Body Contouring Orange County Body Contouring
BODY CONTOURING HISTORY
Twenty five years ago, it was rare to have a patient walk into a plastic surgeon’s office after substantial weight loss. But these days, we routinely see patients who have lost in excess of one hundred pounds. Eighty or ninety per cent of the massive weight loss patients we see did so with the assistance of bariatric surgery – such procedures have been designed to either decrease the size of the stomach pouch or some variety of “bypass” which shunts food down the intestines quicker without absorbing as many calories. We are in the midst of an obesity epidemic in America, but this problem is not one limited to the industrialized world.
In California, 10% of adults were considered obese in 1991, 17% in 1998, and over 23% in 2005. Currently, two thirds of men and almost one half of women in California are considered to be overweight. $7.7 billion was spent last year in California to treat obesity or conditions caused by obesity.
Obesity leads to adverse metabolic effects on blood pressure, cholesterol and insulin resistance (higher incidence of diabetes) as well as non-fatal but debilitating health problems such as musculoskeletal problems, infertility and respiratory difficulties.
The World Health Organization has stated that worldwide, currently, over a billion adults are overweight, and that at least 300 million are grossly obese (more than a hundred pounds overweight). The degree of obesity is commonly assessed by calculating the body mass index, or BMI. A BMI greater than 25 kg/m2 is defined as overweight and over 30 as obese.
Over the past decade, increased awareness of this issue has prompted a number of people to lose massive quantities of weight as a result of diet/exercise programs or a variety of advanced surgical procedures (known as bariatric surgery). The two most popular bariatric procedures entail some type of gastric bypass, in which the GI tract is rearranged so eaten food bypasses a large portion of the absorptive portion of the digestive tract, thus absorbing less calories, or a “band” procedure in which a band is placed around the upper portion of the stomach, physically decreasing the amount of food a person can eat at one sitting, both of which usually result in weight losses from one to two hundred pounds in those who are morbidly obese. With the advent of laparoscopic surgery and the more sophisticated bypass and stapling techniques, the efficacy, safety and popularity of such “bariatric” surgery has sky rocketed. This year over 200,000 bariatric procedures will be performed in the United States, and the numbers keep climbing higher each year as more centers with expertise in such procedures open up. But a small percentage of the weight loss patients we see achieved their results the good old fashioned way, by altering their diets and by exercising regularly! Allergan®, the maker of the Lap Band® that is used to decrease the upper portion of the stomach, has stated that over 500,000 such procedures have already been performed in the United States. Weight loss is accompanied by numerous health benefits, but leaves patients with undesirable quantities of excess skin. This skin excess varies from person to person, but generally involves an excess of facial/neck skin, upper arm and thigh skin, deflated/droopy breasts and massive degrees of excess involving the anterior and posterior trunk. The facial and breast recontouring procedures are covered in separate sections entitled facelift and breast reduction/uplift/augmentation. This hand out will address excess skin in the arm, thigh, anterior and posterior trunk/back areas.
The following information has been prepared to familiarize you with facts regarding a variety of surgical procedures that are utilized to tighten excessively loose skin, frequently after massive weight loss. A smaller group of patients, who are normal weight and have never been overweight, will present with loose enough skin to warrant surgical tightening in the inner arm, posterior trunk, buttocks or thigh regions, but most of the patients with a significant skin excess have lost large amounts of weight. If you fall into the post massive weight loss category, you are first to be congratulated for losing so much weight! Study after study has demonstrated the benefits of weight loss in patients who are morbidly obese.
Your heart and lungs will not have to work as hard. Your legs will have less weight to carry. If you had adult onset diabetes, it will surely have improved or may even have gone away after the weight loss. Unfortunately, as you have found, skin does not go back to its pre-stretched condition. Most patients who loose a large quantity of weight desire to have the excess remaining skin from their faces/necks (“facelift”), extremities (“thigh lift or brachioplasty”), abdomen and backs removed (“body lift”) and their breasts uplifted (“mastopexy or breast lift”), with or without an implant (“breast augmentation”), or rarely, reduced (“breast reduction”). Face and breast surgery are covered in separate sections. This section will focus on procedures utilized to address skin laxity along the inner arms, upper and mid back regions, buttocks and thighs, abdominal walls and flank/back regions.
You are requested to read this information thoroughly and to discuss any questions which might arise with your surgeon before you give your consent to proceed with this procedure. You are also requested to keep this form as a reference in the postoperative period.
