PREPARING FOR NECK LIFT SURGERY
Cosmetic Clinic Dubai | 15 October 2019
Neck lift plastic surgery is designed to reduce excess skin from the neck, tighten the underlying muscles and eliminate unsightly neck bands. The procedure should be preceded by a detailed preparation process in order to achieve safe and desirable outcomes. When a patient is thoroughly prepared for the surgery, they will go through minimal pre-surgery anxiety and will have a better chance of achieving safe and predictable results.
Neck Lift Preparation Guidelines
The following basic guidelines will help a patient to prepare well for the neck lift plastic surgery:
Arrange to send the past medical records directly to the surgeon’s office
Note down all the medications, including prescription drugs, blood thinning medications, NSAIDs, herbal supplements and vitamins, that the patient may be currently taking
Get any medical tests done as instructed by the surgeon.
If any prescription drugs need to be adjusted before the surgery, have the surgeon speak to the prescribing physician
Stop smoking for at least the period specified by the surgeon before and after the neck lift surgery
If any pressing tasks at home or office are pending, have them completed prior to the surgery in order to have a stress-free post-op recovery
Arrange for a family member, friend or a caregiver to assist during the initial recovery phase, as needed.
Have someone responsible to drive the patient back home after the surgery
The patient should have the commitment to follow the surgeon’s instructions for preparation for the sake of their own safety.
Neck Lift – Other Instructions
The surgeon’s office may provide a set of common instructions to the patient as a part of the preparation for neck lift surgery. These may include:
Do not use aspirin, ibuprofen and other blood thinners and NSAIDs for at least a week before surgery
Avoid taking vitamin E, vitamin C, homeopathic and herbal remedies as well as dietary supplements for two to four weeks before surgery
On the day of the surgery, do not wear makeup, nail paint, jewelry, body piercings or contact lenses to the surgery center
Wear comfortable clothing and shoes on the day of the surgery. The top should button in the front as the procedure involves upper part of the body.
Do not consume alcohol for at least 48 hours before the surgery
If neck lift is to be performed using general anesthesia, avoid eating or drinking for eight hours before the surgery
If the patient is a diabetic, they should have their parameters checked on the morning of the surgery
Many patients experience mild pre-op stress and anxiety a day before the surgery. The surgeon may prescribe a calming medication to be taken the night before the surgery.
WHAT HAPPENS IF I GAIN WEIGHT AFTER LIPOSUCTION?
Cosmetic Clinic Dubai | 12 October 2019
The new contours of the body will be more or less permanent after liposuction plastic surgery. But if the patient gains a moderate amount of body weight (below ten pounds), their new figure will not change significantly. They would simply look like a slightly larger version of their new body shape.
As long as the patient does not gain excessive amounts of weight, they can enjoy their new body contours. Time will take some toll on the body shape due to the natural process of aging. However, the results of liposuction will still continue to be visible.
How Changes in Body Weight Affect the Figure
Good liposuction candidates will be committed to maintaining stable body weight even after the surgery and will follow a balanced diet and regular exercise program. Post-liposuction weight gain will impact the appearance of the new body contours. Patients should ideally weigh less after liposuction by at least the amount of fat removed.
For instance, if a person with an original body weight of 140 pounds undergoes liposuction to remove six pounds of fat, they should weigh nearly 134 pounds after the surgery.
But if the patient puts on six pounds to weigh 140 pounds after the procedure, the cosmetic outcomes will still be appealing. However, they will diminish marginally.
If the patient gains an extra 16 pounds to weigh 150 pounds after liposuction, the overall results will be significantly impacted. For people who lack the discipline to maintain stable body weight after liposuction, it may not be a suitable procedure.
Liposuction is not a guarantee that someone will remain that same weight indefinitely. If they don’t eat properly and/or exercise on a normal basis then in short order or a few years later that same person could be back in the same spot. They will not be happy with their appearance and wondering if they should do this procedure again.
Fat Accumulation after Post-Liposuction Weight Gain
If the patient puts on significant amounts of weight (ten pounds and above) following liposuction plastic surgery, then the body will potentially produce new fat, and this fat must go to various parts of the body. The new fat will usually be stored in areas of the body depending on the number of fat cells in each site.
As a result, the liposuction treated areas will collect relatively lesser fat. But the sites that have not been treated with liposuction will accumulate significant fatty deposits. If the patient gains weight after liposuction of the hips, outer thighs, and abdomen, the new fat will accumulate in areas such as the neck, upper arms, breasts, legs, face, and back.
Maintaining Body Weight Post-Liposuction
The surgeon will offer the patient instructions on following a balanced diet and exercise regimen after their liposuction surgery. In the initial one to two weeks after the procedure, the patient should only take mild walks around the neighborhood or on a treadmill. They can gradually increase their activity level in the following two to three weeks. But the patient should be careful not to put pressure on the incisions.
In around one month, the incisions will heal properly. The patient can perform more vigorous exercises after the incisions heal. They should take a diet that is rich in veggies, fruit, and fiber, and avoid processed foods and saturated fats.
GETTING TO THE BOTOM OF A BRAZILIAN BUTT LIFT
Cosmetic Clinic Dubai | 5 October 2019
Gluteoplasty, more commonly known as a butt lift, is a type of plastic surgery that aims to enhance or correct the appearance of the buttocks. For many, sagging due to age, genetics or excessive weight loss can leave the backside misshapen or drooping. A butt lift is an ideal option for those who would like to make a lasting, significant change to their buttocks.
Brazilian butt lifts are a specific type of butt lift that is growing in popularity. The basic butt lift typically focuses on the lifting and tightening of excess skin around the buttocks. The Brazilian butt lift can include liposuction, lipoinjection and body contouring. When all of these techniques are combined, a Brazilian butt lift makes dramatic changes to your figure and the size of your buttocks.
BREAST AUGMENTATION IMPLANT SURGERY CANDIDATES
Cosmetic Clinic Dubai | 3 October 2019
Most women choose breast augmentation implant plastic surgery for cosmetic reasons such as increasing the size of naturally small breasts, improve symmetry between the breasts, or simply achieve a more voluptuous looking figure. But some women may require breast implants as a part of breast reconstruction surgery after a mastectomy.
Need for Breast Augmentation
To determine a woman’s candidacy for breast augmentation implant surgery, the surgeon will first try to assess the reasons why she wants this surgery. Only the patient can provide a true answer about her innate need and desire for enhanced breasts, and what kind of expectations she may have from this procedure. Based on this feedback, the surgeon can create a customized plan for breast augmentation plastic surgery.
Some of the reasons why women want breast augmentation include:
Desire to make the breasts appear normally sized if they are disproportionately small.
Remove imbalance between unevenly sized or shaped breasts.
Achieve a more feminine look.
Restore breast volume after weight loss or pregnancy.
Correct congenital defects in one or both breasts.
