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: Obesity

Not all fat is created or treated equal.

January 27th, 2012 — 11:13pm

Seattle Plastic Surgeon blogs about the importance of distinguishing belly fat a.k.a. visceral fat from subcutaneous fat.  Pull up a chair.  This is going to be a long one.

Abdominoplasty a.k.a. tummy tuck is a BIG operation and it is in every ones best interest to do everything possible to make sure that the surgery is safe and effective.  Careful patient selection is the key.

Abdominoplasty does several things:

  • Tightens the muscle layer by pulling the two rectus muscles together in the midline.
  • Removes the excess skin of the abdomen.
  • Removes the excess fat between the skin and the muscle.
  • Fixes a ventral or umbilical hernia (if present).

One really important thing that abdominoplasty does not do:

  • Remove the excess fat inside the abdominal cavity, so called visceral or belly fat.

Take a look at this before and after photo.  Depressing, huh?  BTW – this is NOT my patient!

My guess is that this patient is not very satisfied with her result.

This patient had mostly visceral fat and this fat resides inside the abdomen.  It surrounds the intestines, infiltrates the liver and collects in a structure called the omentum.  The only way to reach this fat is to go inside the abdomen.

Even if the surgeon were really, really aggressive and went inside the abdomen, it still would not be possible to remove this fat.  The structures that collect the fat are either vital organs or carry the blood vessels to vital organs.

So how does one get rid of belly fat?  Not with surgery but rather with weight loss.  As a patient loses weight, the belly fat melts away and the abdomen becomes flatter and flatter.  If there is a lot of excess and loose skin left after the weight loss, then the patient likely is a  candidate for abdominoplasty.  Here’s a patient of mine that shows it very well.

In the first photo, most of this patient’s fat is visceral fat.  She wanted an abdominoplasty and I told her that she would have a lousy result and needed to loose weight first.  (This is NEVER what a patient wants to hear but it is what they need to hear from a doctor.)  She worked very,very hard to change her lifestyle and came back a year later having lost almost all of her excess weight.  She looked and felt like a million bucks.  I could not have wiped the smile off her face.  She was now the perfect patient and I did an abdominoplasty and a breast lift on her and she got a really, really nice result.  We were both thrilled.  She is a great success story and has kept her weight off.  She really has a whole new life.

I can take credit for about 10% of her new life.  She did 90% through diet, exercise and changing her whole lifestyle.  She not only looks so much better, she feels better and is in much better health.

So when I say “no”, and believe me, saying “no” is hard to do, it is because I don’t want a patient to go through the expense, time, discomfort and risk for a really, really mediocre result that they will likely be unhappy with.

Thanks for reading.  Dr. Lisa Lynn Sowder.


Body Contouring, Obesity, Plastic Surgery, Tummy Tuck

Weight loss victories

November 10th, 2011 — 8:29pm
Permanent weight loss – here’s what I’ve learned from my patients

How to lose weight for good according to Dr. Lisa Lynn Sowder’s weight loss patients.

I am a bit of an expert on weight loss, not because I have ever had major weight loss, but because I know so many patients who have and have been able to maintain their weight loss.  These are patients who come to me for body contouring procedures such as abdominoplasty, breast lift, upper arm lift, thigh lift, flank lift, lower body lift and so forth.   


I always ask them how they managed to finally lose the weight and keep it off.   I ask them to go into some detail.  This is not because because I want to write the next “diet bestseller” and buy a small island in Greece (although that would be nice) but because I want to pass on their secrets of success to other patients who struggle.

 About 40% of my weight loss patients have undergone weight loss surgery.  That’s another blog.  The other 60% have done it through life style changes. Here is what that 60% have told me:

  • Without exception, they have all sworn off sweets and refined carbohydrates.
  • Many have embraced a very low carb diet – think Adkins  diet.
  • Almost all have maintained regular aerobic exercise – walking and biking are the most popular with my patients.
  • Many of my patients have been helped with support groups such as Overeaters Anonymous, TOPS, and Weight Watchers.
  • A few of my patients have been helped with nutritional guidance from a physician or nutritionist.
  • I cannot remember a patient who mentioned a prepackaged food or liquid diet system. 