BODY CONTOURING INTRODUCTION
The areas which we can address with plastic surgery in removing excess skin are the neck and face, breasts, inner arms, abdomen and back of trunk, hips, thighs and buttocks. Here, we will focus on procedures designed to improve the inner arms, abdomen, posterior trunk, hips, thighs and buttocks. In all of these areas, the problem is an excessive amount of skin in all dimensions – most resections usually only remove skin in one dimension! For example, with a body lift, in which a transverse wedge of skin is removed from the abdominal wall and trunk, relatively vertical tightness will result, but some horizontal excess will remain, unless a vertical excision is also planned. It must be stressed that some long term skin laxity in these areas is absolutely normal. Every patient over the age
of 20 will have some skin laxity in these areas, and the only time they should be addressed surgically is if the amount of skin laxity is much more than average, and if the degree of correction to be achieved can be justified by the resultant scarring.
Procedures such as liposuction, rhinoplasty, breast augmentation, eyelid surgery and a face lift most frequently do not leave any visible scars.
Body contouring procedures, on the other hand, ALWAYS leave a long and wide scar – each patient will have to decide for themselves if the improvement in the skin laxity will be justified by the resultant scars, cost and risks of surgery.
An inner arm brachioplasty is an operation in which excess skin and fat from the inner arm, between the axilla (arm pit) and elbow, is removed and the remaining skin tightened. This is accomplished by excising a large ellipse of this excess skin. The resultant scar will run along the inner arm, hidden with your arm down along your side but definitely visible if a patient is wearing a short sleeve shirt and has their hands up in the air!
The posterior trunk can contain excess rolls of skin either continuing around the back at the level of the breast or lower down as a continuation of the abdominal skin rolls. The upper back excess can be excised by removing wedges and leaving the final scar at the level of a brassiere in a female. The lower trunk is usually addressed in conjunction with an abdominoplasty and is called a “body lift” or a “belt lipectomy”. Such body lifts result in a tightening of the abdominal wall and the lower posterior trunk, including the hip/thigh area and upper buttocks. The incision follows the fold along the lower abdomen, above the pubis, and continues on the backside just above the buttocks. Such scars, while noticeable when unclothed, are usually easily hidden within standard shorts. It is important to understand that during such procedures, a transverse wedge of tissue will be removed and the patient will experience a vertical tightening of the skin – if you pinch your abdomen or lower back vertically, a very significant tightening will be appreciated, but if one pinched horizontally, no appreciable tightening will be noted.
A body lift is an operation in which excess skin and fat from the abdominal wall, particularly below the navel, and posterior trunk/back is removed. This will result in a removal of the hanging abdominal wall skin and a tightening of the skin over the sides, lower back, upper lateral thighs and upper buttocks areas. This is accomplished by first placing the patient in the face down position and resecting the excess posterior trunk/lower back skin. In patients who have been left with a very flat buttock, some of this tissue from the lower back can be replaced, as a flap, into the buttocks area to enhance that area simultaneously. After returning the patient to a face up position, the abdominal skin is elevated from the anterior muscles, the muscles are tightened as necessary, the excess skin is pulled downward, and the excess skin excised. This procedure is particularly effective in removing vertical skin excess and stretch marks from the lower abdomen, but it must be understood that not all stretch marks can be eliminated, and that significant laxity, particularly noticeable when flexing the hips or when pinching the skin horizontally, will persist. The same navel is reinserted into the skin after the tightening procedure.
Frequently, particularly after childbirth or weight loss, patients present with a weakness of the abdominal wall muscles and fascia; in such cases, the defect between the anterior muscles is repaired (fascial repair) before trimming the excess skin and fat. This procedure can be combined with other non-abdominal operations such as liposuction, arm lifts, breast uplifts (with or without implants), facelifts or other procedures. It has been shown that the risks of surgery/anesthesia are infinitesimally small for any length of time up to six hours, but that thereafter, risks of infection, blood clots and other risks begin to rise. As all of the procedures here mentioned are elective, your surgeon will discuss your desires and formulate a plan based on how much can safely be done in one sitting that does not exceed six hours –patients desiring full correction of their deformities usually return for two or three procedure until their goals are met. The operation is directed toward an improvement and does not in any way guarantee complete obliteration of all folds and stretch marks. You must accept the judgment of your plastic surgeon and realize that he/she will remove as much as is safe and suitable. Particularly in patients with thicker abdominal walls or marked skin excess, it may be desirable to return for a secondary liposuction of the abdominal wall or an additional skin excision to obtain an optimal result. Should this prove desirable, the patient will be responsible for all costs associated with all secondary surgical procedures.