Reconstruct breasts after mastectomy or breast injury.
Improving body image and self-confidence.
The surgeon will incorporate the patient’s aesthetic needs and goals into the breast augmentation plan, and at the same time, help her to form realistic expectations. Experienced plastic surgeons at the Virginia Institute receive patients from Richmond, Virginia, and nearby areas for breast augmentation implant surgery.
Health Requisites
The patient should be generally healthy and fit to be considered for breast augmentation implant surgery. The surgeon will go through the patient’s medical and surgical records, and assess the breast anatomy and skin elasticity in the breast area. Specialized mammograms may be ordered in some cases. The patient should disclose all necessary information about her current and previous health conditions.
The surgeon will advise the patient against smoking for at least a few weeks prior to breast surgery, and may stop her from taking certain medications, herbal supplements and vitamins for some time. The schedule of prescription medications may have to be modified in consultation with the prescribing physician.
The patient should have a stable body weight, no untreated infections, and should not be currently pregnant or breastfeeding. She should also be free from any cancerous or pre-cancerous breast tissue.
QUESTIONS TO ASK YOUR NECK LIFT PLASTIC SURGEON
Cosmetic Clinic Dubai | 1 October 2019
A smooth and youthful neck can accentuate the overall facial appearance and make a person look slimmer and attractive. At the time of pre-op consultation, the patient will have an opportunity to learn all about neck lift plastic surgery as well as familiarize themselves with the surgeon’s practice.
The patient should feel free to ask questions and clear any doubts and concerns they may have. They should know what a neck lift surgery can or cannot do for them, and what are its potential risks and benefits. The patient should also learn about the surgeon’s professional credentials and satisfy themselves completely before making a final choice.
Informed and Independent Decision
For any plastic surgery procedure such as neck lift, the candidate should be personally convinced about the surgery and the choice of surgeon. They should make the decision independently, without being influenced by what a magazine, celebrity or a friend may have to say. The patient will have to fill the consent forms prior to the surgery, which will mention that the patient is making a voluntary decision while being aware of the potential risks involved in the surgery.
The patient should review the surgeon’s website to learn about their professional credentials as well as other aspects of their practice. They should request for a brief office tour during the initial consultation, and may also speak to one of the staff members. Reviewing testimonials of past patients is also a good way to assess the practice from another patient’s perspective.
Key Questions to Ask
The patient may ask the following important questions during the neck lift consultation:
Are you board certified in plastic surgery, and if yes, from which board?
How many years of training and experience do you have in this field?
Have you previously performed neck and face surgery procedures?
Will you perform my surgery using general or local anaesthesia?
Do you have staff privileges at a local hospital or surgery center to perform my neck lift?
Do I make a good candidate for this procedure?
What kind of neck lift surgery technique would you use in my case?
Will I need to make any lifestyle adjustments before and after the procedure?
How painful will be my recovery, and when can I return to work after the procedure?
Are there any risks and complications that I should know of?
Will I have lasting scars on the neck after the surgery?
Can you show me neck lift before and after photos to understand the potential effectiveness of the procedure?
How much will the neck lift surgery cost me, including pre- and post-operative expenses?
Why You Should Try Vitamin IV Infusion Therapy
Cosmetic Clinic Dubai | 30 September 2019
Convenience is always the name of the game – and that’s why IV drip therapy has gained so much popularity. IV drips offer a new way for you to receive your vitamins. This type of intravenous injection refers to a liquid mixture composed of different vitamins and minerals that work synergistically to help you recover from dehydration, fatigue, help to enhance your immune system, and detox heavy metals from your blood. Some IV drips are also designed specifically to help with hangovers and jet lag.
Getting vitamins and minerals through IV infusion
Receiving vitamins and minerals through IV infusion has become increasingly popular, but what exactly is it and how do they help you? You might typically think of intravenous therapy as being a common part of hospital treatment, where an IV bag is placed beside a hospital bed with a needle attached for purposes of rehydration. Certain IV infusions that contain high amounts of glutathione, vitamin C, and magnesium have become increasingly sought after because of their positive effects on skin and hangover recovery. In addition, shifting your diet to become more whole and balanced is always recommended. Intravenously injecting antioxidants, vitamins, and minerals allow for the bypassing of the complex and multifaceted digestive process and goes straight into your bloodstream making them more bioavailable. You may also feel the effects faster than you would be taking them in supplement form.
Some important ingredients found in IV drips include:
Magnesium – plays an important role in glucose metabolism, protein synthesis, cardiac and smooth muscle contractibility, and nerve function
Vitamin C – assists in collagen production, plays a role in neurotransmitter and hormone balance, serves as an antioxidant – protecting our cells from free radical damage, prevents aging, and boosts immune system
Glutathione – found in every cell in the human body, this powerful antioxidant helps to protect our cells from and alleviates oxidative stress that leads to cellular damage and premature aging
Vitamin B12 – regulates red blood cell function; deficiency in b12 includes a type of anemia that will result in weakness and fatigue
Proline – an amino acid that serves as a collagen building block and helps to repair damaged skin. It’s also important for supporting gut health and healing leaky gut
Taurine – the most abundant amino acid, taurine plays an important role in regulating hydration, supporting central nervous system function, and serves as an antioxidant
IV drips are highly sought-after because of their ability to restore hydration within our cells, prevent cellular aging and enhance digestion, among the many other benefits. They are surely making their way out of hospital settings and into the world of preventative medicine and wellness.
Lip Fillers – Look & Feel Younger – For Longer
Cosmetic Clinic Dubai | 28 September 2019
Lip enhancements can provide a natural, fuller lip body and contour, and replace collagen loss. This lovely treatment can restore lips to their youthful plumper look.
Over the years have you noticed your lips becoming thinner and disappearing? Restoring the soft collagen in your lips giving you a natural, sexy fuller look again. You can enjoy using your favourite lipsticks and gloss, having the confidence your lips look beautiful and natural, helping frame the face.
Will It Look Natural?
Usually only 1ml of dermal filler is administered to the top and bottom lip. This gives a very natural result. Look Lovely Lip rules to ensure a natural look:
- The lower lip should always be fuller than the upper lip. If the upper lip becomes bigger this gives a trout pout effect.
- Full pouty lips can be sexy, but if you look like you are pouting even without making that facial movement, so all the time, you have too much filler in the lip. The full-pout is a clear giveaway you have over done it on the fillers.
- The lower lip should be around 1.6 times fuller than the upper lip. Ratios are important. The upper lip should be slightly more than half the size of the lower lip to be natural. A thin upper lip can be augmented nicely with fillers to match the classic ratio.
- do precise injections to give the best possible results.