And here are a few patients I will never forget:

  • One gentleman lost 60 pounds when he quit drinking with the help of Alcoholics Anonymous.
  • One lady was able to stay 180 pounds overweight despite her gastric bypass through continuous and careful overeating.  She finally dropped her weight 150 pounds when she addressed her emotional issues with a psychologist and the help of Overeaters Anonymous.
  • One lady lost over 100 pounds by jogging.  She started really, really slow and got faster and faster as she lost weight.   She became addicted to a runners high which I guess is better than most addictions.
  • Several of my patients were able to slim down only after leaving a dysfunctional relationship.
  • One teenager lost 40 pounds just by giving up soda.
  • One lady in her 60’s lost 100 pounds after having bilateral knee replacements.  She had been very, very sendentary and once pain free,  became more active.

So there you have it folks; Dr. Sowder’s  Guide to Slow, Deliberate, Difficult, Soul Searching, Sweating, Hungry but Long Term Weight Loss.    Just think, I could have written that best seller and here I am just giving it away.

Thanks for reading.  Dr. Lisa Lynn Sowder



Body Contouring, Breast Lift, General Health, Obesity, Plastic Surgery, Tummy Tuck

The truth about breast surgery in the obese patient

November 4th, 2011 — 12:01am

Seattle Plastic Surgeon tells it like it is for obese women seeking breast surgery.

A recent article published in The Journal of Plastic & Reconstructive Surgery caught my attention.  This article looked at breast surgery outcomes in  7982 patients (that would be almost 16,ooo breasts!!!!) and divided the patients in obese and non-obese.  Their results were not surprising to me but they may be surprising to you.  The obese patients had a nearly 12 fold increase in postoperative complications when compared to non-obese patients.

Breast reduction is the most common breast operation performed in obese women.  That operation has a nearly 9 fold increase in postoperative complication in obese women compared to the non-obese.

This is not news for those of us who do a lot of reductions.  The sort of problems that obese women tend to have are fluid  collections (seroma), bleeding, delayed healing and infection.  These complications sometimes require a trip back to the operating room and they always require many, many postoperative visits.  Despite a rocky postoperative recovery, many obese women are still glad they had a reduction after everything is healed up.

So what’s the big deal?  All’s well that ends well, right?    Let’s look at this from an few different points of view.  If insurance pays for the reduction, they don’t want to see more bills for a hospital readmission to stop postoperative bleeding or a bajillion office visit bills to treat an infected wound.   And insurance companies are looking more closely at surgical outcomes and costs and using this information to rate surgeons.

If the reduction is private pay, the surgeon is unlikley to bill for increased postoperative visits which can run into 10 – 20 additional visits during recovery.  This can get very time consuming and expensive.

And for the patient it is no picnic having to pack an area along the suture line that either became infected or fell apart.  Post operative complications are just a total bummer all around, especially when the surgery is totally elective.

And here another issue.  Let’s say an obese lady has 5 pounds of breast tissue (which is 99% fat) removed and her weight drifts back up to her preoperative weight which almost always happens.  This means that she has gained 5 pounds of fat.  If that fat is just external fat, say on her hips, it’s not a big health issue but if it is intraabdominal fat a.k.a. belly fat a.k.a. visceral fat, it is a huge health risk.  Her breasts may no longer be killing her neck and back but her belly fat may literally be killing her.

So what am I really trying to say here.  Obese patients need to understand that breast reduction has a high rate of complications and that a reduction may actually make them less healthy if they gain back their weight as belly fat.

So this is a real sticky wicket.  Obese reduction patients are usually helped with back and neck pain with a breast reduction but weight loss would also help those back and neck pain issues.  Non surgical weight loss has no surgical risk and is accompanied by a host of improvements in a patients health.  Think high blood pressure, type 2 diabetes, arthritis, high cholesterol, etc.

So if you are obese and want a breast reduction from me, you will get a little weight loss lecture from me and may get turned down for surgery until you are able to shape up and slim down a little.    You may be willing to accept a high risk for a postoperative complication but I may not be.

Thanks for reading.  And if you have a quick, easy way to lose weight, please let me know.  I’m all ears.

 Dr. Lisa Lynn Sowder

Body Contouring, Breast Contouring, Breast Reduction, Health Care Costs, Obesity, Postoperative Care

The mathmatics (arthmetic really) of body contouring surgery.

November 2nd, 2011 — 9:54pm

Seattle plastic surgeon blogs about the arithmetic of body contouring surgery.

