Board certified plastic surgeon Dr. Lori Saltz talks about body contouring surgery

So, you’ve had your children and your abdomen simply is not what it used to be. Not only that, but diet and exercise just aren’t helping. But what else is there to do and how do you decide? Sometimes the answer is unclear. It took me over a year to decide what I wanted, so don’t feel bad if the answer doesn’t just pop into your mind.

Every surgeon you see will look at you differently and may reach different conclusions. Not all surgeons will explain their recommendations in enough detail for you to grasp the finer points and, more importantly, the trade-offs. I feel it is important for you to know what to look for so that during your consultation, you will be armed with the knowledge to ask the right questions and weigh the recommendations.

Men look at our bodies differently than we do. My goal is to explain the things I look at in evaluating a woman for body contouring. My hope is that you will be able to use the information to evaluate your own body so you can decide which trade-offs you are willing to accept (or not) to get the results you want. Only you can decide what you can live with. I want you to know enough to make the decision yourself and not find out later there were other options you were not told of or consequences you were not warned of.


Excess Fat and Liposuction

Many of us have put on pounds over the years—and many of us have tried multiple diets without lasting success. Liposuction is meant to remove fat in a way that the contours of the body are enhanced; it is not a means of losing weight, nor does it tighten the skin to a significant degree. When you pour the drippings off the roast, it’s the fat that floats. It doesn’t weigh as much as muscle, but the volume is greater pound for pound. Unfortunately, it’s the volume that limits how much can safely be removed at one time, not the weight.

The ideal candidates for liposuction are within ten to fifteen pounds of their ideal weight. This includes BMIs from 20-24. The higher the BMI, the less rewarding liposuction will be for you. There is a limit to how much fat can safely be removed at one time, and five liters is generally considered the safe limit. That is two and a half of those two liters bottles of soda you are familiar with. 20-30%t of that volume is the fluid we inject into the tissue before we start. In those five liters, at best eight pounds of it will be fat.

If your BMI is greater than 30, you should consider weight loss before undertaking liposuction. If your BMI is 35 or greater, you are not a candidate for liposuction in an outpatient setting. You need a weight loss solution, not liposuction. You may be wondering, “Should I lose weight before surgery”? If your BMI is under 30 and you can, then of course. But let me qualify that by saying that you should aim for a weight you can maintain. It may not be the “ideal” weight, but it’s better than yo-yoing up and down. No body contouring procedure will prevent you from gaining weight afterward—only you can do that. Don’t set yourself up for disappointment by over-dieting before surgery only to gain it back afterwards.


Excess Tissue and Laxity

Think of your belly button as a nail. Any laxity in your upper abdomen get hung up on it. Sometimes, it is enough to form a bulge or roll. You may also have laxity in your lower abdomen, and while there can be laxity in both the upper and lower abdomen, usually there is more in the lower abdomen. A mini-abdominoplasty will address the laxity in the lower abdomen. However, when there is laxity in both the upper and lower abdomen, a standard abdominoplasty (or “tummy tuck“) is a better option because it will tighten the laxity in both locations.

Very little of the laxity in the upper abdomen can be smoothed and tightened without making an incision around your belly button so that the skin can be pulled down. Once the tissues have been pulled down, a new hole is made so that your belly button can be pulled through and sewn in place right where it’s always been. More about this later.

When there is even a small amount of laxity in the upper abdomen, a mini-abdominoplasty that has been pulled tight in the lower abdomen looks strange in my opinion. Either the lower abdomen should be tightened to the same degree as the upper abdomen or a standard abdominoplasty should be considered. You may hope for a mini-abdominoplasty, but in most cases it will give you less improvement than you desire. Consider this in your decision-making: You may be willing to compromise to save yourself the scars, but when you lean forward your upper abdomen may still sag. The best candidates for a mini-abdominoplasty are the lucky few that have a tiny bulge across the lower abdomen, usually along the upper edge of the C-section scar, while the rest of their abdomen is smooth with little laxity or protuberance.

Also consider taking a close look at the laxity along your outer thighs and buttocks because the scar can be extended to address these areas at the same time. This is becoming a more popular option as the scars can be kept within the bathing suit line. The smoother look of the thighs and lifted appearance of the buttocks may be worth it to you if you spend lots of time by the pool or at the beach.


Abdominal Protuberance

In some women the protuberance of their abdomen is the main problem. You may have very little tissue to excise. Check it out: stand in front of the mirror and relax your abdominal muscles. I know it’s hard, but you can do it. In most women it is just part of the problem. The muscles in your abdomen run vertically on either side of the midline.

There is a separation between the abdominal muscles made of a tissue called fascia. The fascia stretches when your abdomen expands due to weight gain or pregnancy. Exercise can tighten the muscles, but not the fascia. That is why during an abdominoplasty the muscles are usually sewn from edge to edge, tucking the fascia inward down the midline. Nothing is cut.