Tummy Tuck – When to Consider Surgery
Tummy Tuck Dubai | 26 September 2019
After pregnancy or weight loss, excess skin and fat can distort the appearance of the abdomen. In particular, many women find that after their second child or after bearing twins, their muscles and skin do not return to their original appearance secondary to repeated stretch of the abdomen. The abdominoplasty, or “tummy tuck” procedure, creates a flatter, firmer abdomen by removing excess fat and skin, and tightening the abdominal muscles. You are a good candidate for a tummy tuck if you are at a stable weight and are physically healthy, you have realistic expectations, and you do not smoke.
Anatomy of the Abdomen
The abdominal wall consists of skin, fat, and muscle. The rectus abdominis muscles, whichform the “six pack” of muscles on the abdomen, are covered by a firm sheath called the rectus fascia. This fascial layer frequently weakens and stretches out with pregnancy and weight gain. As a result, once a patient loses weight or has her children, she may be left with laxity of the abdominal wall. During surgery , the fascial layer over the rectus abdominis muscles is tightened, and the excess skin and fat are removed.
Tummy Tuck steps
The abdominoplasty procedure is performed with a horizontal incision in the lower abdomen within the bikini line. In patients who have undergone a prior C-section, the incision can be made in the same location and extended to the sides. The rectus abdominis muscles of the abdomen are tightened, and the excess skin and fat are trimmed and redraped. Most abdominoplasty surgeries require repositioning of the umbilicus, or navel through a second incision. In the “mini” abdominoplasty procedure, lower abdominal muscle tightening with fat and skin removal are performed through a limited horizontal bikini incision only, without repositioning of the navel. The resulting scar is usually low on the abdomen, and therefore can be concealed within most bathing suits and clothing. Small drain tubes are placed with both techniques.
Tummy Tuck Top Tips
Tummy Tuck Dubai | 24 September 2018
The abdominoplasty / tummy tuck procedure is one of the more intensive body contouring procedures, but it can transform your midsection to create a tight and toned look. Many women who have undergone multiple pregnancies get a tummy tuck in Dubai to restore their pre-pregnancy figure, but we also perform this type of surgery on weight loss patients that want to get rid of the extra skin that tends to stick around the midsection, as well as patients that have a protruding stomach due to a weakened or stretched abdominal wall. You must follow my post-op instructions carefully to ensure optimal results.
Tummy Tuck Dubai – Here are five essential tummy tuck recovery tips:
1. Eat a healthy and well-balanced diet. You need your body to heal as quickly as possible after a body contouring procedure so it’s important that you eat plenty of nutritious foods. Eat protein-rich foods like salmon and chicken, and make sure to add some healthy fat to your diet so that your skin can recover and heal properly.
2. Start walking. You will be limited to walking for exercise after tummy tuck surgery so plan on heading outside for a 20 to 30-minute walk each day, or hitting the treadmill for a light walk. Walking is great for circulation and can support the recovery process after surgery.
3. Change your sleeping position. Sleeping in an inclined position will reduce pressure and stress on the abdominal area. Use large body pillows to support your body and help you maintain the right position while sleeping.
4. Wear recommended compression garments. You will experience a significant amount of swelling around the treated area for weeks after the procedure. I may recommend you wear a girdle or binder to support the healing process — even while you sleep. This can help manage some of the swelling and also help with skin re-draping after surgery.
5. Stay hydrated. You need to drink plenty of water before and after your procedure to help your body flush out toxins and also reduce the risk of complications. Get into a routine of drinking plenty of water throughout the day to prevent dehydration and support your recovery.
I can provide you with more information about the recovery process during your abdominoplasty / tummy tuck consultation.
While traditional abdominoplasty methods can successfully achieve the objective of restoring a flat appearance, the results can be artificially board-like, lacking the subtle anatomical features of a three-dimensional abdomen, thus creating the potential for patient dissatisfaction. While often difficult to articulate, patient criticism is almost always distilled to the ubiquitous concern that the surgical abdomen lacks the natural features of an authentic, youthful abdomen. In an effort to provide a more anatomically accurate outcome and improve patient satisfaction, I have made a series of technical modifications to the abdominoplasty that I now perform. Ten key technical refinements, including a modified “Anatomy Defining” Progressive Tension Suture technique, were successively incorporated in 177 patients during the first 5 years of 2000-2014. All have been applied consistently in 961 abdominoplasty procedures during the subsequent 10 years, often accompanied by liposuction of adjacent lateral (non-abdominal) areas to ensure harmonious propor- tion. This series of refinements adds precision and detail by redefining the native anatomical nuances of the abdomen, an aesthetic objective that has been consistently achieved in BMI ranges between 20 and 35. Overall satisfaction with results was high (94%). The 10 elements described are safe, effective, and lasting.
Tummy Tuck Dubai – traditional abdominoplasty methods
While traditional abdominoplasty methods can successfully achieve the objective of restoring a flat appearance, the results can be board-like, lacking the subtle anatomical fea- tures that characterize a youthful, attractive female abdomen. Previous methods have not consistently placed a primary em- phasis on recreating specific anatomical features of the native abdomen. In addition, the technical tools required to attain the anatomical details present on the ideal aesthetic abdo- men were limited prior to the publication of the Progressive Tension Suture (PTS) technique.1
Numerous published studies have contributed to a more thorough understanding of the vascular anatomy of the entire abdominal unit, providing critical guidelines for more advanced techniques. By incorporating selective detailed maneuvers, three-dimensional anatomical character can be achieved safely and consistently.2,3
In my experience, anatomical authenticity is a particu- larly important objective in a prospective patient’s search for any cosmetic procedure, including abdominoplasty.
The surgical stigma of the traditional abdominoplasty dis- suades many prospective patients from considering it as an option for improvement, except in the most profound situa- tion, such as the major weight loss condition, where a cum- bersome redundant panniculus is present.
During the initial consultation, an increasing number of my prospective patients express a desire to avoid the uni- formly flat abdominal appearance which characterizes many of the abdominoplasty results they have viewed in person or online (Figure 1). In my opinion, their candid comments are a direct consequence of the abundance of digital media
Figure 1. (A, B) Six months after undergoing abdominoplasty with another surgeon, this 36-year-old mother of three sought a second opinion on her procedure results, which she described as unnatural and overly surgical in appearance.
available, which includes before and after photos and de- tailed conversations in women’s internet forums. These re- sources cultivate scrutinizing, sophisticated consumers whom I am seeing in consultations on a regular basis.
In 2000, Pollock and Pollock1 published the technique they originated (PTS), with the primary objective to reduce abdominoplasty-related clinical complications. This tech- nique dramatically reduces seroma formation and theoreti- cally enhances vascularity by distributing tension over the entire flap rather than at the incision line only. I began using this technique at that time, incorporating a modified anatomy-defining application as I became more proficient with the method. In addition, over the ensuing 5 years, I in- corporated numerous other technical modifications aimed at improving overall aesthetic results and patient satisfaction.
