flexible tubes placed during surgery which attach to small suction bulbs, continuously pulling out fluid for the first few days or occasionally weeks after surgery.  The drains are left in place until the fluid output decreases, and then are removed during an office visit.

What’s wrong with drains?

While having drains in place after an abdominoplasty is generally not painful, many patients find them to be a real nuisance.  They must be emptied 2-3 times a day, can be difficult to conceal under clothing, the site where the drain exits the incision or drain requires care, they sometimes clog, and they may inhibit showering or bathing.  If they are removed too early, fluid may accumulate beneath the incision which will require drainage.

The No Drain abdominoplasty

When performing a no-drain abdominoplasty, additional sutures are placed between the abdominal wall and the overlying fat and skin, closing off the space where fluid would otherwise accumulate.  In addition to making drains unnecessary, the sutures are used to relieve some of the tension on the final skin closure, potentially helping to keep this scar from widening.  The procedure takes a little longer to do, but the convenience and comfort for the patient after the operation certainly makes it worthwhile.

We can’t perform a no-drain abdominoplasty on every patient, but find that it is possible for most.  Be sure to ask us during your consultation we can do it for you.

For many years, we looked for a facelift that bridged the gap between a full facelift and the non-invasive lift procedures (laser, Fraxel, string lifts, feather lifts, etc.).  Traditional facelifts are great, but are a little more extensive than many of our patients needed.  Non-invasive facelifts have limited down time and risk, but the results are generally fairly limited and of short duration.  We had many patients, especially those in their 40’s, 50’s and 60’s, that needed a procedure to improve their modest age related sagging but weren’t ready for a full face lift.

We became interested in the principles behind the MACS lift, a short incision facelift that lifted the face in a more vertical direction while keeping the incision scar shorter.  After reviewing the studies in the plastic surgery literature, hearing the presentations at national meetings, and hearing about the advantages and limitations directly from the early innovators of this procedure, we began adapting this procedure and modifying it to fit our patients.  Around the office, we nicknamed this procedure the “Refresh lift” as it best described the results we were seeing in our patients.

Why do we like it so much?

First, this is a real facelift.  We reposition the deep tissues, remove excess skin, and reshape the underlying tissues in a way that is impossible with non-invasive facelift techniques.  Yes, there are incisions, swelling, bruising, and some downtime, but the results are more significant and long lasting than non-invasive techniques.

Second, it utilizes shorter scars and less extensive surgery than a traditional facelift.  It takes less time to do, and patients generally recover faster than with a traditional facelift.

Third, the result is natural looking, not pulled and tight.  With a more vertical lift, rather than a backward pull, you are less likely to see that “wind tunnel” appearance of an overdone facelift.

Finally, the whole concept makes complete sense.  As we age, the force of gravity pulls the face falls down, not forward.  To reverse this, it only makes sense to lift the face up, not pull back.  The Refresh lift utilizes this vertical lift to give the face a more youthful appearance without the unnatural pulled look.

We have been doing the Refresh lift for several years now, and have really been impressed with the results.  We still do full facelifts and necklifts as well, but this has now become our most popular procedure.

While smoking is detrimental to a person’s health for a number of reasons, it is poses particular problems for patients undergoing surgery.   Nicotine, whether from cigarettes, patches, gum, etc., causes vasoconstriction in the small vessels that we count on to heal newly created wounds.  This is especially true in certain procedures where the normal blood supply is disrupted and the tissues are tightened at the time of closure, such as with a facelift, abdominoplasty, breast lift, breast reduction, and breast reconstruction.

We feel strongly that in certain cases the risk of significant wound healing problems outweighs any benefit we would provide with the procedure.  In these types of cases, we will decline to do the operation unless our patient is nicotine free.  This does not apply to all procedures we perform, so be sure to ask us when this rule applies.

Some patients may choose to go elsewhere for their surgery because of our caution on this issue.  While surgery on patients that use nicotine products can be successful in some cases, we feel the risks of a bad outcome are unacceptably high.

Not really.  While a patient may loose a few pounds after the procedure, it really is not an effective weight reduction tool.  Frankly, there are a lot easier and cheaper was to lose a few pounds!  While large volume liposuction has been done in which 10 or more pounds are removed, we don’t advocate this as a procedure to be used when weight loss is the primary goal.