Okay, here’s a question I get all the time from my body contouring patients:  “Will the fat come back?”  And my answer is always:  “New fat will accumulate if you gain weight after surgery and I cannot predict where the new fat will go but I can almost guarantee it won’t go where you want it to go!”. 

And then I review a little simple arithmetic with them.  For example:

  • Their preoperative weight is 146 pounds.
  • I removed a total of 7 pounds of fat with liposuction and a tummy tuck.
  • Their new preoperative weight is 139 because I removed 7 pounds of fat with surgery.
  • If they come back three months later at 146, unless they have been weight training like a fiend, they have gained 7 pounds of fat.
  • 146 – 7 + 139 and 139 + 7 = 146.

And then I tell them my story of a patient I did liposuction on over 15 years ago.  She was a very fit and lean distance runner who had some stubborn fat on her lateral thighs (so-called saddle bags).  I did liposuction on her and she had a great result.  She can back a couple of years later having gained about 30 pounds after some personal issues including a knee injury that precluded her running.  She had the weirdest shaped thighs.  She had caved-in  lateral thighs where the fatty layer remained thin when the surrounding area’s fat pad had increased in thickness.  Yikes!   All I could tell her was that is she got back down to her healthy weight it would get better and in fact she did and it did. 

So this is why liposuction is about shape and spot reduction.  It is not about weight loss!

Body Contouring, Liposuction, Obesity, Tummy Tuck

Supersized marshmallows. So why are we getting so fat?

July 7th, 2011 — 6:11pm

Seattle Plastic Surgeon is shocked, shocked! at the size of these marshmallows.

As a plastic surgeon, I am often asked what I think is causing the obesity epidemic.  I’m not an epidemiologist or an endocrinologist but I  am a mom who shops for her family and I think I know the answer.

Last weekend, I was shopping for our Fourth of July celebration and the makings for S’Mores was on my list.  The grocery store had a nice display of everything one needs for these tasty campfire treats including these gigantic marshmallows.  I estimate they are four times the size of a “normal” marshmallow.  Yikes!  What is next?  Graham crackers and chocolate bars the size of an ipad?

One of my sons thought these supersized marshmallows were great until he roasted one.  Due to the decrease in surface area/size of these monsters, the inside does not get gooey enough unless the outside is over-roasted.  This makes for an unsatisfactory S’More that is too thick to fit into even the largest mouth.

So we’re giving a thumbs down to the supersized marshmallows and hopefully to the expanding waistline.  It’s easy for my growing, active kids to burn up the calories from all of our oversized food.  But for those of us of a certain age, it would take 12 minutes on the rowing machine to burn off one of these sugar bombs.

Thanks for reading.  Dr. Lisa Lynn Sowder

Body Contouring, General Health, Obesity

What can dog toys teach us about obesity?

June 22nd, 2011 — 6:45pm

Meet Henrietta and Earl

Seattle Plastic Surgeon shares her dog toy wisdom.

My aussie/border collie/snapping turtle, Stella, just loves her Henrietta and Earl chew toys.  Henrietta emits a high pitched squeal when chewed.  Earl produces a realistic flatus-like sound.  Stella, Henrietta and Earl make for some great hilarlity – for about 30 seconds.

Henrietta and Earl do, however, have some redeeming qualities in that they are very useful for obesity education.

Henrietta has a problem with external obestiy.  Her excess fat is mostly external and distributed kind of all over – her hips, back, chest, upper thighs and tummy.  This fat is unsightly but not much of a health issue.

Earl, on the other hand, has the dreaded internal belly fat.  Earl, who has an inappropriately elevated level of self esteem, will say, “It’s muscle, not fat.  Feel it, baby, it’s hard.”  Well, it’s not muscle, Earl.  It’s belly fat and it puts Earl at risk for diabetes, high blood pressure, stroke, heart attack, etc.

Henrietta’s fat is best addressed with weight loss but it can also be addressed with breast and body contouring surgery.  Earl’s fat on the other hand can only be addressed with weight loss.  Surgery cannot remove Earl’s internal fat although Stella is doing her best to chew it off.

Thanks for reading!  Easily asmused Seattle Plastic Surgeon, Dr. Lisa Lynn Sowder

Body Contouring, General Health, Now That's a Little Weird, Now That's Cool, Obesity, Patient Safety

Laser Liposuction? No Thanks.