PATIENT EVALUATION AND TECHNIQUE
During the physician-patient consultation of a potential abdominoplasty candidate, four elements of the abdomen require evaluation: skin laxity, excess subcutaneous fat, diastasis/hernia, and intra-abdominal fat. As part of my strategy, the abdominal flap is fully mobilized in nearly all cases; therefore, I have been reluctant to perform concomi- tant liposuction of the central flap.
If significant intra-abdominal fat is present, regardless of whether other factors also exist, pretreatment weight loss is necessary to provide a safe procedure and to achieve optimal aesthetic outcomes. If diastasis or skin laxity is present, an abdominoplasty of some type is recommended. The type of abdominoplasty (mini, modified, full) is based upon the specific anatomical location of skin laxity, excess fat, and diastasis. The most favorable circumstance, where liposuction alone is recommended, occurs when there is
good skin tone with no more than moderate excess fat present (usually in the nulliparous young patient). The key aesthetic goals of this abdominoplasty procedure include the following:
(1) low scar positioning to facilitate concealment in a modest undergarment or swimsuit;
(2) uniform upper and lower fascial repair, limited to the defect present, to ensure congruent restoration;
(3) differential fat thickness of the abdominal flap to more accurately replicate the native condition;
(4) uniform skin tone of the entire abdominal aesthetic unit, from the costal margin and xiphoid to the sym- phisis pubic and inguinal crease;
(5) subtle three-dimensional character that delineates the linea alba and linea semilunaris and the contour depression of the lateral abdomen/anterior waist;
(6) concomitant mons treatment for skin laxity, atrophic loss of skin tone, and excess fat content within the aes- thetic unit;
(7) smooth soft tissue transitioning at the incision line to reduce the “step-off” effect;
(8) attentive treatment of the entire torso unit, particularly the hip and waist, to ensure overall aesthetic harmony; and
(9) a deeply-contoured, vertical umbilicus that accurately recreates an attractive prepartal umbilicus.
From 2000 to 2014, I performed a total of 1138 abdomino- plasty procedures. Within the first five years of this period, the technical details described here were progressively em- ployed and refined through repetition. In the ensuing 10 years, all of these elements were consistently employed in all patients. Ten key technical elements comprise this
Tummy Tuck Dubai – Strategic Low Position of the Incision
The incision is placed approximately six centimeters above the vulvar commissure as described by Lockwood4 and Matarasso.5 This allows resection of hair-bearing suprapu- bic skin, providing the advantage of avoiding elevation of the hairline. The scar is horizontal to 1-2 cm above the in- guinal crease and ascends at a slight 20-30 degree angle to a point approximately 6-9 cm (dependent on bony anatomy and torso length) below the anterior-superior iliac spine. This design most closely follows the underwear waistband or swimsuit bottom in women’s current styles (Figure 2).
Not infrequently, low positioning of the incision necessi- tates vertical closure of the umbilical defect at some point between the umbilicorraphy and the suprapubic incision. Attentive Scarpa’s fascia approximation of the vertical repair, from beneath the raised flap, usually prevents an unattractive scar depression. During lower abdominal inci- sional repair, a three-point fixation of Scarpa’s fascia to the rectus and external oblique fascia with a 0 ( polydioxanone) plus suture (PDS) suture helps reduce the tendency toward superior migration of the scar. Finally, a low incision puts the lateral femoral cutaneous nerve more at risk for injury, necessitating cautious dissection and avoidance.
Figure 2. Pretreatment markings demonstrated on a 34-year-old woman. The linea alba and linea semilunaris are defined. Suprapubic incision is marked 6 cm above the vulvar introitus, with the incision rising at a 20 to 30 degree angle laterally to a point approximately 6 to 9 cm below the anterior superior iliac spine.
Figure3. Thoroughmobilizationoftheabdominalskinflap demonstrated on a 27-year-old female. The superior extent of the dissection is continued to the base of the xiphoid process. Above the umbilicus, it extends laterally to a point medial to the lateral rectus perforators. Discontinuous undermining is per- formed laterally along the upper and lower flap as needed to fa- cilitate mobility.
Tummy Tuck Dubai – Thorough Abdominal Flap Mobilization
To facilitate the technical details of this procedure, a thor- ough abdominal flap mobilization is required. The flap dis- section is continuous centrally to the xiphoid, preserving the superior lateral rectus perforators along the upper third of the rectus muscle. Cautious discontinuous dissection is performed along the costal margin lateral to the lateral rectus perforators, preserving segmental perforators as well. The extent of discontinuous dissection is made intrao- peratively when the vascular anatomy and flap mobility can be more accurately assessed. Because the flap is thor- oughly mobilized as described with this technique, liposuc- tion of the central flap is not performed (Figure 3).
Tummy Tuck Dubai – Complete Diastasis Repair
Ideally, in most circumstances, an accurate correction of the rectus muscle separation along its medial edge, and no more, provides the best chance for balanced harmony of the aesthet- ic abdominal unit. This is achieved by applying equal tension above and below the umbilicus, from the xiphoid process to the umbilicus and from the umbilicus to the symphysis pubis, utilizing a single, two-layer, running permanent monofila- ment suture (#1 Prolene) for each segment. Additionally, a separate purse string periumbilical repair (#1 Prolene) is in- corporated in order to strengthen this weak zone and subtly invaginate the umbilicus for a more deeply contoured umbili- corraphy, described in Element 10 (Figure 4).
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Tummy Tuck Dubai
Figure 4. Umbilicorraphy involves several sequential steps, as demonstrated on a 27-year-old woman. (A) A lax periumbilical fascia is often present after upper and lower diastasis repair. A circumferential marking is demonstrated for the planned periumbili- cal repair. A long umbilical stalk will require both shortening and stabilization at the 1, 5, 7, and 11 o’clock positions. (B) Circumferential purse string periumbilical repair with 0-Prolene deepens the appearance of the umbilicus and balances the overall diastasis repair. The shortened umbilical stalk is secured to the rectus fascia at the 1, 5, 7 and 11 o’clock positions using 3-0 PDS. The planned area of fat resection at the umbilicorraphy inset site is demonstrated. (C) A substantial vertical fat deficit is demon- strated after umbilical detachment. (D) Completed resection of fat at the umbilicorraphy site simulates the native condition.
Sub-Scarpa’s Fat Thinning
Once the abdominal flap is elevated, the vascularity of the deep fat is dependent upon the subdermal plexus of the super- ficial fat pad.6 Therefore, the deep fat pad below Scarpa’s fascia can be safely trimmed along the linea alba, linea semilu- naris, and external oblique fascia. A thinner fat pad over the external oblique muscle deepens the waist and improves ana- tomical accuracy. In addition, thinning the sub-Scarpa’s fat over the external oblique exposes Scarpa’s fascia, facilitating secure placement of Anatomy Defining-Progressive Tension Sutures (AD-PTS) (2-0 PDS). This emphasizes definition along the semilunaris by simulating the zone of adherence. The lateral skin flap can then be advanced inferiorly and medially to enhance waistline definition (Figures 5 and 6).