The lower buttocks and thighs (buttocks lift, thigh lift) can be tightened in a similar fashion, with the resultant scar location to be determined by the areas of your most significant skin excess. As with the body lift or abdominoplasty, the skin tightening will usually occur in one plane, usually vertically, and not result in significant horizontal tightening. If massive skin laxity is present, both a horizontal and a vertical tightening might be desirable. In such situations, a “T” shaped scar may be designed with a transverse incision along the upper inner thigh, perhaps extending obliquely onto the buttocks, as well as a vertical scar down the inner thighs towards or to the inner knees.
Most patients who have lost a lot of weight have multiple areas to address. These body contouring procedures can be combined to address multiple areas, with certain limitations and exceptions. It is not safe to address the inner thighs and abdomen at the same sitting because of blood flow interruption to the pubis and strip of skin between the inner thighplasty scars and abdominoplasty or belt lipectomy scars. But with either procedure, it would be safe to address, for example, the inner arms, breasts or face.
Such procedures may also be combined with non-skin tightening operations such as liposuction, eyelid surgery or other unrelated procedures such as a rhinoplasty. Your overall health and age will also help determine how much surgery you can tolerate in one day. But even if you are in perfect health, it is unwise to electively schedule procedures that are designed to be longer than six hours in length because after that time, your chance of developing a blood clot in your calves or other complications will become more likely.
The operation is directed toward an improvement and will not in any way give you complete obliteration of all folds, laxity and stretch marks. You must accept the judgment of your plastic surgeon and realize that he/she will remove as much as is safe and suitable. Particularly in patients with thicker fatty layers or marked skin excess, it may be desirable to return for additional skin excisions to obtain an optimal result. Should this prove desirable, the patient will be responsible for all costs associated with all secondary surgical procedures.
The type of skin, degree of elasticity and age of the patient all influence the overall result that is obtained. The operation should not be undertaken if the patient’s weight is not stable or if a patient has not made a commitment to themselves to keep the weight off in the foreseeable future. While it is not necessary for the patient to reach a certain weight before surgery may be performed, it is desirable that the patient's weight be stable for at least six months prior to surgery and that the patient be at a weight he/she feels can be maintained after the procedure.
A common question is, "How long will the results of this procedure last?" This is impossible to state. Factors affecting the length of the result include age at the time of operation, physical conditioning afterwards, type of skin, and alterations in weight. In general, it is not necessary to repeat these procedures after an optimal result has been achieved. Should the patient wish to repeat the operation, regardless of the length of time since the initial operation, the degree of laxity or fatty excess remaining, each patient will be responsible for the cost of a subsequent procedure.
BODY CONTOURING PREOPERATIVE PREPARATION
You may visit your surgeon as many times as you wish, to have all of your questions answered. At your final preoperative visit, your final questions will be answered and you will confirm that you understand the procedure to be performed, that this material has been explained to you, that you have read and understand these information sheets, and that you accept the risks by signing the informed consent forms. You will be given prescriptions for surgical soap that will be used before surgery, as well as for pain pills and antibiotics, along with instructions for their use. Certain laboratory tests will also be required within two weeks of surgery. If you are over the age of 40, you will have to obtain a cardiogram. You may have blood drawn by our office nurse during your final preoperative visit, or, if you prefer, at your family
doctor’s office or any state licensed laboratory (e.g. Kaiser Hospital, etc.).
All patients will be asked to stop smoking at least a month prior to surgery in an effort to maximize your body’s ability to heal the incisions following the operation.
It will be necessary to scrub the surgical sites for ten minutes the evening prior to surgery and a final time the morning of surgery before leaving home. Washing the surgical site these two times with Hibiclens® soap will lower the possibility of an infection occurring after surgery.
As with all other elective procedures, the patient should avoid ibuprofen (Advil®), Aspirin® and large doses of Vitamin E (the small amount contained in most multivitamin preparations is not harmful) for two weeks before surgery, as these inhibit the clotting mechanism and increase your chances of unnecessary operative bleeding. A separate list of other medications, which can potentially affect clotting capabilities, will be discussed along with your preoperative instructions. Body contouring surgery patients frequently have low blood counts and are asked to take iron tablets prior to and after surgery (such as ferrous sulfate or ferrous gluconate, approximately 300 mg each, twice daily, beginning two weeks before surgery and continuing for two weeks after the procedure or longer if strength has not yet returned).
Ordinarily, your anesthesiologist will call you the night before surgery to discuss the anesthetic care plan with you. But if you miss the call or your anesthesiologist does not call you, do not worry as you will be able to discuss your anesthesia and have all your questions answered in the morning, at the Surgery Center prior to your procedure (Orange County Surgery Center in Newport Beach, Southern California or Tracy Surgery Center in Tracy, Northern California). You must make arrangements to have someone drive you to and from the Surgery Center and stay with you at home for the first three or four days afterwards. Arrangements can also be made to have a registered nurse care for you for the first night or two as well, either at your home or at a hotel close to the Surgery Center.
