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: Tummy Tuck

Tummy tuck t-incision.

October 9th, 2017 — 9:39am

This patient had more muscle laxity that skin laxity. Here she is at 3 months with a very flat tummy. Her scar will fade with time.

I just love doing tummy tucks because this procedure allows me to tighten skin, fix muscle position, remove fat and improve a belly button in one operation.   Usually this can be done with an incision that is admittedly quite long but is where the sun doesn’t usually shine.  But sometimes, maybe 10% of cases, it is necessary to leave a scar in the lower mid-line.  Sometimes a patient really needs a full tummy tuck to correct muscle separation but doesn’t have quite enough skin laxity of remove all of the skin between the pubis and the belly button and in those cases a “t-incision” is necessary.  In most cases, I have a pretty good idea before surgery if I am going to need a t-incision but once in a while I cannot quite get that skin to stretch enough and have to leave a t-incision without prior warning to the patient.   This occurred recently and I had a husband hopping mad at me for the extra scar.  The alternative would have been to make the abdominal skin closure so tight that the patient would never be able to stand up straight again or position the really long horizontal scar quite high which would probably look worse than a nicely healed t-incision.

These intraoperative decisions are very, very difficult and sometimes, quite frankly, agonizing.  I am hoping that this particular patient heals well and her vertical scar becomes a non-issue as is usually the case.  And sometimes I just wish patients and their families could spend a day in my operating room clogs.  It’s not so easy!

Thanks for reading and letting me get that one off my chest!  Dr. Lisa Lynn Sowder

Follow me on Instagram @somdermd and @breastimplantsanity

Body Contouring, Tummy Tuck

FAQ: If I gain weight after liposuction, where will the fat go?

September 2nd, 2016 — 9:43am

Seattle Plastic Surgeon answers common Liposuction FAQ:  Where will the fat go if I gain weight?

Before hip liposuction, after hip liposuction, after significant weight gain. It's not pretty.

Before hip liposuction, after hip liposuction, after significant weight gain. It’s not pretty.

This is one of the great plastic surgery mysteries because in any given patient, I cannot really predict where the fat will go if a patient gains weight after liposuction.  I can say with confidence that it won’t likely go to the area(s) liposuctioned and it will likely go somewhere the patient does not want it.

So here’s the deal.  Liposuction removes unwanted fat cells.  Weight gain, at least short term weight gain,  makes existing fat cells fatter.  Soooo, if I remove, say, one half of the thickness of the fat pad of your lateral thighs and you gain weight, there are only half the previous fat cells in that area to get larger.  So the area may get a little thicker but not as much as the surrounding areas where fat cells were not removed.

And the same goes for other types of body contouring like tummy tucks (a.k.a. abdominoplasty), body lifts and breast reduction.  And this is why I am so adamant about patients having body or breast contouring when they are at a healthy and reasonable weight (did you notice I did not say ideal weight).  And then after surgery, their healthy and reasonable weight is their pre-op weight minus the weight removed surgically.  So if I removed 5 pounds doing a tummy tuck, my 145 pound patient should end up weighing (after recovery of course), 140 pounds.  See this blog on the Arithmetic of Body Contouring.  And see this blog on Predicting Patient Satisfaction after Body Contouring.

Thanks for reading!  Dr. Lisa Lynn Sowder

Body Contouring, Liposuction, Obesity, Tummy Tuck

A cancelled operation is like an empty airliner taking off.

October 14th, 2015 — 2:58pm
blog empty airline

An empty airline is almost as sad and an empty operating room.

Yesterday I had to cancel a case.  This patient was having a tummy tuck and I do not do tummy tucks on smokers.  She showed up for her surgery and confessed that she indeed had not completely quit smoking but was only smoking about 5 cigarettes a day.  Even that relatively small amount of nicotine puts her at significant risk for major healing problems and also puts her at risks for anesthesia problems because of airway irritability and increased secretions.

Soooo……………………we canceled her surgery, much to her disappointment.  This lady had arranged for time off work, child care, a caregiver for herself etc.  I don’t blame her for being disappointed and I have to say that I was a little disappointed too.  I had assembled an anesthesiologist, two registered nurses and a surgical tech not to mention my operating room.   And there we were, ready to go with no patient.  Canceling a case is sort of like flying an empty airliner around.  Lots of overhead but no paying passengers.

I am grateful that this patient was honest with us about her smoking.  I would much rather have an empty airliner on my hands than a surgical complication.  We got her rescheduled for after the first of the year and this time, I think she will take the no smoking instructions more seriously.

Thanks for reading and please don’t smoke.  Sometimes it can just ruin a good case.                                                                                                                                                                                    Dr. Lisa Lynn Sowder

Patient Safety, This Makes Me Cranky., Tummy Tuck

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


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

Pregnancy After Tummy Tuck

April 9th, 2013 — 2:29pm

Seattle Plastic Surgeon discusses pregnancy after tummy tuck.

blog pregnancy testThere must be something in the water lately.   I just got word of another one of my tummy tuck patients being pregnant.  This will be the third one and they have all been in the past year.

All of these ladies were several years out from their surgery and all of the pregnancies have been unexpected but not necessarily unwanted.  The first two had no problems with their pregnancy and both had a remarkable recovery of their abdominal tone after delivery.  I hope this most recent patient does as well.

There is nothing about a tummy tuck that would interfere with pregnancy but there is certainly a chance that after another child, the abdomen would need a little re-tightening.    This is why tummy tucks are recommended after childbearing is complete.  It’s a great operation but the recovery can be tough and you only want to go through that once!

Thanks for reading.  Dr. Lisa Lynn Sowder

Tummy Tuck, 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

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

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