Anatomy Defining-Progressive Tension Sutures
Progressive tension sutures1 are strategically placed to en- hance anatomical definition. After midline fat thinning over the linea alba via small cannula liposuction or direct excision,7 a running AD-PTS is utilized to further define and add tone to the midline sulcus. This usually requires 10-12 loops of 2-0 PDS in a running fashion, advancing the midline from the origin of the xiphoid process to the base of the umbilicus. The linea semilunaris is reestablished with a series of 5-6 interrupted 2-0 PDS AD-PTS on each side along the confluence of the external oblique and anterior rectus fascia. The lateral skin flap is advanced medially and inferi- orly to define the anterior waist and to reduce the potential
976 Aesthetic Surgery Journal 35(8)
Figure 5. Sub-Scarpa’s fat resection, as demonstrated on a 27-year-old woman. (A) Once the flap is completely mobilized, sub-Scarpa’s fat resection is performed from lateral to medial on each side. (B) This intraoperative view demonstrates exposed Scarpa’s fascia on the right side of the elevated flap after sub-Scarpa’s fat resection.
Figure 6. In order to enhance linea alba depth, midline fat re- section precedes placement of AD-PTS, as demonstrated on a 27-year-old woman.
for lateral skin redundancy (dog ears) with an additional series of 2-0 PDS interrupted sutures (6-8) on each side. Additional interrupted 2-0 PDS progressive tension sutures (6-8) are placed centrally and inferiorly to advance the flap and reduce potential space (Figures 7 and 8).
Element 6: Vertical Closure of Umbilical Defect if Needed
In the technique described here, a priority is placed on keep- ing the horizontal incision very low, as described in Element 1. When inadequate skin is available to allow complete resec- tion of skin from the suprapubic incision to the umbilicus, a vertical umbilical defect repair may be required. The vertical defect is first approximated from beneath the abdominal flap
while it is still elevated. Deep internal flap repair of Scarpa’s fascia may reduce the chance that a scar contracture with a contour depression (referred to as “second belly button” by some patients) will occur.
Element 7: Mons Rejuvenation
Resection of excess fat and redundant skin are frequently both required for adequate treatment. This is initiated by sub-Scarpa’s fat resection, thinning the mons fat pad while also exposing Scarpa’s fascia. Superior mons advancement and stabilization is then accomplished by utilizing 3-5 inter- rupted deep 0 PDS sutures, attaching the exposed Scarpa’s fascia to the underlying rectus fascia. After mons advance- ment, additional resection of lax hair-bearing pubic skin may be necessary to maintain a low superior pubic hairline and to ensure equalization of skin tone of the abdominal- mons aesthetic unit (Figure 9).
Element 8: Customization of the Abdominal Skin Flap
Skin flap resection as the standard initial maneuver in an abdominoplasty may limit precise evaluation of redundan- cy. Over-resection of the skin flap may sometimes occur, leading to the adverse effects of excess skin tension and su- perior scar migration. Thorough flap mobilization, diastasis correction, and flap advancement with progressive tension sutures facilitate a truer assessment of skin laxity; for that reason, I prefer for this step to precede resection. The flap design can then be shaped along the lower incision for a precise match and tension-free repair (Figure 10).
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Tummy Tuck Dubai
Patronella 977
Figure 7. Anatomy defining-progressive tension sutures. (A) This schematic represents the sequencing of anatomy defining- progressive tension sutures. Restoration of the linea alba is completed first. Restoration of the linea semilunaris and advancement of the lateral skin flap proceeds from medial to lateral. (B) The intraoperative sequence for placement of anatomy defining- progressive tension sutures is demonstrated on a 33-year-old woman for the right side of the elevated flap.
Figure 8. Profile view of abdomen. (A) This is an intraoperative view of a 33-year-old woman of the linea semilunaris (LSL) marking and the vector of advancement for the lateral flap. (B) An immediate posttreatment profile view displays the effect of Anatomy Defining-Progressive Tension Sutures upon the linea alba, linea semilunaris, and the lateral skin flap; umbilical depth is also shown.
Element 9: Precise Tissue Transition at Incision
Soft tissue equalization at the incision line by sub-Scarpa’s fat thinning of either the upper flap or mons, subject to rela- tive thickness, is frequently required to achieve a smooth transition at the incisional repair. A comparatively thicker abdominal flap at the incision may result in an unnatural looking step-off. The fat thickness of the inferior horizontal incision is usually much thinner than the upper flap,
requiring sub-Scarpa’s fat resection of the upper flap. In ad- dition, deep repair of Scarpa’s fascia is performed to reduce the potential for a depressed, contracted scar (Figure 11).
Element 10: Deeply Contoured Umbilicus
As the initial maneuver, the umbilicus is assessed for an umbilical hernia, which is especially common in the post- partum patient. On occasion an umbilical hernia may be detected intraoperatively when it wasn’t recognized
978 Aesthetic Surgery Journal 35(8)
Figure 9. Mons rejuvenation: view of mons from cephalad, as demonstrated on a 27-year-old woman. (A) Sub-Scarpa’s fat resec- tion and superior advancement of the mons is frequently required to harmonize the abdominal-mons aesthetic unit. (B) Once the mons is advanced and secured, additional skin resection is often required to avoid elevation of the public hairline.
Figure 10. Skin flap customization demonstrated on a 34-year-old woman. Skin flap design and resection follows advancement with progressive tension sutures.
pretreatment. When present, I utilize the subfascial tech- nique described by Bruner et al.8 The umbilical hernia is ac- cessed through a 2-3 cm vertical fascial incision 2 cm inferior to the umbilical base, and repaired with one or two horizontal mattress 2-0 permanent sutures. This technique is simple and reliably preserves an umbilical blood supply (Figure 12).
When redundant, the umbilical stalk is shortened by direct skin excision to a length of approximately 50% of the skin flap
depth. The umbilical skin at the base is then deeply fixated to the rectus fascia with 3-0 PDS at the 1, 5, 7, and 11 o’clock po- sitions to create a stable, vertically-oriented foundation.
After umbilical base fixation, a periumbilical purse string suture of 0 Prolene is utilized to strengthen the weak zone bet- ween the upper and lower diastasis repair. This technique also shortens and subtly invaginates the umbilicus and surrounding periumbilical area to assist in deepening the umbilicus.
A generous vertically-oriented fat resection is performed at the umbilicorraphy inset site to replicate the native con- dition and enhance the appearance of depth.
