Blog — Notes of a Plastic Surgeon

Welcome to my blog. I am a plastic surgeon in Seattle and have been in private practice since 1991. I've seen more than a few interesting faces and cases through my years spent in the exam room, the operating room and the emergency room. And I have an opinion on just about everything relating to plastic surgery (and a lot of unrelated stuff). If you like my blog, let me know. Thanks for reading! Lisa

Category: Body Contouring


Progressive Tension Sutures in Tummy Tuck – well worth the extra 15 minutes

May 20th, 2014 — 8:10pm
Progressive tension sutures secure the abdominal fat pad to the muscle.

Progressive tension sutures secure the abdominal fat pad to the muscle.

Seattle Plastic Surgeon explains why she uses progressive tension sutures in her tummy tuck patients.

I saw a patient today for a tummy tuck consultation.  She had spent quite a bit of time researching tummy tucks on the Internet and had a lot of questions about my technique.  I went down her list of questions with her and answered them as best I could.  Her last question, “do you use progressive tension sutures?”, was the first time I have had a patient ask me about that particular part of the procedure.  My answer was a resounding YES!!!

Progressive tension sutures are also called quilting sutures or mattress sutures.  These stitches secure the underside of the abdominal fat pad to the abdominal muscle layer.  They serve several purposes.  They take tension off the incision line which can result in more favorable healing and scarring.  They close off the potential space between the abdominal fat pad and the muscle and help prevent fluid (a seroma) from accumulating.  Drains can come out much sooner:  after 2 – 4 days instead of after 7 – 10 days.  These stitches also help the patient remember not to twist or turn in the first weeks after a tummy tuck because those actions will cause a little twinge.

I have been using progressive tension suture ever since I attended an instructional course in this topic taught by Drs. Harlan and  Todd  Pollock.  My rate of post-operative fluid collections (seroma) went from about 25%  to (honest to God)  ZERO.   This addition to my abdominopasty adds about 15 minutes of operating time but has reduced the time and hassle of draining seromas after surgery.   It’s a good investment in my time.  Every time I see either Dr.  Pollock at a medical meeting, I thank him for introducing me to this very, very useful technique.

Thanks for reading!  Dr. Lisa Lynn Sowder

 

Body Contouring, Mommy Makeover, Tummy Tuck

Mons pubis reduction: Yes, it is a procedure I perform.

April 24th, 2014 — 8:51am

Seattle Plastic Surgeon blogs about the saggy and/or fatty mons pubis.

blog monsI get a lot of email inquiries about the mons pubis.  This is a problem area for many women and there just is not a lot of information out there about treatment options.  So, here’s some info about that mons pubis a.k.a. the Mound of Venus (I just loooove that term).

The mons pubis tends to sag with gravity like everything else and like most structures, the larger it is the more gravity works on it and the more it sags.  Weight fluctuations, which are not good for the skin, can result in severe sagging.  Also, some people just have lousy skin tone.  And some ladies just have a lot of fat in the mons, even if they are quite slender.  Why, why, why?  I don’t know but I do know how to make it better.

The mons pubis should always be evaluated in the tummy tuck patient.  Lifting and/or reducing the size of the mons should be an integral part of the tummy tuck procedure in patients who have issues.  Addressing the mons pubis adds very little time to the tummy tuck procedure and does not make for a longer recovery.  Not addressing a heavy and/or saggy mons at the time of tummy tuck can result in an imbalance between the abdomen and the mons pubis and can look really, really odd.

Mons lift and/or reduction can be done separately from a tummy tuck in patients who have already had a tummy tuck or in the occasional patient who has a heavy mons pubis despite a trim abdomen.  If she has great skin tone, liposuction is often very effective.  If the skin tone is not so good, liposuction plus skin tightening is done.  This latter procedure leaves a scar much like a C-section scar.  Because it is difficult to keep this area of the body elevated after surgery, post-operative swelling can last awhile but usually after a few weeks, the difference is very obvious and at three months, most ladies are thrilled with their trimmer public area.

Oh, one other thing:  This type of surgery does not effect genital sensation at all.  The nerves to the real lady bits do not travel through this area.  The actual mons might be a little numb for a few weeks or months but that has not been an issue with my mons pubis surgery patients.

Thanks for reading!   I hope I didn’t make you blush.  Dr. Lisa Lynn Sowder

Body Contouring, Mommy Makeover, Tummy Tuck

More on BELLY FAT

April 9th, 2014 — 11:10am

Seattle Plastic surgeon shows why belly fat cannot be treated with liposuction (with a little help from Oprah and Dr. Oz).

This, folks, is belly fat. It is inside the abdomen, deep to the abdominal muscles. It cannot be removed with liposuction or tummy tuck (abdominoplasty). Losing weight will make it shrink.

I saw a patient a couple of years ago who was requesting abdominal liposuction.  I did my usual body contouring evaluation and had the unenviable task of informing him that he was a really lousy candidate for liposuction or an abdominoplasty (tummy tuck).  His abdominal girth was caused by belly fat a.k.a. intrabdominal fat a.k.a. visceral fat a.k.a. beer belly fat.   The way I could determine this was to have him lay down on the exam table.  His belly did not flatten out.  See photo on the right.