BODY CONTOURING OPERATION
The operation will be performed in an outpatient facility under deep sedation or a light general anesthetic. With a body lift, an incision is made clear around the lower body (thus the term “body lift” or “belt lipectomy”), beginning above the buttocks and extending, in a curved line over the hip areas and across the lower abdominal wall above the pubic area. The posterior skin is excised as a big wedge, with little undermining unless flaps are desired to enhance the buttocks area. The skin and fat of the abdominal wall are elevated to the rib margins. The navel remains attached to the abdominal wall, but is released from the surrounding skin and fat through a diamond shaped incision around the navel. The abdominal muscles are tightened by suturing them together in the midline. These internal sutures are permanent
but all of the remaining sutures used for the skin closure are absorbable. The excess skin and fat from the lower abdomen are trimmed.
A tighter abdominal wall can be obtained by excising a vertical wedge as well, resulting in an inverted “T” scar, with the vertical component extending up the abdominal midline from the pubic area to the rib cage – this scar tends to spread and is avoided unless absolutely necessary.
With brachioplasties, thigh lifts and other trunk wedge excisions, the incisions will be made as discussed with you preoperatively, and the excess skin and fat will be trimmed. Sometimes, your surgeon may be required to extend the incisions or place them in a different location than discussed preoperatively. This may become desirable if, in the surgeon’s opinion, such diversions from the operative plan will improve the final result. On occasion, it may be appropriate to suction some of the excess fat that can not be resected, but there is a limit to how much can be removed without jeopardizing the viability of the skin flaps.
Rubber drains are frequently inserted prior to suturing the wound closed; these drains will be removed later in the office after the drainage has decreased to less than 25-30 cc. (about an ounce) of fluid per day. This usually takes about a week to ten days but can take up to a month or even longer. In addition, small catheters (pain pumps) which infuse local anesthesia into the surgical field may be inserted – these are usually removed 2-4 days after surgery. The pain pump catheters will reduce the discomfort normally associated with such procedures. Most of the sutures are placed below the surface of the skin and are absorbable but until they do, and this can take six months, threads can protrude through the skin and will have to be taken out during office visits.
BODY CONTOURING POST-OPERATIVE CARE
Adequate pain medication will also be prescribed. All patients, who go home on the day of surgery or the next morning, will find that an assistant at home is a necessity for the first two or three days. High bulk foods are highly encouraged and laxatives may be necessary to prevent straining associated with constipation. The patient will be encouraged to walk as much as possible at home after surgery as this will reduce the possibility of pneumonia or of clots forming in your calf veins. Patients are also encouraged to wear Tedd® compression stockings for the first few weeks thereafter. It will be necessary to avoid flexing the hips after thigh or buttocks procedures for the first few weeks to prevent excess tension on the suture lines. The patient will usually be allowed to shower after the drains
have been removed, but soaking in a bathtub is to be avoided for another two weeks. Wounds are generally closed with buried absorbable sutures. The incisions are covered with a surgical adhesive, which will peel off as you shower over the next few weeks. It is highly recommended that patients begin applying MD Performance® Ultimate Scar Formula once the glue peels off to the incisions to optimize healing.
The Ultimate Scar Formula should be applied twice daily as directed until the scar has finished healing (scar should turn flat, soft and without a trace of pink or purple left). The skin may itch after any surgical procedure. After the first week, the skin can be moisturized with the MD Performance® Avocado CoQ-10 Body Balm – this will relieve the dryness and itchiness and help any crusts fall off the suture lines quicker.
Your first post-operative visit will generally be scheduled two to four days after surgery at which time the pain pump catheters will be removed, or a few days later if you choose not to have the pain pumps. The drainage tubes will be removed at a subsequent visit, when the drainage has essentially stopped. You will be required to have someone drive you to the office for your first, few office visits. Most patients find that they can gradually increase their activity levels after the first few days. You may drive a car with caution, wearing a safety belt, beginning 48 hours after your last pain pill or sedative, if you feel comfortable and physically able to do so.
Social activity should be limited while the patient is uncomfortable. Lifting anything that causes discomfort should be limited for approximately four to six weeks to allow the tissues to heal properly. Strenuous activity should be avoided during the initial six to eight weeks. Basically, most patients find that they can return to normal activity as the discomfort of the operation fades away.