A deepithelialized vertically-oriented oval, measuring 2 cm × 1.2 cm superiorly and 2 cm × 0.8 cm inferiorly, is created, overlying the stabilized umbilicus. An “X” incision is made in the dermis of this oval, creating four separate dermal flaps (superior, inferior, right lateral, and left lateral) that can be utilized to advance the oval deeply to the rectus fascia with long lasting 3-0 PDS sutures. Umbilical length is then reassessed, and shortened if needed to approximate the dermis of the deepithelialized skin edge to the umbilical dermis.
This approach is similar to that described by Pollock and Pollock,9 except that the umbilical skin edge is not included in the suture advancing the abdominal flap to the rectus fascia but approximated independently so that additional re- dundant umbilical skin can resected once accurately as- sessed as the final manuever. The umbilicus is inset into a vertical oval skin excision, slightly wider superiorly than in- feriorly, in the skin flap directly over it. Meticulous dermal edge closure with a subcuticular absorbable suture (5-0 Monocryl) reduces the chance for suture cross hatches. The combination of these independent steps assists in bringing the scar posteriorly toward the base and reduces the poten- tial for widening and/or eversion of the umbilicorraphy (Figure 1).
![Tummy Tuck Dubai](https://www.plasticsurgerydubaiuae.com/wp-content/uploads/2020/10/shutterstock_1488889271-300x200.jpg)
Tummy Tuck Dubai
Figure 11. Intraoperative profile views of soft tissue equalization, as demonstrated on a 49-year-old woman. (A) Residual thick- ness of the abdominal flap requires additional resection to avoid a step-off deformity. (B) Fat thickness equalization ensures a smooth transition at the incision line.
RESULTS
In my series, 210 consecutive abdominoplasties (207 women, 3 men) performed during a 27-month period from January 1, 2012, through March 31, 2014, with an average follow-up period of 7.6 months (range 2-30 months), were retrospective- ly reviewed. Age ranged from 26 to 67 with an average age of 41.3. BMI ranged from 19 to 38, with an average of 25.4 (Table 1).
In 83% (174/210) of patients, concomitant liposuction of lateral areas (hips, flanks, thighs) was performed. Because the technique described here requires full abdominal flap mo- bilization to the costal margin, central liposuction of the ab- dominal skin flap was not performed in any patient. In addition, 34% (71/210) of patients had an adjacent hip/flank skin excision for redundancy or a formal lower body lift procedure. In 30% of patients (63/210), a vertical umbilical defect repair was required to avoid a high horizontal incision. An umbilical float was performed in 2.3% (5/210) of patients.
A major complication rate of 2.3% (five patients) was seen (Table 2). All five patients developed hematomas requiring evacuation under anesthesia in the operating room. An additional patient (0.5%) required evacuation of a small hematoma under local anesthesia. In our cohort, all 210 abdominoplasty patients were treated with deep vein thrombosis (DVT) chemoprophylaxis using Xarelto for 5 days posttreatment. Since April 2014, we have switched to Eliquis because of a higher than acceptable posttreat- ment hematoma rate with Xarelto. There were no occur- rences of major flap necrosis (≥5 sq cm), while 1.4% (3/ 210) of cases had minor (<5 sq cm) ischemic necrosis along the lower abdominal incision line. There were no clinically relevant seromas in our series.
In approximately 8.1% (17/210) of my patient cohort, revi- sion of the lower abdominal horizontal scar, lateral dog ears,
and/or vertical scar under local anesthesia to correct contrac- tion/depression, protruberance, or hypertrophy was neces- sary to optimize aesthetics (Table 3). An additional 4.3% (9/ 210) of patients required umbilical revision for residual redun- dant skin, lack of sufficient depth, or scar constriction.
In summary, a total of 15.2% (32/210) of patients required a secondary procedure, of which 2.3% (five hematoma evac- uations) were performed under general anesthesia and 12.9% (26 scar revisions and one hematoma evacuation) were per- formed under local anesthesia in the office (Table 4).
An unvalidated satisfaction survey request was sent by direct mail and by email through Constant Contact (Waltham, MA), an independent online survey company, to 156 consecutive abdominoplasty patients treated over the 18-month period from October 2012 through March 2014) with a minimum follow-up of 6 months. All requests allowed complete anonymity. A total of 139 patients actual- ly received the email request, with 17 bouncing back as un- deliverable. Of the 139 receiving email requests, a total of 67 patients returned completed questionnaires. An addi- tional 23 patients returned questionnaires by direct mail in self-addressed envelopes. All surveys were tallied by an in- dependent observer. A total of 90 patients completed ques- tionnaires via Constant Contact or direct mail, out of a total 156 receiving them (58% response rate). A grading scale of 1-5, ranging from poor to excellent, was provided. The survey results are provided in Table 5 (a blank copy of the survey is available as Supplementary Material).
DISCUSSION
Positive advances in aesthetic surgery predominantly focus on transformation that is safe and natural, as they should. The ten elements described provide a surgical plan that is
Figure 12. Illustrations demonstrating umbilicorraphy. (A) De-epithelialization of an asymmetrical vertical oval (2 cm × 1 cm) over the secured umbilicus. (B) An X-incision through the dermis creates four small V-shaped dermal flaps that retract, exposing remaining umbilical fat. (C) Remaining subdermal fat is resected to expose the umbilical skin. (D) The small dermal flaps are ad- vanced sequentially at the 12, 3, 6, and 9 o’clock positions, incorporating the umbilical stalk and the rectus fascia with 3-0 PDS. (E) After dermal advancement, the remaining excess umbilical length is shortened. (F) The skin is approximated via a subcuticular repair at the dermal epidermal interface (ie, edge of de-epithelialized skin). (G) Deep umbilical inset completed. Illustration credit: Mike de la Flor, CMI.
straightforward to implement, and which has achieved pre- dictable and improved aesthetic outcomes for my abdo- minoplasty patients.
The ten elements described provide a methodical strat- egy for most patients, regardless of potentially limiting factors generated by preexisting conditions such as higher or lower than ideal body mass index (BMI) or history of major weight loss. In my practice over the last two decades, abdominoplasty surgery has trended toward lower incisions as a direct result of patient demand. Women are very con- sistent in their criticism of a scar that cannot be concealed
in underwear or a two-piece swimsuit. In my experience, patients overwhelmingly prefer a short vertical closure of the umbilical defect to a high abdominoplasty scar, when given a choice.
While a vertical scar from an umbilical defect repair is not ideal, a high horizontal scar seems to be more unfavorable to women when inadequate upper abdominal skin laxity pre- cludes complete skin flap excision to the umbilicus. In my experience, a vertical scar, in the patient’s mind, is not a de- finitive characteristic of a “tummy tuck,” and therefore the patient is more comfortable in a two-piece swimsuit than
Infection (minor cellulitis)
1 26 (12.4)
1 (0.5)
32 (15.2)
Hematoma evacuation (general anesthesia)
5 (2.3)
she would be with a high horizontal scar. Generally, when approximated well, a vertical scar is inconspicuous and less identifiable as a stigmata of abdominoplasty surgery than a high horizontal scar.
