A ^Retired Plastic Surgeon's Notebook

How to give the gift of plastic surgery.

Looking for the perfect gift this holiday season?  That perfect gift may just be a plastic surgical procedure.  Here are a few tips if you are considering this most thoughtful and personal of presents.

• Only consider this if your loved one has confided in you that he/she is considering “doing something” or that he/she just wishes that he/she could just “get rid of this ______(fill in the blank)”.  Remember, it’s about him/her, not about you.
• Make sure the lucky recipient is a good candidate for surgery.  Good candidates for surgery are in good heath (physically and mentally) and are in a socially stable place in their life.   If in doubt, shoot me an email and I can probably make an educated guess.  Do not, I repeat, do not give the gift of liposuction as a substitute for weight loss.  Need convincing that doing so is a bad idea?  Check out my blogs on obesity.
• Make sure that you can afford the surgery!  You wouldn’t want to have to back out because of sticker shock.  I have a lot of ball park prices posted on my web site.  Or feel free to shoot me an email and I can give you a financial idea of how much this could set you back.
• Make sure that lucky guy/gal will be able to take enough time off of work and/or household duties to recover.  It’s misery to try to get back to work too soon.  You want your gift to be a positive experience.  I have recovery times listed for most procedures on my web site.  Or shoot me an email.
• Make sure you have nice package to present.   You can’t wrap up a tummy tuck or eyelid lift, but you can wrap up something they might love to wear or use after all the discomfort and bruising is gone.  Maybe something sassy from Hanky Panky for that mommy makeover patient or a pair of beautiful Firefly earrings for that eyelid lift patient.  Or for that dude of yours, how about a nice pair of Ethica boxer briefs You can include one of my practice brochures and a procedure brochure.  Oh, I can just hear the shrieks of joy now!

And just think, your gift of plastic surgery will last years, even decades.  You and your loved one will be enjoying the benefits much longer than a new car or television or laptop.  Do the math.  It could end up being a great value as well as a great gift!

HAPPY SHOPPING AND THANKS FOR READING!  Dr. Lisa Lynn Sowder

I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.

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

Seattle Plastic Surgeon Discusses Mommy Makeover on Mother’s Day

Ah, the joys of motherhood! I can wax eloquently about fat little feet, apple cheeks, wet baby kisses and so on but one of the joys I did not expect was a boost in my Plastic Surgery practice, especially my “mommy makeover” patients. Since becoming a mother myself, I speak “mommy” really well. I know first hand the glorious details of feeding, bathing, changing, and schlepping the baby. I can recite the stages of the toddler, the preschooler, the gradeschooler, the tween, the teenager and currently I am becoming an expert on the joys of being the mother of young adults.  

Being familiar with all that being a mother requires makes me much better at counseling patients about the process and timing of a “mommy makeover”.

“Mommy makeovers” usually combine breast surgery (augmentation and/or lift or reduction) with body surgery (usually abdominoplasty and/or liposuction). Most women are healthy enough to have a combination of procedures during one operative session. It is, however, the first couple of post operative weeks that are the most challenging for the patient.

Mommy is used to taking care of everyone but herself. After surgery the Mommy needs to take of only herself. She needs to be “Queen for a Week or Two” and resist the urge to cook, clean, change, wipe, mop, vacuum, load, unload, fold, etc. And if her youngest weighs over 20 pounds, she may not pick him/her up for at least two weeks if breast surgery was done and for at least six weeks if an abdominoplasty was done. The little one can crawl into Mommy’s lap for a cuddle but NO HEAVY LIFTING for Mommy. This also applies to the dog.

It’s very important to for patients to discuss these issues with their families. I’ve had a few ladies who have underestimated their recovery time, have done too much too soon and have turned what should be a relatively comfortable and relaxing recovery into a very sore and frustrating one.

So, calling all mothers interested in a “mommy makeover”: Plan ahead and get your husband and your children and your friends on board. Make a sign for your bedroom door. “DO NOT DISTURB – MOMMY RECOVERING”.

Seattle Plastic Surgeon answers another FAQ.

It is common to combine surgical procedures and often makes a lot of sense to do so.  Combining procedures saves a trip to the operating room, saves some money and consolidates recovery time.  Procedures often done in combination include breast lift with a tummy tuck and face lift with blepharoplasty.