February 21st, 2011 — 8:15pm

Seattle Plastic Surgeon Discusses the Risks of                         Laser Liposuction.

blog subdermal plexus 2I just returned from the annual meeting of the Northwest Society of Plastic Surgeons. The best presentation was a panel on new technologies – when, how and why or adopt them or, in many cases, not adopt them. A very interesting statistic was presented. Ninety-five percent of new technologies – meaning the latest and greatest, gotta have it, cannot survive without it – did not exist 5 to 6 years after it’s introduction. Wow, what a number. Laser liposuction was one of the featured new technologies that this panel of plastic surgeons did not think would make the cut. In fact, a recent survey of fully trained (as opposed to the imitation) plastic surgeons who had used laser liposuction, over 96% did not like it. This is the first time that I have heard that 96% of any kind of surgeons agree on anything.

One of the panel members, arguably the most laser friendly plastic surgeon on the planet, summed up laser liposuction with this comment: “Last time I checked, the subdermal plexus still existed.”

Stay with me; You are about to learn something important. Take a look at the illustration of your largest organ (the skin) above. See where the pink (skin) turns yellow (fat). That is the subdermis and that is the target of the laser in laser liposuction. After removing fat, the laser is used to heat up the subdermis in an effort to get the skin to shrink. I always get the image of bacon frying for some reason. Well, it’s not nice to heat this layer because the blood vessles that supply the skin live here. If a large enough area of blood vessles is fried, the skin will die. Dead skin is a very, very bad thing.

Non-laser liposuction spares most of the blood vessels because the intruments used (cannulas) are blunt and push the vessels aside rather than damage them. Because most skin has some elastic quality, the overlying skin usually shrinks to some degree once the underlying bulk is reduced.

I have seen my share of skin necrosis in patients who have heard the siren song of laser liposuction thinking it would spare them the necessity of a truly skin tightening procedure such as tummy tuck. I remain sooooo glad that I did not invest in one of these very, very expensive gizmos. It would be keeping our old furniture in our basement storage unit company.

Body Contouring, Liposuction, My Plastic Surgery Philosophy, Obesity, Patient Beware


September 15th, 2010 — 3:54pm

Seattle Plastic Surgeon discusses possible hazards of removal of superficial fat. 

cc - rubenesque - CopyThe Wall Street Journal recently ran an article about non-surgical fat removal using two different devices. One freezes the fat under the skin and the other zaps the fat with a laser than is focused under the skin. These two procedures basically kill the fat cells, they leak out all their fat and then the body removes the fat droplets, metabolizes and excretes the fat. Over weeks to months, the treated areas slim down.

Does that sound sweet or what??? But stop and think about it…………

The fat treated this way and with other techniques like liposuction, tummy tucks and body lifts is subcutaneous fat. It’s just the fat that resides under the skin and is harmless as far as overall health is concerned. Yeah, it’s unsightly and can get in the way but it’s harmless.

Visceral fat, on the other hand is bad news. This is the fat that is internal and encases and infiltrates the internal organs. This is the fat that causes the “beer belly” in many men and in some women. This is the fat that makes one an “apple” as opposed to hip and thigh fat that makes one a “pear”. Visceral fat produces all sorts of bad substances that lead to metabolic and cardiovascular disease and cancer.

Stay with me here. If subcutaneous fat cells are removed using fat removal methods and the patient gains weight, those fat cells are not around to enlarge and store the excess fat. Soooo….the amount of visceral fat may increase instead. A person may have slimmer hips or thighs or their love handles may be smaller, but their “beer belly” and all the health issues that go with a “beer belly” may increase.

It always bears repeating what I have been telling prospective patients for years. Liposuction and body contouring such as tummy tuck and lower body lifts is for patients that are at a healthy and stable weight. These procedures are not to be used as a substitute for diet and exercise. They are only for the left over, stubborn bulges and/or lax skin. Using these procedures as a weight loss tool will leave many patients disappointed and, if patients gain weight after surgery, at increased risk for obesity related diseases.

Thanks for reading.  Dr. Lisa Lynn Sowder

Body Contouring, General Health, Laser Liposuction, New Technology, Non-invasive, Obesity, Patient Beware, Plastic Surgery, Tummy Tuck

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