Category Archives: Blog

Breast reduction surgery and obesity

Numerous studies and our own large experience have shown that breast reduction surgery is very successful in relieving symptoms in a wide range of patients, regardless of their weight. However, studies have shown that obese patients (defined a Body Mass Index of 30 or more) undergoing surgery are more prone to complications at the time of surgery and during recovery.   While the overall risks of complications still remains low with breast reduction and the surgery goes very well for most patients regardless of their age, breast size or weight, we want to make you aware of these increased risks that we have noted in performing several hundred of these procedures.

Wound Healing Problems    The blood flow to the skin and breast tissue is altered by the removal of breast tissue and skin undermining during surgery. The effect of this decreased blood flow increases the risks of wound healing problems more in obese patients. While these wound healing problems are generally minor and do not require additional surgery, it may mean that there are areas along the incision lines that will require wound care (antibiotic ointment application and gauze) for several weeks. While healing is delayed the final result is usually not significantly affected.

Persistent folds on the sides and back   Many patients who are significantly obese have folds of excess skin and adipose tissue that extend from the side of the breast and wrap around the chest to the back. These cannot be removed by breast reduction surgery alone and require a more extensive procedure which is outside of the scope of the standard breast operation covered by insurance. We will do our best to minimize and improve the appearance of these folds during your breast operation but cannot eliminate them entirely.

Major complications  Major infection, bleeding, cardio-respiratory problems, blood clots, and other significant complications seem to occur more often in obese patients in some studies but we have not observed this in our practice. If we feel the  risk of these complications is too high because of other medical conditions we will not perform the surgery. The incidence of all these complications is very low making it difficult to spot any trends in our practice.

Minor complications  The appearance of scars, changes in nipple sensation, asymmetry, post operative pain, and others do not appear related to the patient’s weight at the time of surgery in our experience.

Some practices reject patients for breast reduction surgery based solely on an elevated BMI. We feel this is arbitrary and wrong and our experience proves it. We have had great success in performing breast reduction surgery on all patients regardless of weight, age and breast size and welcome the opportunity to care for these patients.


All I can say is “Wow”.  We’re really impressed with the results we’ve been getting with microneedling!   Although this skin treatment has been around for years with so-so results, the new technology which refines and mechanizes this technique with high speed untrafine micro needles is giving us better results at a lower cost than anything we’ve seen.  We now have a treatment that we can use year round with lower cost and less downtime than laser treatments and we’re finding it’s great for skin rejuvenation and even acne scarring.

I have to give our aestheticians, Patty and Cheri, total credit for this one.  They urged me to take another look at microneedling, a technique I had looked at a number of years ago when it was being done with mechanical rollers and was unimpressed.  They arranged for a demo of the SkinPen in our office on some patients and staff and we liked what we saw.  We completed our training and in just over 2 months they have done over 100 treatments, mainly on the face, neck, and chest.  Patients love the results and are telling their friends.  We have introduced this at our Topeka Elite Esthetics office as well with similar enthusiasm.  In over 20 years I’ve never seen a new treatment, device, or procedure that was so rapidly embraced and asked for by our patients.

Those of us who have been in the skin rejuvenation field for many years  are accustomed  to hearing the exaggerated hype that comes with any new product, procedure, or device. We tend to be pretty skeptical.  But we think this one is the real deal and is here to stay.


Abdominoplasty and BMI

We were recently asked by a patient how BMI affects our decision to perform abdominoplasty. We thought this was an excellent question and I’ll paraphrase it below.

Every case is individual and I don’t necessarily have a cutoff or absolute BMI number that determines if I will or won’t do an abdominoplasty. I lot of factors play into the decision.

I tell all my patients I want them to be at a stable weight before the surgery. Significant weight changes after the surgery can compromise your result. I don’t insist patients reach an “ideal” weight, but at least I’m not trying to aim for a moving target.

Lower BMI patients are generally going to get a better result than higher BMI patients, but I’ve had many higher BMI patients who were extremely happy with the amount of improvement we were able to achieve. They were realistic in their expectations and I was able to meet or exceed these.

In the higher BMI patient, I consider multiple factors before deciding if I will recommend an abdominoplasty. These include:

Overall health and potentially complicating medical conditions
Weight distribution
Previous abdominal scars
Potential for improvement
Patient expectations
and other factors

If I don’t feel the operation can be done safely or the result will fall short of the patient’s expectations, I’ll tell them at the consultation. I’d rather disappoint them at our initial consultation than have them be disappointed (or endangered) by the operation.

The Team Approach to Breast Reconstruction

As recent articles in the media have stressed, successful breast cancer treatment and reconstruction involves close collaboration among all those treating the patient. Angelina Jolie and her plastic surgeon have been very public about her mastectomies and reconstruction and have helped shine a light on the importance of a close, collaborative relationship among the doctors and patients. We couldn’t agree more.

We are fortunate to have such a team here in Lawrence, and have recognized the importance of this team approach for many years. Even before establishing the Breast Center around 10 years ago we were already working closely with our general surgeons, oncologists, pathologists, and others to begin planning a treatment strategy for the patient shortly after the diagnosis of cancer was made. As reconstructive surgeons, we often meet with patients early in the process to discuss available options and make suggestions as to the most appropriate reconstructive approach and timing (immediate or delayed). Most importantly, we have often already been in communication with your other providers before we even meet you for the first time and continue to work closely with them throughout your treatment. Even if a patient chooses not to undergo reconstruction at the time of her mastectomy, we can help her make this informed decision and even become involved in the mastectomy planning, so that incisions are placed to make reconstruction easier in the future if the patient should change her mind.

Breast reconstruction should not be seen as an isolated procedure but part of a collaborative effort to treat the breast cancer patient and restore her to physical and emotional health. Communication is an old fashioned, low-tech approach that consistently makes our advanced treatments work better.

No-drain Abdominoplasty

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 if we can do it for you.

The “Refresh” lift

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.

Why is it important to be nicotine free before surgery?

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.


Does liposuction help with weight loss?

Not really.  While a patient may lose a few pounds after the procedure, it really is not an effective weight reduction tool.  Frankly, there are a lot easier and cheaper ways 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, it 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 causes 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 you really are trying to lose weight rather than trying to do it with liposuction.

Do you do the DIEP flap for breast reconstruction?

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.

Is breast reduction surgery covered by insurance?

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.