Liposuction is really designed as a method to contour the body by removing excess fat from specific areas.  Used alone, can be a great way to get rid of excess fat in the outer thighs (“saddlebags”), abdomen, flanks (“muffin top”), and other areas in a patient who is otherwise well proportioned.  We also find it a helpful technique when combined with other surgery, such as to improve the contour of the trunk during an abdominoplasty.  We utilize the tumescent technique to perform liposuction, which allows us to use smaller diameter cannulas and cause less blood loss than traditional liposuction.  Although there are a number of newer technologies being marketed as significant improvements in liposuction which use ultrasound, laser, water jet, freezing, etc., we have not yet found that the overall results are really any better than those achieved with tumescent liposuction.  In any case, it’s the surgeon, not the machine, that determines your result.

The list of ways to lose weight is a long one.  Various diets, regular exercise, medications, supplements, medically supervised weight loss programs, gastric surgical procedures, and more.  We would recommend exploring these options if what you really are trying to lose weight rather than trying to do it with liposuction.

We don’t do the DIEP flap at Lawrence Plastic Surgery for several reasons.  A recent article in our local paper discussed this procedure being performed at a nearby teaching hospital and pointed out they were the only ones performing this procedure within “several hundred miles”.  Although this procedure was first being performed almost 20 years ago, it has not gained widespread popularity.  Here’s why:

• It requires a much longer operating time than other techniques, especially if both breasts are reconstructed immediately after mastectomy.  In the same recent article the patient mentioned her “14.5 hour surgery”.  This is significantly longer than a traditional TRAM flap operation or tissue expander/implant reconstruction.  Longer operations, as you can imagine, are harder on patients than shorter ones.

• The post-operative stay is significantly longer after this surgery as compared with a tissue expander/implant reconstruction.  Most of our immediate reconstruction patients are discharged the day following surgery when we use a tissue expander reconstruction as opposed to several days after a DIEP flap.  The time to return to normal activities, including work and exercise, is much longer with a DIEP flap.

• The advantages of a DIEP flap over a pedicle TRAM flap (which we perform) are still debated in the plastic surgery community.  As we only utilize a portion of the abdominal muscles in a pedicle TRAM, functional muscle loss is usually not significant in most patients.

• Tissue expander/implant reconstruction is getting better all the time.  The use of skin/areola/nipple sparing techniques along with the use of acellular dermal matrix products (Alloderm, etc.) and better implants has given us much better results than even just a few years ago.

• Many patients are simply not good candidates for a DIEP flap due to inadequate tissue, body habitus, or other medical problems.

• The available abdominal tissue in a DIEP reconstruction determines the size of the reconstructed breasts.  With tissue expander/implant reconstruction, a patient has more options in determining the final size of her breasts.

While we admire those surgeons who are performing the DIEP flap, and many patients can attest to their good results, we still have misgivings about performing this procedure, as do many other plastic surgeons involved in breast reconstruction.  There are more than 10 times as many breast reconstruction operations performed with tissue expander/implant techniques than the DIEP flap.  We believe there is a good reason why the number of tissue expander/implant reconstructions continues to increase year after year while the number of DIEP flaps performed has remained relatively flat over the years despite initial enthusiasm about this procedure.

Usually.  When we meet with a patient we discuss their symptoms and history of treatment, exam and measure the breasts, record their height and weight, and take photographs.  After the visit, we will write a letter to your insurance company discussing our findings and ask for a predetermination as to whether the procedure will be a covered under your policy.  Depending on the company, we usually get a response in 1-3 weeks.  Once they have given their approval, we can arrange to get your surgery scheduled. While breast reduction surgery is a covered benefit under most policies, some plans do not provide it as a benefit.  Unfortunately, if your plan excludes coverage of this procedure, there is simply no way we can get around this.  In order to have the operation, you would have to pay for it yourself (many patients do and consider it money well spent) or wait until you change to a different insurance plan that covers the procedure. Sometimes the amount of tissue we plan to remove does not meet the threshold for coverage by your insurance company.  For example, we might estimate that we will be removing 500 grams of tissue (a little over a pound) from each breast at the time of surgery but your insurance company guidelines say 800 grams need to be removed from each side for the surgery to be covered.  In this case, we are in a bind.  If we remove enough tissue to get the procedure covered, the result might be very disfiguring for the patient.  We do our best to avoid this situation by accurately stating the amount of tissue we will remove in our predetermination letters.  In all honesty, there are a few insurance companies that set their threshold for coverage so high that only patients with ENORMOUS breasts could ever qualify.  Fortunately, most insurance companies are more reasonable. If you are denied coverage, the letter from the insurance company will usually give an indication why they have reached this decision.  If it is an “excluded benefit”, then you’re out of luck.  No amount of appeal will change this unless your policy coverage changes.  Sometimes they may request additional information such as records from your primary doctor, chiropractor, physical therapist, etc., documenting your efforts to seek non-surgical relief from your symptoms.  Some companies have requested we call their physician reviewer directly for a phone conference to discuss the patient and we have sometimes (not always) been successful. While it is not really our job to coerce your insurance company into paying for your surgery, we will do our best to accurately convey our findings and opinions and help make the case for coverage when we feel you have a valid claim and help guide you through the process.

