Tummy Tuck West Palm Beach by Dana M. Goldberg MD Tummy Tuck Plam Beach
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Palm Beach Cosmetic surgery Expert Dana M Goldberg MD discusses Tummy Tuck surgery, and loose skin removal options. As a Female Board Certified Palm Beach Plastic Surgeon Dr. Goldberg has completed too many tummy tuck surgeries to count. This presentation is intended for Tummy tuck West Palm Beach patients. http://www.drdanamd.com
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Tummy Tuck West Palm Beach by Dana M. Goldberg MD Tummy Tuck Plam Beach
- 1. Body Contouring After Massive Weight Loss Palm Beach Plastic Surgery Center www.DrDanaMD.com This presentation is only for education purposes only. Any medical advice can only be given during a consultation.
- 15. Arm Lift Area where skin is removed What the incision will look like after healing www.DrDanaMD.com
- 17. Breast Incisions Amount of skin removed in light tan The incision will be around the areola, down to the breast crease, and then side to side in the breast crease. www.DrDanaMD.com
- 20. Thigh Incision Where the incision will lay. Where the skin is removed www.DrDanaMD.com
- 27. The Pictures . . . www.DrDanaMD.com
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- 62. * No Implants www.DrDanaMD.com
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Notas del editor
- Congratulations for being here and taking difficult steps to improve your health by losing weight. Your weight loss means a healthier body for you…fewer problems with blood pressure and diabetes, and a lower risk of heart disease. But, you may not be as happy with your new shape as you would want to be. This entire presentation is dedicated to showing you how you can start to enjoy your weight loss on the inside AND the outside. In 2007 over 360,000 body contouring procedures were performed in the US. I will talk with you tonight about what surgeries are possible and what you can expect with insurance coverage, the risks involved, and your recovery. Let ’s get started…
- The most important question is “Will I need surgery and if so when?” Most people will need plastic surgery after you losing about 50 pounds or more. When you gain weight, your body actually grows new skin over time. It is almost impossible for the body to shrink down the skin down to fit your new, thin body. Plus, gaining and losing weight ruins the elasticity, so that it CAN ’T shrink even if your body wanted to. It’s like when you stretch a t shirt over your knees for too long when you were little, and it wouldn’t go back to the normal shape. Also, there are protein fibers iust under the top layer of the skin like rubber bands. When you gain and lose too much weight too quickly, the bands snap and cause stretch marks. The skin can ’t be fixed, and the stretch marks, like any scar, may improve over time, but the only way to get rid of them is to remove the skin. The problem of extra skin is so bad that many patients are not able to fully enjoy their weight loss. Many patients tell me that they look in the mirror and still see them selves as very overweight because of all that extra skin. It is as if you only see extra skin and wonder if you are really better off. Skin reduction surgery after bariatric surgery will be the final step in your journey. It will let you look as good as you feel. Your skin will fit your new body!
- People always wonder if exercise will simply take care of the problem of extra skin. Unfortunately, it will not. The reason is that exercise only affects the muscles of the body and does not affect the skin at all. This means that if you have a very, very small amount of extra skin, exercise will take care of it by making your muscles bigger so that the loose skin is “filled” up with muscle. Almost like putting more stuffing in a pillow to take up the slack in a pillow case. However, it would be impossible for most people to grow their muscles to the point that all of the extra skin is used up. That is why surgery is the only way to help your body finally lose that extra skin.
- So, when do you need to start thinking about skin reduction surgery? The most important factor is how much weight you are still losing. When your weight loss is 1 to 2 pounds per month, you are ready for the initial consultation. If you are still losing 5-10 pounds per month, your body is still in a “destructive” phase and would not be ready to heal from surgery. Also, if you continue to lose weight once your skin in tightened, you will have more loose skin and the results of your surgery won’t last. BMI <30 decreases complications by half compared with higher BMI. You will also need to plan when you want to have skin reduction surgery (when you can take time off work, when you can be away from household duties/picking up small children). The initial and preoperative consults, scheduling, and financing issues can take up to 2 months. So try to come in for a consultation about 3 months before you actually plan to have surgery.
- Non smoker (smoking increases risk of wound healing problems, blood clots, and breathing problems after surgery) Stable comorbid diseases (bp and blood sugar under good control) Adequate nutrition (protein, vitamins…keep in close contact with your pcp and bariatric surgeon) Expectations: body will never look like you weren ’t overweight. Extra skin can be removed, but it will never look the same (stretch marks, thin skin) Always keep in mind, you are trading the shape you want for scars (the more extra skin you have, the longer the scar will need to be to improve the shape).