The omentum from a deceased obese person vs. the omentum from a deceased slender person.

 

 

 

 

 

 

Belly fat collects in the mesentary, which is the structure that carries blood vessels to the abdominal organs, and the omentum, which is an apron like structure that hangs off the stomach.   In an obese person, they are very, very thick.  In a lean person, the mesentary and omentum are very thin and translucent.   Here is Dr. Oz holding the omentum of a fat person and Oprah holding the omentum of lean person.  There is NO WAY a fat omentum can be sucked down to a thin omentum.  The only way to reduce an omentum is to lose weight.  I referred the patient to Dr. Richard Lindquist at Swedish Medical Center Weight Loss Services.

I asked him to follow-up with me but I haven’t heard from him.  And he never went to Dr. Lindquist.  I hope he did not find a surgeon ignorant or desperate enough to do surgery on him.  If he did, my guess is that he is sorely disappointed with his result.

Thanks for reading!  Dr. Lisa Lynn Sowder

Body Contouring, Liposuction, Obesity, Tummy Tuck

Body Lifting 101

September 11th, 2013 — 1:26pm

Seattle Plastic Surgeon discusses the importance of “translation of pull” in body lifting after massive weight loss.

Try this at home!  If you get a lot of lift and smoothing of the skin by pulling, you will likely do well with a body lift.

Try this at home! If you get a lot of lift and smoothing of the skin by pulling, you will likely do well with a body lift.

I have seen quite a few massive weight loss patients interested in body lifts in the past several weeks.  The fall and winter months are the best time to have this type of surgery and these patients are wanting to sort out their options so they can take advantage of cool and dismal months and  be fully recovered by the time spring rolls around again.

Body lift is a really big procedure and should only be considered if the patient has a really good chance of getting a lot of improvement.  The requirments for this procedure include excellent health,  a stable and healthy weight, a good support system, the ability to take enough time off of work for healing, and good translation of pull. Translation of pull refers to how much the skin reacts to traction.

Many massive weight loss patients are like this lady where the skin can be yanked up almost like a pair of panty hose.  In this case, she is likely to have great result.

Some patients, however, either because of residual fat or thick and tethered skin, hardy budge with this manuver.  Sometimes additional weight loss helps but sometimes it does not.  Those patients with lousy translation of pull will not see much improvement with a body lift.  And a body lift would be a very, very long run for a very, very short slide for these patients.

Thanks for reading!  Dr. Lisa Lynn Sowder

Body Contouring, Preoperative Care

Visualize Liposuction

March 26th, 2013 — 11:20am

Seattle Plastic surgeon teaches patients to visualize liposuction volumes and weights using butter.

Seattle Liposuction

One pound of butter = one pound of fat.

One of the most frequently asked questions in my office is “how much fat will you remove?”  The answer usually ranges somewhere between 1 – 10 pounds.

So how much is 1 – 10 pounds?  This can be hard to visualize.  I recommend thinking of excess fat as sticks of butter.  One stick of butter is 1/4 of a pound.  A box of butter – 4 sticks- is 1 pound.  Ten  boxes of butter – 40 sticks – is 10 pounds.  That’s a lot of butter and a lot of fat!

Liposuction results in targeted weight loss which is why liposuction is so useful in patients with uneven fat distribution – think of the lady with a narrow waist but heavy thighs.  She would have to starve herself to see much slimming of her thighs.  Liposuction could remove several pounds – think several boxes of butter – of fat from each thigh.

Liposuction is not so useful in patients who are significantly overweight all over.   It is not possible to safely remove an extra thirty pounds with liposuction.  That weight needs to be lost through lifestyle changes.   Once a healthier weight is reached and if there are still areas of recalcitrant fat, then liposuction will likely be indicated.

Thanks for reading!  Dr. Lisa Lynn Sowder

 

Body Contouring, Uncategorized

Downton Abbey – those corsets remind me of tummy tuck surgery

March 11th, 2013 — 11:16am

Seattle Plastic Surgeon riffs on how those Downton Abbey women stay so slim and what it all has to do with the modern day tummy tuck.

A tummy tuck is a little like having an internal corset.

A tummy tuck is a little like having an internal corset.

The ladies of Downton Abbey spend a lot of time having their corsets laced up by their maids – and it’s always right before they go down for dinner.  No wonder they all stay so slim.  Who can overeat when laced up tight?

And this brings me to a recent study about weight loss in ladies who have had a tummy tuck.  This is a common observation in my practice but I had never before seen it reported in the plastic surgery literature.  It seems that the internal corset that is part of most tummy tuck operations results in automatic portion control just like an old fashioned corset does.

Just another great thing about tummy tuck.  You get to wear your corset 24/7 and you don’t even need a maid!

Thanks for reading!  Dr. Lisa Lynn Sowder

Body Contouring, Now That's Cool, Obesity, Tummy Tuck, Wardrobe Observations

Woman inherits her mother’s plastic surgery fund.