Patients who are considering breast surgery such as breast augmentation, breast reduction, or a lift often ask us about their ability to breast feed after surgery if they have children.  They want to know if breast-feeding will be possible, and have often heard different answers from various medical practitioners and friends.  The answer depends on the type of surgery being performed and how it will be done.

After Breast Augmentation

In most cases, yes.   Of course that’s the same answer I would give a woman who has not had a breast augmentation.

Most women without breast implants are able to successfully breast feed their babies, but some struggle with inadequate milk production, mastitis, and other problems that may make breast-feeding difficult.

The same could be said for women after breast augmentation.  Because the implants are placed behind the breast tissue, pushing it forward, the glands and ducts that allow for milk production are left intact.  Therefore, although most women are able to breast-feed after surgery, it cannot be guaranteed.

After breast reduction and breast lift (mastopexy) 

As in the case of breast augmentation, the answer is usually yes, but the full answer is a little more complicated.

I always ask patients who have previously had children about their ability to breast feed during the consultation.  I am struck by how many of these patients describe difficulties despite the large amount of breast tissue present.  When I warn patients about the possibility that a breast reduction operation may interfere with breast-feeding, most are willing to accept this potential loss.  To paraphrase these patients, “If you think my breasts are big now, you should have seen me when I was pregnant!  I’m not going through that again.”

Since breast tissue is actually removed during the operation, the technique used during the operation may affect the ability to breast feed afterward.  We utilize a technique that has proven to be reliable in preserving the nerves, ducts, and blood supply to the nipple, and therefore most patients are able to breast feed successfully after surgery.

Rarely, the breast is so large that we must actually remove the nipple completely from the breast and place it back on as a graft.  When we anticipate this will be required, we tell our patients preoperatively that they will not be able to breast feed after surgery.  In almost 18 years of breast reduction surgery, I have only had to perform this type of reduction twice, and both patients were past their childbearing years.

With a breast lift, we typically are removing little to no breast tissue, so the chances of disrupting nerves, milk ducts, or the blood supply to the breast tissue are less than with a reduction.  However, there is still a chance to interfere with breast feeding if a significant reshaping is performed.

In summary, while most patients are able to breast-feed after a reduction, breast augmentation, or breast lift, we cannot guarantee it.  If this is a risk you are unwilling to take, it might be better to delay your surgery until after you are finished having children.

Are silicone implants safe?

There were certainly problems  associated with the silicone implants made many years ago which prompted them to be removed from general use 20 years ago until further research could be performed.  The result was that many manufactures left the market, many designs were abandoned, vigorous research and close follow up of patients with silicone implants was performed, and much was learned.  The result is that we now know more about silicone implants than ever before, the implants now manufactured are much better that those made in the 60’s, 70’s, and 80’s, and I feel confident recommending them for my patients.

What’s different now?

1)    The outer shell of the implant is thicker and stronger than many of the older styles.

2)    The silicone gel that fills the implant is thicker and more “cohesive”, meaning that it doesn’t leak out of a small hole in the implant as in the older styles.  In our office, we can demonstrate this to patients by sticking a large needle in an implant without any of the gel leaking out.

3)    The implants are tracked carefully by the manufacturer.  While respecting federal laws concerning privacy, this allows the manufacturer to notify patients in the future if there is ever a problem discovered with their implants.

4)    Studies of thousands of patients who have implants have indicated there is no increase in systemic illnesses (autoimmune disease, breast cancer, and others) associated with silicone breast implants.

We were among those physicians who participated in the adjunct study trial which allowed us to place silicone implants in certain patients (mainly patients who had undergone mastectomy) in the years when their use was restricted by the FDA and therefore have been using silicone implants for almost 15 years.

While we feel confident recommending silicone implants to our patients, we are also comfortable placing saline filled implants when this is a more appropriate choice for the patient.  We’re always happy to discuss the differences between these implants, and will do our best to give patients a good result with whichever implant they choose.