A ^Retired Plastic Surgeon's Notebook

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”.

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 clears up some confusion about postoperative “issues.”

I recently did a pre-operative visit on a lady who will be having a face lift next month.  We have patients read an extensive informed consent document and discuss any issues that arise from that document.  She was most concerned about nerve damage that may leave her face “paralyzed and numb.”  This got me thinking about surgical complications and trade offs.

Facial paralysis after a face lift is an exceedingly rare (as in it has never occurred in any of my face lift patients) but possible complication of face lift surgery.  That is in contrast to facial numbness after a face lift which is not a complication at all.  It is a trade off meaning that it happens because of what the surgeon must do to accomplish the face lift.  In raising or peeling up the skin on the face, many teeny, tiny sensory nerves are cut and this leaves the face numb until those teeny, tiny sensory nerves grow back and the sensation returns (this usually takes about a year).

Here is another example:   A trade off for a tummy tuck is the hip to hip scar.  An incision must be made to remove the excess skin and all incisions heal with a scar so a normal scar is not a complication.  It is a predicatble and expected trade off.   Now if the skin on either side of the incision becomes infected or falls apart  and the scar ends up being really wide or indented, that is considered a complication.  It was not expected.

Complications are not expected but can happen and patients need to be aware of their risks.  Trade offs are expected and will happen and patients need to be accepting of them.

Wow, it was good to get that cleared up, at least for me it was.  Thanks for reading!  Dr. Lisa Lynn Sowder

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.

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

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

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

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

Seattle Plastic Surgeon discusses one of life’s little surprises.

I have seen 2 patients in the past week who had babies after having had a tummy tuck.  These were surprise pregnancies and both patients had been concerned about 1) the effect of their surgery on their baby and 2) the effect of their baby on their surgery. 

The post tummy tuck abdomen is perfectly capable of s-t-r-e-t-c-h-i-n-g and there is no evidence that the tightened abdomen  interferes with pregnancy. 

If after delivery, the abdomen does not return to a satisfactory shape, re-tightening can be done but in my two patients, their tummies snapped back into shape after a couple of months and a lot of crunches and no re-tightening was needed.    

Soooooo……………………if you have a tummy tuck and then get a little surprise, make an appointment to see me a couple months after delivery and I’ll take a look and let you know if re-tightening is indicated.  Make sure to bring the little surprise package in with you.  We all love babies in my office!

Thanks for reading!  Dr. Lisa Lynn Sowder