Surgery after Massive Weight Loss

As gastric bypass procedures have become more common, patients who have lost a large amount of weight following gastric bypass, who now have significant laxity of their skin have also become more common in our office. As you'd expect, the areas that are commonly affected after massive weight loss (MWL) include: the abdomen and trunk, the breasts, the arms, and the inner and outer thighs.

While plastic surgeons have long had operations to fix these problem areas by removing the excess skin, we've learned through experience that the MWL patients are a little different than regular non-MWL patients when it comes to wound healing, complications and results.

For example, problems like anemia (from iron or vitamin B12 malabsorption) and certain other vitamin deficiencies are much more common in someone who has had a previous gastric bypass, compared to a non-bypass patient. Also, poor protein absorption caused by the effects of bypass surgery can result in low protein reserves and subsequent troubles with slow or impaired wound healing.

MWL patients are also more prone to have a higher rate of certain post-surgical complications. These include: wound separation, fluid accumulations under the skin known as seromas, and scars that may be more obvious in color or size compared to the non-MWL group.

Also, the MWL- patient's skin tends to stretch out more over time, due to decreased elasticity. So, even though we pull the skin as snug as we safely can, some relapse of the lifted area can occur.

Overall, this makes surgery for MWL patients more of a challenge - but the results are usually very gratifying for both surgeon and patient alike when it is completed.

Celebrity Plastic Surgery

Recently, I got a e-mail from a former employee, an attractive young nurse who had moved out to the West Coast. In it, she comically mentioned "not wanting to look like some Hollywood-style bad plastic surgery victim", and asked me for some recommendations about who to see out there. But it got me thinking...

I spent some time looking at "bad celebrity surgery", and started to notice some patterns. I think it boils down to a combination of facial distortion, loss of one's distinctive initial appearance with reduction of recognizability, and the "stigmata" of poorly performed or ill-advised work.

Here is my highly opinionated list of "problems to be avoided", if at all possible.

1. Excessive botox - particularly in the glabella and medial forehead area, when it can drop the position of the inner portion of the eyebrows, giving a diabolical or "vulcan" look.

2. Excessive lip fillers. While a full, pouty lip can look youthful and pretty - there is a limit. The upper lip should certainly not be larger than the lower lip. Respect the anatomic details of the lip - the lip should not look like a sausage. In general, straight men should avoid lip augmentation, as it can feminize the appearance.

3. Facial fat removal. As we age, we naturally lose our facial fat. Removing it surgically with liposuction or direct excision, in order to give a more "sculpted" appearance, can be a set-up for a skeletal, gaunt appearance in the future. And it's hard to fix.

4. Cheek implants - are not a substitute for a facelift, and do not make a good replacement for loss of facial fat. Poorly performed cheek augmentation can distort the facial width, or look like a chipmunk storing nuts in its cheeks. Cheek & chin implants can work wonders for people that don't have good underlying bone structure - if they are properly sized, and meticulously placed by an expert.

5. Overdone rhinoplasty. An excessively thinned, pointy nose, with distortion in the nostril area or visible irregularities. Celebrity gossip pages are full of these.

6. Unfortunate facelift results. We'll talk more about this in future posts - but "pixie ears", loss of hair in the temple area, peculiar direction of cheek wrinkles, visible scars, the "tight face-loose neck" combination....these are all tip-offs that a facelift didn't work out very successfully or had some technical problems.

7. "Tan-orexia" - when your skin tone is the color of pumpkin pie from the over-use of self-tanning products, it's not good.

8. Too much of everything / too young / too many operations. Trying to slow aging is one thing. Starting to look like someone else is another.


Best wishes for 2009!

Liposuction - keys for success

In order to get a good quality result with liposuction, there are a couple of key factors. These can be nicely divided into "patient" and "surgeon" factors.

On the patient side:
1) Good skin elasticity. Probably the most important factor, as liposuction relies on the natural elastic recoil of the skin for the "shrinking up" effect that occurs after the procedure. Liposuction will not make loose, floppy skin tighter. People with loose skin are not good candidates for liposuction, and usually need some form of body-lift surgery (tummy tuck, etc.)

2) Liposuction is not: a cure for cellulite, or a weight-loss method.