- The financial aspect of surgery is something that deserves careful consideration. My patient coordinator, Rosy, and my billing specialists Angela and Terry have years of experience in plastic surgery and will work with each patient to do everything possible to help the insurance process. Unfortunately, the insurance companies are not as cooperative. Sometimes, even when it is medically necessary, they will still not pay for the surgery. Some insurance policies or employers specifically exclude surgeries related to weight loss. So how do insurance companies decide if it ’s medically necessary?...
- The most common medical problem is called intertrigo. This is the medical term for rashes, yeast infections, or boils in the folds of your skin. For insurance companies to believe this, the problem must be documented by photographs or by notes from your family doctor. At your consultation, please mention if you have ever been prescribed antifungal powders or ointments or if you have taken antibiotics for rashes or infections underneath the folds of your skin. Many people with open bariatric surgery will have hernias. Unfortunately, having a hernia does not guarantee that you will have skin removal from your abdomen approved. Even if it ’s not covered by insurance, you can still benefit from combining the procedure with another abdominal surgery that is covered by insurance since this will help defray some of the costs of anesthesia. Plus you can recover from both at one time. Another factor insurance companies sometimes consider is if you have difficulty walking because of excess skin that hangs down from the abdomen or thighs. This is harder to prove to the insurance companies and often requires several appeal letters, but it does apply to some patients.
- There are two main ways to help reduce the skin on the abdomen. The first is a panniculectomy and the second is a Abdominoplasty. The belt lipectomy addresses the stomach plus the extra skin of the lower back. It also helps lift the buttocks and outer thighs. Results depend on: Distribution of Fat and your body shape Location of scars on abdomen (sometimes limits the amount of lifting due to effect on the blood supply to the tissues) Hernias Skin tone and Quality Tattoos may be removed (sometimes partially!)
- A panniculectomy removes only that skin that hangs over the groin area. It does nothing to the all of the extra skin above the belly button, doesn ’t tighten the abdominal “six pack” muscles, it doesn’t address the groin area or the overall shape of the belly. The incision for this is across the bottom, from hip to hip. This is the most commonly covered operation covered by insurance.
- The next level up is to perform a true tummy-tuck. In this operation there are four things that make it better then a panniculectomy. It tightens the muscles in your belly, removes ALL of the extra skin, tightens the groin area, and shape the belly into an hour glass shape. The skin within the white lines is all of the skin that is removed with the anchor incision. The arrows show how the skin is pulled together. You can see, this incision would also pull some skin from the back and tighten that also. For patients that have lost a lot of weight, most will have excess skin in two direction, sideways and top to bottom. The incision is like an anchor, across the bottom of the belly, from hip to hip and then straight up and down. Therefore, you can see, the anchor incision is the only one that will remove all of the extra skin . The lower incision is hidden by underwear. This will give you a belly that is flat, firm, tight, and as thin as possible. It can sometimes be combined with liposuction in certain people to improve the shape even more
- This can often help change up to 6 sizes in clothing. In many patients, losing weight can result in deflation of the tissues. In those patients, tightening the tissues can flatten their buttocks further. Some patients benefit from rearranging the tissue instead of removing all of it. This helps shape the buttocks while giving a buttocks lift.
- Surgery is usually done in an outpatient surgery center, but sometimes needs to be done in the hospital with an overnight stay. This depends on your medical problems and the extent of surgery you are having (lower body lift vs panniculectomy) Drains for 10-21 days on average (some may come out a little sooner, some may need to stay longer, and a few need to be put back in) Binder should be worn for 3 weeks at all times and another 3 weeks around the house. This helps prevent fluid collections and helps show the final contour sooner.
- For many people after weight loss, the excess skin on the arms can be very disturbing. It can prevent you from wearing certain types of clothing and it is hard to move your arms without being self-conscious about them. The incision for the arm surgery starts at the elbow and goes up to the armpit. In the armpit, it goes side to side. In the end, it will look like a “T”. Rarely, just the incision in the armpit is necessary, but 95% of the time, the full incision is necessary to remove all the extra skin. I try to keep the scar above the elbow because the scar tends to look very obvious below the elbow, but for some people, the amount of extra skin might make a longer incision worth it to get a better shap. This is an outpatient surgery, and you will not usually have drains. You will need to have ace wraps around your arms for about 6 weeks after surgery to prevent fluid collections and to help achieve the final shape sooner.
- Risks: same as abdominal (fewer risks of blood clots and serious complications). Same risk (1-2%) of infection or bleeding. Also, risk of damage to nerves of the arms causing areas of numbness.
- Many women are upset that after their weight loss they have lost all the fullness and firmness in their breasts and have no cleavage even in push up bras. It is possible to lift the breast tissue by removing extra skin and rearranging the breast tissue The incision for the breast is around the areola, straight down to the breast crease, and then side to side in the breast crease.