In addition, excessive skin flap removal and a high- tension closure have numerous potential disadvantages, both clinically and aesthetically. Vascular compromise can result in skin flap necrosis, with the distressing attendant physical and emotional consequences for both the patient and the surgeon. Many discriminating female patients con- sider a high scar aesthetically unacceptable because it fails to achieve a common goal to wear a two-piece swimsuit without the obvious stigmata of a “tummy tuck.” Equally disappointing adverse aesthetic consequences of excessive skin flap removal are an unattractive elevation of the pubic hairline and altered genital anatomy. Hypertrophic scarring is also more likely.
So that all elements of this technique can be effectively implemented, a thorough mobilization of the abdominal flap is required (Figure 3). Full flap mobilization facilitates skin tone equalization between the upper and lower abdomen and allows an even, thorough distribution of AD-PTS. The advantages are:
(a) uniform skin tone can be restored over the entire ab- dominal aesthetic unit;
(b) zones of adherence can be recreated; and
(c) skin advancement will facilitate more accurate skin removal and maintenance of a stable low incision place-
ment by reducing excessive tension at the incision.
Preservation of the superior row of lateral rectus perfora- tors can be accomplished with cautious discontinuous upper flap separation. Exposure of the upper midline over the xiphoid process is necessary to adequately thin the
An abdominoplasty satisfaction survey of 90 patient respondents is demonstrated. A total of 156 consecutive abdominoplasty patients received requests (58% response rate).
superior origin of the linea alba and taper the diastasis repair to avoid a potential epigastric bulge. In addition, full mobilization facilitates advancement of the upper flap,
Figure 13. (A, C, E) Pretreatment and (B, D, F) 1-year post- treatment views of a 35-year-old woman who underwent abdominoplasty; liposuction of hips, flanks, and outer thighs; lower body lift; breast augmentation; and mastopexy.
with progressive tension sutures from the costal margin to the lower incision so that an even skin tone of the entire abdominal unit can be established and toned definition
of the linea alba and linea semilunaris can be achieved (Figure 13).
Inadequate flap mobilization may result in abdominal unit disharmony, most commonly seen in mini-abdominoplasty surgery. This occurs when there has been excessive lower ab- dominal skin resection and/or isolated lower diastasis repair without treatment of upper abdominal skin laxity or diastasis, leaving a relative upper abdominal protuberance that appears unnatural (Supplementary Figure 1). The isolated lower fascial repair focuses tension in an unequal manner on the lower segment of the aesthetic unit, potentially creating an unusual and unattractive convexity of the upper abdomen. In my experience, the resulting abdominal unit disharmony is a common source of patient dissatisfaction. The well-informed potential patient may describe this as a “botched tummy tuck,” decreasing their confidence in the procedure when it is recommended. Revision surgery is often required.
Diastasis is an attenuation of the intermuscular raphe with widening of the distance between the rectus abdominus muscles, most often occurring during pregnancy. There are no non-surgical corrective techniques or exercises to correct this. During surgical exposure there is an identifiable defect between the medial edges of the rectus muscles that can be outlined and repaired. Much has been written by Nahas and others about the technical details of diastasis repair.10-16 When overcorrected beyond the medial edge of the rectus muscle, van Uchelen et al.11 demonstrated recurrence to be as high as 40%. In my experience, when overcorrected, the risk of intraoperative fascial tears and intramuscular hematomas is much higher despite the use of muscular paralytics em- ployed during this portion of the procedure. Posttreatment, when pain, spasm, and movement occurs, theoretically there may be an even higher likelihood that fascial tears, bleeding, and separation will result.
In addition, overcorrection beyond the medial rectus may not accurately recreate the native anatomy as it existed prior to pregnancy. In my opinion, adequately treated diastasis is more likely to restore a more natural state that gives a slight concavity of the upper abdomen and a slight convexity of the lower abdomen represented by a soft lazy “S” on oblique view (Figure 13).
The primary advantage of the PTS technique as originally described by Pollock and Pollock in 200017 is the success- ful reduction in the risk of clinically relevant seromas. My ex- perience has paralleled that of Pollock and Pollock17 and Antonetti and Antonetti18 regarding seroma formation. There have been no clinically significant fluid collections in the 210 consecutive cases in this cohort. Preventing seroma formation and the potential sequela avoids adverse aesthetic consequences as well.
This technique can also now be utilized to enhance aes- thetic outcomes through an anatomy defining application. In its natural state, the three-dimensional character of the well-
Figure 14. (A, C, E) Pretreatment and (B, D, F) 1-year post- treatment views of a 29-year-old woman who underwent abdominoplasty; liposuction of hips and flanks; lower body lift; breast reduction; and breast lift.
toned, attractive abdomen exhibits differential fat thickness along the different zones of the abdominal aesthetic unit.
Once the flap is elevated, the deep sub-Scarpa’s fat is en- tirely dependent on its vascularity through the sub dermal plexus. Therefore, it is safe to thin sub-Scarpa’s fat in a precise pattern over the linea alba, linea semilunaris, and external
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oblique fascia, recreating a more aesthetic three-dimensional effect that characterizes the youthful, well-toned abdomen (Figure 14). Precise advancement with progressive tension sutures along the zones of adherence of the linea alba and linea semilunaris, as well as over the external oblique, further accentuates definition of these features. The anterior waist is also deepened and the soft contour depression over the exter- nal oblique is restored with sequential progressive tension sutures. In addition, strategic advancement of the flap from the costal margin to the inguinal crease and symphysis pubis with progressive tension sutures facilitates restoration of a uniform skin tone over the entire aesthetic unit. By distribut- ing tension over the entire abdominal flap, there theoretically may be less tension at the incision line, thus a reduced tendency toward superior scar migration.
Minor visible indentations of the skin flap created by the sutures will resolve when the sutures are resorbed complete- ly in 4–6 months. The sutures splint the flap precisely along the linea alba, the linea semilunaris, and the lateral skin flap over the external oblique for a period of 12 weeks or more while the sutures still have their integrity. Theoretically, by eliminating potential space and minor pseudobursa forma- tion from fluid collections, and promoting scar tissue adherence along these anatomical landmarks, a stable and durable effect is achieved with long-lasting absorbable sutures (Supplementary Figure 2). Among the absorbable suture groups, PDS has the most durable profile, with 50% of its strength still present at 4 weeks and complete resorp- tion not occurring until about 26 weeks. In my experience, progressive suture advancement and stabilization allows a more toned appearance of these anatomical landmarks than is achieved with fat thinning alone. The skin laxity of the upper abdomen can also be worked down with progressive tension sutures to improve the overall consistency of skin tone of the entire aesthetic unit.