On the surgeon side:
1) Remove the fat evenly and smoothly. Sounds obvious - but surgeon skill is a big part of getting good liposuction results. Experience counts. Don't over-do the suction in one area, or you'll risk a post-operative "divot". I prefer to maintain a little fat just below the skin, to reduce the risk of irregularities and grooves, avoiding what's known as "superficial liposuction".

2) Don't think that the "latest gadget" replaces the need for surgical skill. There's a great deal of marketing hype about new liposuction technology - and it's important to scientifically evaluate the often-exaggerated claims that a manufacturer makes. We've seen this type of hype recently with the wave of new laser-assisted liposuction machines.

Do I need a lift, Doctor?

A common question from patients who are considering a breast augmentation is whether they would need a breast lift or not.

There are several methods that plastic surgeons use to decide whether or not there is significant droop of the breast, known as "breast ptosis". Essentially, it all has to do with the position of the nipple, compared to the position of the crease underneath the breast, known as the "infra-mammary fold".

If the nipple is positioned above the horizontal level of the infra-mammary fold when you are standing up - then any ptosis you may have is considered "mild". If the nipple has descended below the level of the crease, then the breast droop is more significant, and you may indeed benefit from a breast lift, in addition to any augmentation you might be considering.

Another easy method to check for breast ptosis involves clasping your hands on top of your head, and looking at what happens to the nipple position in the mirror. If the nipple position is still too low for your liking, then a lift operation might be beneficial.

When the amount of droop is mild, often we can use a short-scar technique for the lift, avoiding the long anchor-shaped incisions used in the classic breast lift. The benelli or "donut" lift, for example, allows us to can use one circular incision around the nipple - and get three benefits with it: use it to place the implants, make the areola smaller in size, and get a little bit of a breast lift all at the same time.

Hello, Evolence!

Here's a new twist on an "old friend" - collagen is back, in a new & improved way. Known as Evolence - and don't ask me how they come up with these names - it's an FDA-approved filler with a good track record for wrinkle correction after being on the market several years in Europe. It's now available in the USA.

Compared to the old collagen products (Zyderm & Zyplast), Evolence offers several advantages:

1) no need for a skin test prior to treatment to check for sensitivities or allergies, which happened in about 1% of people with the old product;

2) much longer-lasting correction. European studies show a duration of about 12 months; and

3) minimal bruising from the injection.

Overall, it looks promising, and we're now going to offer it in my practice, adding another option to the many other FDA-approved fillers we have.

What will be really interesting is a head-to-head comparison study comparing Evolence to some of the better hyaluronic gel fillers. This study is underway. "Which filler will reign supreme?"...we'll have to wait and see!

Goodbye, Artefill.

In an unexpected turn of events, Artes Medical, the makers of Artefill, have filed for Chapter 7. They blame this on the difficult economy and the resulting downturn in their cosmetic business. Their product, Artefill, will no longer be available, as the company is in the process of liquidation. Even some of their reps were caught off-guard!

Artefill was one of the few semi-permanent FDA-approved fillers, and was a unique formulation. We had some nice results with it, when it was appropriately used in the nasolabial (cheek) lines.

Oh, well...

Beautiful eyelashes

Sometimes a drug side-effect can turn out to be a beneficial thing. An FDA-approved eye medication, called Lumigan, used regularly to treat glaucoma patients, was found to have a beneficial side effect - it makes eye lashes grow. It has few other side effects.

Ophthalmologists at the University of Miami, confirmed this finding of eyelash growth in a recently completed scientific study. With daily application of Lumigan to the eyelash with a mascara brush, the average lash length increased by 2.01 mm over a six week time period, compared to the placebo-treated side.

Allergan, the makers of Botox and Lumigan, recognized a good thing - and have developed a spin-off of Lumigan, called Latisse, just for women who want to have longer, fuller lashes. Latisse has the same active ingredient as Lumigan. Latisse is waiting for FDA approval, but this is expected in the first part of 2009.

In the meantime, Lumigan can be used "off-label" by prescription for those that just can't wait for Latisse. And yes, experiments on whether this drug can work for hair-loss elsewhere on the body are in the works....

While several other cosmetic companies market products for eyelash enhancement, by law, they can't use any ingredients as potent as these prescription-strength products. Also, the FDA-approved products like Lumigan have all sorts of safety data behind them, which is always reassuring.

"Scarless" breast reduction

Recently, a number of surgeons have been promoting the concept of "scarless breast reduction". While technically, there is a single small incision, compared to a standard surgical breast reduction, it's nearly scarless.