There are some procedures, however, that I will not combine.  Here is an example:  Posterior hip liposuction and facial surgery.  Why?  Liposuction involves some heavy physical labor.  I work up a sweat with most major liposuction cases.  That heavy large muscle effort leaves me with a fine tremor for about an hour or so and I don’t want to do fine facial surgery with a fine tremor.  So can’t I do the facial surgery first?  No that won’t work either.  The posterior hip liposuction requires the patient to be face down on the OR table.  Positioning a patient who has just had facial surgery face down is NOT a good idea.  Another example:  Brachioplasty (upper arm lift) and tummy tuck is not a good combination.  A tummy tuck really leaves the patient without core strength for several weeks so the patient is very reliant on the arms to move around in bed or get up from lying or sitting down.  Arms that are fresh from a brachioplasty are very sore and should not engage in heavy work.

So, when patients are looking at more than one procedure, sometimes it makes sense to combine them but sometimes it doesn’t.  Oh, and one other factor is surgeon fatigue.  Yes, even badass surgeons like me get tired.  More about that in another blog post.

Thanks for reading!  Dr. Lisa Lynn Sowder

These arms are NOT the result of plastic surgery!

Seattle Plastic Surgeon discusses options for upper arms.

The thermometer in Seattle is finally hitting 70 degrees after the most wretched sping in recorded weather history and I’m getting a lot of questions about upper arm enhancement.

The First Lady’s arms are the result of good arm genes and a great personal trainer.  Also, she has not yet entered the menopausal years (more about that in a future post).  For those without Mrs. Obama’s genes or trainer, there are a few procedures that can be done to improve the upper arm.  Which procedure is the most appropriate is dictated by several factors:

• Skin tone
• Thickness of the fat layer
• Condition of the underlying muscles
• Scar history

Patients with a thin layer of fat and poor skin tone are usually older and thin.  The only procedure that will improve the upper arm is a brachioplasty.  This procedure involves removing the excess skin of the upper and inner arm.  This always leaves a scar from the axilla (arm pit) to the elbow.  I strive to keep this scar on the surface that is hidden against the side when the arms are down.  The question patients must ask them selves is: “Am I willing to trade these bat wings for a scar?”  In patients who heal well and the scar is narrow and light, the answer is usually “yes” but I do have one brachioplasty patient who has a lovely arm shape and excellent scars who is still too self-conscious to go sleeveless.  I may have hit a surgical home run with her but I don’t consider the case a complete success.

Patients with chubby upper arms and good skin tone are great candidates for the CAST procedure.  This procedure involves circumferential treatment of the arm with very careful tumescense power- assisted liposuction.  The fat removal is limited to the outer arm where the excess fat resides but the inner arm is also treated with undermining the skin with the blunt liposuction cannula off of suction to stimulate shrinkage and tightening of the skin.  Patients wear a compression bolero to help the skin tighten postoperatively.

Patients who are “in between” are often candidates for a combination procedure where the incision and resultant scar can be confined to the axilla and the very, very upper inner arm where the sun hardly ever shines.

So if you want perfect Mrs. Obabma’s arms, sorry it’s not likely to happen.   But is you want better arms, there is likely something I can do to get you to your personal best.

Thanks for reading!

Seattle Plastic Surgeon, Lisa Lynn Sowder, M.D.

What’s the ideal weight for plastic surgery?

Which Oprah will do best with surgery? Probably the one in the red dress!

I get this question a lot from patients who are thinking about having breast and/or body contouring.  It’s an important question and I am always glad to hear it because it tells me that the patient understands that weight fluctuations can make a difference in surgical outcome.  Take Oprah for example.  There have been times in her life where her weight has yo-yoed all over the place.  Operating on her during these times would be like operating on a moving target.  A great result seen two weeks after surgery could turn into a lousy or even bizarre result a few months hence if her weight went up or down 30 – 40 pounds.

Sooo……patients should be at a stable and sustainable and healthy weight prior to surgery.  Did you notice that I did not say ideal?  Ideal weight may be achievable for some patients but unless it is sustainable, I would rather operate on a patient who is a little bit or even quite a bit over their ideal as long as they are healthy.

Healthy is the key word here.  If a patient is carrying a lot of excess weight and has type 2 diabetes, high blood pressure and has trouble walking up a flight of stairs, that person is not healthy and should not be having elective surgery.  That is the type of patient I will refer to a weight loss specialist.  If on the other hand, the patient is carrying extra weight and does not have diabetes, high blood pressure and plays an hour of pickle ball every day, I have no problem doing elective surgery on them.  And at the other end of the weight spectrum there are issues with being too thin.  I screen carefully for patients with eating disorders such as anorexia nervosa or bulimia.  Those conditions are serious illnesses and patients need evaluation, care and support – not plastic surgery.  Thin patients who are well nourished and weight stable usually make excellent surgical candidates.

So as you can see, it’s not about the number on the scale or the BMI or the dress size.  It’s about being healthy.

Thanks for reading!  Dr. Lisa Lynn Sowder

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

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

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.

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