- An important decision will need to be made, about whether or not to have implants. Many women hear the word implants and they think that means they have to be big. This is absolutely not true. Implants can be used just for shaping so that the breast can look as good as possible. Implants benefit most patients who have lost a lot of weight. Today ’s implants are very safe, and after many years of research, there is no proof that they cause any health problems. When you have lost of lot of weight, the breasts often are flat at the top, have no cleavage, and are not firm. With implants all that can be improved. You can have great cleavage, fullness at the top, and firm, youthful breasts. Without implants, the lift will correct the position of the nipple and areola, but that is all. Unfortunately, because, of the weight loss, your breast have lost the firmness to keep the upper part of your breast full or to give you good cleavage.
- The surgery is outpatient, so you will go home the same day. You will need to wear a surgical bra or sports bra for about a month. Most people will take narcotic pain medication regularly for about a week. You can usually return to work for a light duty job (no lifting over 10 pounds) in about 7 – 14 days. Risks: same general risks from anesthesia and regarding bleeding, infection. However also additional risks to nipple (sensation, necrosis). Risks with implant of capsular contracture (scar tissue around implant). If infection, there ’s sometimes need for removal of the implant until infections clears.
- The incision for the thighs starts at the knee and goes up to groin and then up and down the groin, like a “T”.
- Thigh lift surgery is also an outpatient operation. For the recovery, most people need pain medication for about 7 – 10 days and can return to light duty work in about 7 – 14 days. Everyone needs to wear ace wraps on the legs for about 4 – 6 weeks.
- Even with the best of care, there sometimes are events that do not go as planned. As with any surgery, there is the possibility of infection, bleeding. If the infection or bleeding is bad enough, we would have to go back to the operating room to stop the bleeding or clean out the infection. If a breast implant was used, this sometimes needs to be temporarily removed to allow the infection to clear. Blood clots can form in the legs and potentially travel to the lungs and cause breathing problems or even death. I will ask you to walk after surgery to prevent blood clots from forming in the legs. The risks are higher with abdominal surgeries and surgery lasting longer than 4-6 hours, but it can happen with any surgery. You may be placed on blood thinner subq injections after surgery depending on your risk factors and the extent of your surgery. There are some risks that are specific to skin reduction surgery. The first is fluid collection. Sometimes, after the drains are out, your body will continue to make fluid and so it would pool under the skin. If that happens, I would need to drain it in the office with a small needle. Rarely I ’ll have to take you back to the operating room to drain the fluid and replace the drain tube. Also, any time we cut the skin there is a risk of changes in sensation (increased sensitivity, numbness). After the surgery, your skin will be very tight. Sometimes, when you are feeling better and you are more active, you can actually tear through the stitches that Dr. Shah uses. If this happens, it can be disturbing to see because you are probably not used to seeing something like this. However, it is not a big medical problem, We do not need to go back to the operating room, rather it is better for the scar to let it heal on its own. This does take about 3 – 4 months. While the wound is healing, you will be able to go to work and do most of your routine activities. If when the scar is not as good as you would like, I can do a revision to make it better. Finally, sometimes, areas of skin do not get enough blood to live. In that case, the skin will turn into a scab. If this happens, we just need to let it heal from the inside out. This will take a long time, about 3 – 4 months, but it will always heal. Again, when the scar is healed, if it is not good, I will revise it in the office. Breast surgery carries an extra risk of having changes in sensation to the nipple or very, very rarely loss of blood supply resulting in death of the skin of the nipple and areola. This is devastating to have to experience, but the nipple can be recreated. During the consultation, I will go over all of these and other risks of the surgery in much more detail.
- Blood supply to skin was not good enough. She required 6 weeks of dressing changes before the skin healed. Scar is wider, but overall result is still good.
- Scar usually heals very well, and after about a year or so, the color will fade to make it much less noticeable. Even with the best techniques, your body will also determine how good the scar will be. If the scar is not as good as you would like, I will be able to do a revision to give your body a second chance to heal it better. This is especially effective if there was a reason that your scar didn ’t heal well (infection, pulled apart, etc)
- In general most procedures by themselves, can be performed as an outpatient, which means that you would go home the same day. For the belly surgery, you will have 2 or 3 drains. For all other body parts, you will probably not need any drains Binder Most people need pain medication for about 7 – 10 days and then occasionally for a couple of weeks. Most people can return to work in about 2 weeks for individual operations. All of this will be slightly longer if you decide to have more than one area operated on the same day.