Office work can usually be resumed within 1-2 weeks of surgery, but the patient should expect a six-week delay before returning to physical labor or strenuous exercise. It will take longer than a year for scars to fade and the scars to feel soft and relatively normal. The lower abdominal skin may feel numb forever and completely normal feeling is not to be expected.
BODY CONTOURING POSSIBLE COMPLICATIONS
Serious complications after a body contouring procedure are relatively uncommon. However, there will be a long scar that will always be visible without clothing. The scar may remain itchy, painful, thick, or otherwise unsightly. It is unusual, but possible, for some skin to die and areas of fat to liquefy and drain through the incision for many months. As with any body contouring procedure, it is also possible for a suture to become infected and to erode through the skin years later. Fat is poorly vascularized, does not have much tensile strength and does not contribute significantly to holding the wound together. In this type of surgery in obese clients, particularly involving the trunk or lower extremities, there is a very high incidence (50%) of portions of the incisions pulling open.
Occasionally the wound margins can be resutured, but most often the safest course of action is to leave the wound open and allow it to heal by contraction and secondary intention. This might take a few months to occur and may necessitate wound care at home from a visiting nurse.
Should this occur, it may be necessary to perform a secondary scar revision a year or so later. As with all complications or desired secondary procedures, each patient will be responsible for the cost of a subsequent care or procedures.
It is common to experience swelling of the hands with a brachioplasty, or of the ankles following thigh or buttocks surgery. Such swelling is self limiting. Some areas of numbness will be evident following body contouring surgery. Usually, most of the feeling will return within about a year but some patients will experience areas of permanent numbness.
One of the most common problems after body contouring is a persistent collection of serous fluid under your skin after the drains have been removed. Should this occur, this fluid will be aspirated by your surgeon with a needle during your post-operative visits. Such drainage always stops eventually (but may persist for more than a month, or may even necessitate reinserting a drain) and usually does not affect the final results – but may require a trip back to the operating room to resect a residual fluid pocket if the fluid does not stop accumulating.
If wound problems develop, it may take several weeks or even months for healing to take place and the patient will be required to wear dressings over the open wound. Because of the extensive skin and fat undermining, areas of skin may die and slough, or even require surgical debridement or a skin graft. Rarely, phlebitis may develop in leg veins and even more rarely, blood clots could travel to the lungs, potentially leading to a fatal complication.
Perfect symmetry does not exist before or after ANY body contouring surgery. Scars will never be identical from side to side. As mentioned earlier, it will take longer than a year for scars to fade.
Secondary procedures may occasionally be desirable to revise scars or to remove additional tissues. The patient will be responsible for all costs associated with secondary surgical procedures.
It is not possible to list every conceivable complication. As with any operation, there could be potential complications, which could even be fatal. The foregoing is not intended to frighten or upset you but to enable you to make your decision with an understanding of some of the involved risks.
Insurance companies do not pay for the skin tightening during body contouring or other purely cosmetic portions, irregardless of how much weight you have lost, how unsightly the remaining skin folds are, or even if the skin folds interfere with normal function. If there is reason to believe that your insurance company might help you pay for abdominal muscle tightening, the office staff will provide you with the necessary information to submit to your insurance carrier. Payment of all fees, however, is the patient's responsibility; all fees are due prior to surgery and the proceeds of the insurance check will go to you when the check arrives (minus a 6% billing fee if you chose to use our billing service). If requested, the office staff will assist you with forms, but recovery of any insurance benefits is between you and
your insurance company.
The office staff can help you arrange financing if desired. In compliance with suggestions adopted by the American Society of Plastic Surgeons®, it is customary for the patient to pay all fees for cosmetic surgery prior to the desired operation. This insures that the patient is sincere in his/her motivation and can afford the surgery, thus creating a better patient/physician relationship. A non-refundable deposit will be required to secure your desired surgery date. The remainder of the fees must be paid prior to the surgery, usually at the time of the preoperative visit, but no later than two weeks before surgery. Additional fees are also required for laboratory tests, surgical facility fees and the anesthesiologist. If additional surgical procedures become necessary, additional facility, laboratory, anesthesia and professional fees will be incurred. The surgical facility and anesthesiologist fees quoted will be based on our best faith estimate; the final fee may vary as these fees are based on surgical time, and it is not always possible to predict exactly how long a procedure will take to complete.
It is important that you understand that the patient is responsible for all costs associated with all secondary surgical procedures or for the treatment of any complications that may arise as a result of this elective surgery.
Please click here to fill out the patient agreement form.
Except with the ThermiTight™ procedures, pre and post-op photos will be taken of the treatment site for record purposes.