Your abdomen can only be tightened to the extent that the internal contents will permit. We all have internal fat around our organs. Some of us have more inside than outside so that even when we lay down, the abdomen still bulges. Lie down on a flat surface and look at how flat your abdomen is. Remember those people that your mother pointed out as having “beer bellies”? Those smooth round distended abdomens have been pushed outward from the inside. An abdominoplasty will do little or nothing for this problem. Fortunately, this is more common in men. Women tend to have more external fat that causes the bulges.


Scar Length

Scars are the thing that holds many women back from body contouring procedures. Many of the photos you will see have been taken within months of surgery and are still red and prominent. Abdominal scars take a year and a half to two years to flatten and fade. Correctly placed, you will hardly think about them after they turn white.

The geometry of scar excisions works like this: The angle between the upper and lower incisions must be no more than about 20o if the ends of the incision line are to be smooth.

The bigger the angle, the more bulging you will see. For reasons I could never figure out we call these bulges dog ears. Think of a circle with a wedge cut out. Close the wedge and you get a cone (aka dog ear). The larger the wedge, the higher the cone, the bigger the dog ear.

What that means is that the more tissue that is removed, the longer the scar must be in order to achieve the 20 o angle. It will always be longer than you think. You will have to decide whether you want a shorter incision and less excision or a longer incision and greater excision. A short incision and big excision will leave you with dog ears at either end of the scar which is right on your hips where you will notice them every time you look in the mirror. They are never a good look.


Scar position

This is another sticky subject. You must make an incision to excise the extra tissue. For a standard abdominoplasty an incision is made around the belly button, leaving a hole in the tissue when it is lifted off the muscles underneath. As the abdominal tissue is pulled down, the hole moves with it. How far down the hole moves depends on how much laxity there is above the belly button.

Here’s where the decision comes in: where to place the lower horizontal incision. Many surgeons prefer to make the lower incision high enough to excise the hole. This could be very high in some cases, leaving a scar just a few inches below the belly button; higher than many bathing suits. Your pubic hairline will also be much higher. Keep in mind that styles change. Not that many years ago the high cut look was in and women wanted the scars to sweep upward so as to hide them. Now, of course everything is low cut and those scars show. When I look at a naked body, the lower incision just looks less conspicuous to my eye, but you may feel differently.

The alternative placing the lower horizontal incision through the pubic area and closing the hole left by cutting around the belly button into a vertical line. I have never had a problem with a vertical scar other than an occasional scar revision that can be done with local anesthesia.

The take home message here is that you must look at photos of each surgeon’s patients before you sign up. They will tell you what to expect. If you don’t like what you see, move on. Actually this is good advice no matter what procedure you are considering, but especially an abdominoplasty.


Combining Liposuction with an Abdominoplasty

Dramatic results are possible when liposuction is used in conjunction with an abdominoplasty. If you are apple shaped and have more fat in your torso it helps to remove some of it from the waist and hips. While it used to be felt that liposuction of the upper abdomen was fraught with danger, it has been shown that removing the lower layer of fat in the upper abdomen is safe. There is a lower limit of fat that can be removed when an abdominoplasty is done at the same time. If a larger volume of fat is to be removed (say you want your thighs done, too), it may be safer to do all the liposuction first and the abdominoplasty later.

Conclusion

Examine your body with an eye to the things I have told you to look at. Consider your options. There will always be more than one. List the pros and cons of each and decide which trade-offs you can live with. The conclusion that you are not ready is acceptable. The time will come when you are. I hope to see you then.


Evaluate your Body for Contouring Surgery

Be brutal. Be honest. Don’t kid yourself. Do this alone in front of the mirror in good light.

  1. How much do you weigh?_______ What is your BMI?_______
  1. Is there fat you want removed?
    • How much and where?
    • How much laxity is there in these areas now?
    • Will you be satisfied with liposculpturing alone?
    • Would you need to have fat removed before having excisional surgery?
  1. Do you have bulges across your abdomen as a result of excess skin?
    • How much laxity is above your belly button?
    • How much is below?
    • How far does it extend around your hips?
  1. Are the sides of your thighs and/or buttocks also lax?
  1. Look at your side view. How much does your abdomen stick out? Don’t suck it in. Be honest with yourself here.
    • Where is the protuberance?
    • Lie down. How flat is your abdomen now?
  1. Do a crunch. Is there a bulge down the middle of your abdomen?
    • Can you feel a separation of the tightened muscles around your belly button?
  1. Pull down on your lower abdomen.
    • What does your belly button look like?
    • What does your upper abdomen look like?
  1. Estimate how much you think a hole made around your belly button would move down when all of the abdominal tissues are lifted and advanced downward.
    • Would you like a horizontal incision at that level?
    • Would it show in the types of clothing you like to wear?
    • How far up would your pubic hair extend?
    • Would you rather have the vertical scar and a lower horizontal one?
  1. Put it all together.
    • What are your options? Go from least to most in your choices.
    • What are the pros and cons of each? Write them down.

You are ready to schedule a consultation with a surgeon.