- I will perform several different areas of surgery together, and most patients choose this option since this will decrease the time you need to take off work, it is less expensive, and the recovery is only slightly longer. There are some important points to keep in mind when having more then one part of the body operated on together. First, the surgery will be longer and can often be 5 – 7 hrs long. You will need to spend at least one night in the hospital. As the surgery gets longer, the risk of blood clots, bleeding, and infection can be higher. Also, the longer the total length of incisions, the more healing your body has to do and the higher risk you run of wound healing complications.
- Let ’s take a look at some before and after pictures. These pictures are a combination of pictures from from the physician I trained with, and cases I have been involved in. I have chosen them to illustrate some points about the surgery and your results.
- Scar arouf umbilicus and above pubic hair
- Stretch marks still there
- Redness around the T…always the hardest place to heal (blood supply from edges, tension on the closure to get a nice, tight result, This is why not smoking is so important. Every time you smoke even part of a cigarette the blood flow to your skin is decreased for 6 hours. It is my strong preference to operate on people who have quit at least a month before and after surgery (though longer is better for your lungs and skin and blood vessels!)
- Scar is still red since it ’s fairly soon after surgery (6 weeks)
- Notice that shape you start with determines shape you end with…this patient has a protuberant abdomen and even though her overall contour is better, she does not have a flat stomach.
- This woman ’s fat is all outside the abdominal muscles, so it’s removed with the skin operation and tightening the six pack muscles.
- Pubic area is lifted as well
- Also had a breast lift
- Once again…what you start out with strongly influences your results
- Hernia
- Hernia was repaired
- Staged…breasts were done 6 months before rest of the surgery.
- No umbilicus (longer stalk…more risk of necrosis, personal choice combined with how much weight lost/current weight/abdominal shape. Note that the skin is improved (much is removed, remainder is stretched smooth)
- Most of the stretch marks were cut out as skin was pulled from the sides in as well as up and down.
- 6 weeks after surgery. One area didn ’t heal well, but by 2 weeks after this picture, the incision was completely healed.
- No umbilicus
- Another example of wound healing problems at the “T” site
- Front addressed as with the panniculectomy / tummy tuck
- Buttocks lift and change in shape due to removal of extra skin and fat (tends to hang as a unit on the back and not drape over like the front, so some people don ’t realize it’s as much extra skin as it really is)
- Note that the incision is about twice as long…twice the risk of wound healing complications (body requires more energy and protein to heal, harder to remove tension from the incision line since you can ’t bend forward and backward at the same time)
- Note the upper back is only modestly affected. Addressing the upper back requires an incision near the bra line for complete improvement in the shape
- Breast lift with silicone implants 6 months after surgery
- Less fullness and firmness at the top
- Breast lift with small implant 6 weeks after surgery
- Another lift with implants.
- Just implants…breast are far apart to start, very deflated, not much distance between the nipple and the breast fold (due to small breast size)…much better fullness, appearance of a lift just by filling out the deflated skin with an implant
- Breasts are much closer to start …end result is much closer together
- Crepy skin…
- Click the Right Arrow to advance to the next slide when you are ready.
- Leg is smaller (fits in pants better) Scar is right in groin (warm, humid place…hard for incision to heal…common to break down or have delayed healing
- Outer thighs already lifted by lower body lift Now inner thigh is tight as well
- Scar tends to migrate down the thigh due to gravity. Deep stitches secure the stronger deeper connective tissue layer, but we can ’t place the scar any higher because of the risk of dissection in that area.
- The skin looks dramatically better (again, it ’s partly from removing wrinkled skin and partly from stretching the skin that’s left in place)
- Fairly 2 months after surgery…still tight in the axilla until it relaxes, still skin pleating
- Longer time after surgery - 2 things to notice Scar has smoothed out Tightness in axilla relaxed for more natural contour
- Another picture fairly soon after surgery…want you to know what to expect, not just see all the pictures of the end result.
- Small open area where incision comes to a “t”… possible complication (may require dressing change, always heals) tighter result = slightly higher risk of healing problems because of tension on the incision
- Fillers = instant fillers like Juvederm which plump up the skin with a substance called hyaluronic acid that ’s normally found in skin. This reabsorbs over time (9-15 months). Scuptra = 3 treatments actually cause you to grow your own collagen to thicken the skin and fill out flattened, deflated areas (lasts longer)
- If you have any questions, and you don ’t feel comfortable asking in front of the group, you can email me. My email address is on the bottom of the card, and it goes straight to me.
- If you ’re interested in surgery, you can come talk to the office for an exam and specifics that pertain to you. Also to thank you for your time and attention tonight, I’m waiving the usual $75 consultation fee if you mention to the schedulers that you are from the support group. Are there any questions?