Here's the secret: liposuction. Liposuction is used to remove fatty tissue from the breasts, which makes them smaller, lighter, and more comfortable for women who suffer from the weight of excessively large and heavy breasts.

There's a catch, though. Liposuction-based breast reduction works for women who have breasts that are mostly fatty, and doesn't work if the breast is mostly composed of dense breast glandular tissue. Sometimes this determination is tricky - as there is no inexpensive, accurate test. There are some patients, usually younger in age, where this technique won't work at all.

If the breast is droopy, liposuction breast reduction doesn't really lift the breast, but it usually doesn't make the droop worse either. This is the key difference between standard breast reduction methods and liposuction breast reduction. Liposuction breast reduction usually gives you a "smaller version of what you have now", but not a breast lift.

Surgical breast reduction offers the advantages of lifting and re-shaping the breast - but with the trade-off of additional incisions.

In summary: liposuction breast reduction is a useful option to know about, particularly for women who are worried about scars, or who tend to make thick, ropey scars - and who would like a breast reduction.

How to choose a Plastic Surgeon

If you've been doing your research prior to coming in for a consultation, you've probably come across one of those checklists that many of the plastic surgery advice websites seem to have. While I don't mind those lists, there's probably an easier way:

choose a member of ASAPS (the American Society for Aesthetic Plastic Surgery) as a first step.

Right away, you've automatically selected a Board-certified Plastic Surgeon with significant experience and interest in cosmetic / aesthetic plastic surgery. All members of ASAPS have been in practice for at least 5 years, must operate in accredited surgical facilities, must adhere to the ASAPS' Code of Ethics, and have been approved by their peers. Only about one-quarter of all plastic surgeons are ASAPS members - the specialists in aesthetic (cosmetic) plastic surgery.

Then, look for a ASAPS surgeon who has an aesthetic sense that matches yours. I often use the analogy of choosing an interior decorator - if you are redecorating your home, you might get three designers to give you suggestions on how to do it. While all 3 might offer competent designs, one will match your personal tastes better than the others. That's the one to go with. The same applies when choosing your aesthetic plastic surgeon.

Make sure your surgeon explains things well, and that his/her approach makes sense to you. Do they have lots of before and after photos for your procedure? Do the photos look the way you want to look?

Do you "bond" with the surgeon and the office staff? Do you feel comfortable there? Will they look after you, without a big hassle, should there be a complication?

If you can answer "yes" to these questions, then you've found your surgeon. :)

Fractional CO2 laser resurfacing

Every so often, a significant breakthrough comes along in Plastic Surgery - and this, I believe, is one of them. It's a new twist on a familiar theme. In this case, the new twist is a gadget called a "fractional laser scanner". This is an optical-mechanical device that manipulates an incoming laser beam, creating a polka-dot pattern of laser dots. Normal, untreated skin is left in-between the treated / lasered areas, rather than zapping the entire surface of the skin.

Since only a small fraction of the skin is treated, the technique is known as fractional resurfacing. It can be thought of as a kindler, gentler way to do skin resurfacing. It's not as dramatic a result as the traditional CO2 laser - but the recovery is also far, far easier. The down-time is about 3-7 days, with very little pain. I've been using a european machine, called the Ellipse Juvia, for my treatments since march 2007. (I believe we had the first Juvia unit in the entire South-East.) While laser resurfacing is not a replacement for a facelift, it does a nice job improving texture problems, fine wrinkles and clearing up sun damage.


There are about a dozen machines out there that use this fractional co2 laser technology - and to be honest, they are all fairly similar, whether they are called "Active FX", "DOT therapy", "mixto" or "Juvia". What's confusing for the consumer, however, is that the original "Fraxel" machine - isn't a CO2 laser. It uses a different, less powerful wavelength - so the results with the original Fraxel have not been as impressive.

There are also 2 machines - the Fraxel Repair and the Deep FX - that are designed for deeper treatments. The jury is still out on these...as the complication rate may be higher, and as yet, the treatment parameters have not been optimized.

If you decide to have this treatment done, make sure you go to a physician with plenty of CO2 laser experience. While fractional treatments can be done very lightly, all of these machines can be turned up to give a very intense treatment. They are by no means "goof-proof". Experience of the laser operator is the key to a good result.