November 8th, 2012 — 12:31pm

Seattle Plastic Surgeon discusses a very thoughtful mother’s last wishes.

“To my daughter, I leave $$$$$ for the purpose of plastic surgery.”

One question I always ask when a patient is thinking about having a plastic surgery procedure is “why now?”    The answer can be very interesting and often very relavent.  Here are some answers I have received over the years:

  • I’ve always wanted to do this but my husband wouldn’t let me and now we have split up and I can do what I want.
  • I’m old enough to make my own decisions now.
  • I saw a photo of myself at my son’s graduation and was shocked when I saw my double chin.  I didn’t think it was that bad.
  • I flipped a house in Ellensburg and have the money.  (This was, of course, before the real estate crash.)
  • I finally have my kids through school and can spend the money on me instead of them.
  • I’ve worked so hard to get down to and stay at this weight and now I want to do this as a reward.

Recently I received an totally unexpected answer to this question.  My prospective patient had recently lost her  mother after a long illness.  In the last few days, the mother confided in her daughter that she had put aside some money for a face lift.  The mother was a fan of plastic surgery having benefited from a breast reduction years earlier.  She wanted to make sure her daughter used this money for plastic surgery, specifically a mommy makeover.  That mother knew that everytime her daughter slipped into her swimsuit and enjoyed her surgical result, there would be a smile and a “Thanks Mom”.

Thank you for reading!  Dr. Lisa Lynn Sowder

Body Contouring, Breast Contouring, Financial Issues, Mommy Makeover

Rectus Diastasis Explained

September 18th, 2012 — 10:45am

Seattle Plastic surgeon thinks a picture is worth a thousand words in explaining what she does with the muscle during an abdominoplasty a.k.a. tummy tuck.  

Check out these drawings of the abdominal wall.  The one on the left shows what I see during an abdominoplasty a.k.a. tummy tuck.  The white area in the middle is the fascia (it looks and feels like packing tape) connecting the two rectus muscles on either side.  With pregnancy and sometimes weight gain, the muscles get separated and the mid-line becomes very weak and the abdominal tone decreases.  This separation is called rectus diastasis which translates into separation of the rectus.

During abdominoplasty a.k.a. tummy tuck, the surgeon peels up the fat and skin layer and exposes this stretched out area.  Then stitches are placed in the fascia where it meets the rectus muscles and used to pull the edges  back together.  These stitches accomplish what exercise really cannot.  Exercise may strengthen the muscle but it does not move the muscle back into a normal position.   

Maybe this explains why I prefer the term adominoplasty to tummy tuck.  The former acknowledges the repair and reshaping that takes place with this operation.  The latter makes it sound like just a quick nip and tuck.   It’s not!  It’s a real operation but one well worth the recovery for the vast majority of patients.

Thanks for reading.  Dr. Lisa Lynn Sowder

Body Contouring, Mommy Makeover, Tummy Tuck

Do I get a new belly button?

September 12th, 2012 — 2:29pm

Seattle Plastic Surgeon blogs about a common tummy tuck question.

The belly button does not move, but everything around it does.

I do alot of tummy tucks and patients often have questions about what happens to their belly button.  There is a common misperception that somehow we “move” it.    We don’t “move” the belly button but we move everything else.

At the beginning of a tummy tuck, and incision is made around the belly button and it is released from the skin and fat that surrounds it.  It remains attached to a stong band that runs between the two rectus muscles.   That means that NO, I can’t drop it on the floor!  (A common worry with tummy tuck patients).

Then the lower incision is made and the abdominal fat and skin is peeled up to and beyond the belly button.  Then the fat and skin is pulled down with the patient flexed a bit at the waist and the excess is excised, usually the fat roll between the pubis and the belly button.

The belly button is then brought out through a little incision in the remaining fat and skin and stitched into place.   Then the lower incision is closed. 

So the belly button see’s very little action during a tummy tuck.  It just sits there awaiting its new home while everything else is being thinned,  tightened and excisied. 

Thanks for reading!  Dr. Lisa Lynn Sowder

Body Contouring, Tummy Tuck

Improved posture – another benefit of tummy tuck.

September 6th, 2012 — 2:45pm

Seattle Plastic Surgeon observes that many of her tummy tuck patients have improved posture after surgery.

These waistline close up photos show marked improvement in this tummy tuck patient’s posture.

Tummy tuck is one of those great operations that improves both form and function.

Removing the excess skin and fat makes the torso look better but tightening the muscle layer makes the torso function better. 

This before and after photo shows this very clearly.   On the left, the patient had lordosis a.k.a. a sway back.  On the right, after surgery, her lordosis is almost gone.  The tightened abdominal muscles are now working better to support her back. 

Also, many patients who have low back pain prior to surgery find that they have much less pain after surgery. 

The abdominal muscles are important for back support.  Crunches may help but if the abdominal muscles have been separated by pregnancy, a tummy tuck may be necessary to get them back in the correct position. 

Thanks for reading!  Dr. Lisa Lynn Sowder

Body Contouring, Now That's Cool, Tummy Tuck

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