Furthermore, the lateral flap can be more effectively ad- vanced inferomedially to eliminate lateral redundancy (eg, dog ears). The overall effect of these independent maneu- vers creates a more authentic-appearing abdomen than the one that I could accomplish previously.
It is my observation that the optimal aesthetic three- dimensional effect is realized when the abdominal flap is neither too thick (BMI > 30) nor too thin (BMI < 20). In my experience, an average flap thickness between 1.5 to 4 centimeters (BMI 20–30) provides the ideal situation for optimal application of the elements described (Figure 13).
It is vascularly unsafe to thin the subcutaneous fat superfi- cial to Scarpa’s fascia, thereby limiting the three-dimensional effect of AD-PTS in the heavy patient with a BMI > 30.
In the very thin patient with a BMI < 20, inadequate fat thickness reduces the effectiveness of AD-PTS for two reasons. First, fully mobilizing a very thin flap (<1.5 cm) is a more tenuous proposition to accomplish in a vascularly safe manner. Second, the lack of fat reduces the differential
thickness required to create the intended three-dimensional effect with AD-PTS.
A redundant, plump mons is a common source of em- barrassment (Figure 14). In pregnancy, expansion with skin stretching and hormonal fat accumulation of the mons frequently accompanies the same process that is occurring on the abdomen. In this abominoplasty technique, rejuve- nation of the mons is an essential component. Matarrasso19 and others20 have emphasized mons treatment to complete rejuvenation of the aesthetic unit. This requires attentive treatment of excess fat and redundant skin when present. Skin tone equalization between the abdominal skin flap and the mons also provides a more authentic aesthetic ab- dominal unit. After elevation of the mons, further excision of hair-bearing pubic skin is frequently required to avoid el- evation of the hairline.
Soft tissue closure at the incision is optimal when the transition between the upper flap and the lower incision is smooth, reducing the tendency toward a step-off deformity after healing. This is easily accomplished by equalizing fat thickness wherever needed. Additional sub-Scarpa’s fat thin- ning of the upper flap and/or mons prior to closure is usually required to create a smooth soft tissue transition. By equalizing fat thickness and including Scarpa’s fascia in the closure, a more inconspicuous scar is typically achieved. When the lower abdominal scar is not aesthetically accept- able, a revision can usually be performed in the office under local anesthesia (8.1% in this cohort).
Creating a natural and inconspicuous umbilicus has been one the most challenging aspects of abdominoplasty in my practice. Numerous umbilicorraphy methods have been de- scribed over the years with varied effectiveness.21,22 The central purpose for any technique should be the creation of a natural, inconspicuous umbilicus. To accomplish this, a rec- reation of the native condition is necessary. In a recent com- puter analysis of Playboy models, Lee at al.23 demonstrated prevalence of the vertically shaped umbilicus, and conclud- ed that this is an important parameter of the “beautiful um- bilicus.” The goal of my technique has been to create a deep vertical oval shape, which coincides with the parameters of the “beautiful umbilicus” described by Lee.
Many post-partal women with diastasis also have an ac- companying umbilical hernia. Clinical diagnosis pretreat- ment isn0t always successful, therefore close inspection intraoperatively is advisable. Failure to repair an inconspicu- ous and undiagnosed umbilical hernia may become obvious posttreatment, and will adversely affect the appearance of depth and possibly require secondary repair. The subfascial repair described by Bruner et al8 is easy, reliable, and pre- serves native vascularity to the umbilical stalk.
The umbilicorraphy technique described here attempts to recreate the native condition as accurately as possible. Inspection of the umbilical defect beneath the raised ab- dominal flap demonstrates a striking absence of fat in a
spacious, vertically-oriented pattern (Figure 4C). Generous fat removal at the umbilicorraphy site in a matching pattern facilitates a deep umbilical inset. Under-resected fat at the inset site will encroach upon the stalk and limit the desired appearance of depth (Figure 1).
Shortening of the stalk, secure stabilization with durable absorbable sutures (PDS), and advancement of the abdom- inal dermal X-flaps to the rectus fascia at the umbilical base are also all important steps in the creation of a deep vertical umbilicus (Figure 12). A long umbilical stalk and/or one that is inadequately stabilized may result in redundancy and eversion (Figure 4A).
Despite the details employed in the technique described here, there is still a 4.3% revision rate to improve umbilical aesthetics in my cohort. The thin patient (flap thickness <1.5 cm) is the most challenging for achieving the deep vertical umbilicus and, therefore, these patients should be advised accordingly.
In my experience, obtaining the most authentic abdomi- nal contour correlates strongly with the pretreatment condi- tion when applying these elements. The heavier patient, especially one with an excessive intraabdominal fat com- ponent, is a particularly challenging endeavor. Critical evalu- ation and cautious recommendations with appropriate description of expectations is always prudent. For most pa- tients with a BMI less than 35, though, a dramatic authentic effect and significant contour improvement can be achieved with the safe and reliable steps detailed here. All of the ele- ments are applied routinely with each patient, yet variation in the overall achievement in aesthetic goals is more dra- matic in those closer to ideal body weight, as one would expect. Nevertheless, a positive aesthetic effect is still consis- tently seen in all patients under a BMI of 35. (Figures 13 and 14 and Supplementary Figure 1).
Lockwood,24 Matarasso,19 and others have emphasized the importance of rejuvenating the entire torso/thigh aes- thetic unit. Lockwood unambiguously advised, “Be artistic. Think outside the box. … How can we judge our success in body contouring if we don’t look at the entire aesthetic unit?”24
Harmonized contouring of the body should be considered for every patient who requests or is a candidate for abdomi- noplasty. In our cohort, 83% had adjacent lateral hip, flank, and/or outer thigh liposuction and 34% had some type of skin excision procedure of the hip/flank region. The abdomen is only one component of the thoraco/abdominal/ thigh aesthetic unit. Hormonal fat redistribution and skin ex- pansion associated with pregnancy occurs along the lower torso and hip/buttock region as well as the abdomen and mons. Coordinated treatment of adjacent areas will comple- ment and enhance the authenticity of abdominal shaping (Supplementary Figure 3). Consider the artificial contrast of a well-contoured, toned abdomen adjacent to a thick waist- line or a redundant, bulging mons. Such anatomy seldom
exists naturally and will likely create annoying clothes fitting issues for women. Consideration of lipocontouring of the flanks and hips, possibly with a lifting procedure of the hips, buttocks, and outer thighs and/or fat grafting of the lateral gluteal and gluteal areas is complementary as an adjunct to abdominoplasty in many patients. Aesthetic results are not effectively analyzed in the typical scientific sense. Patient perception is an important criteria for analysis. The quality of aesthetic results is often measured by patient satisfaction through referrals. A satisfied patient will often say so and refer other patients. An unsatisfied patient will also say so and negatively impact referrals.
A satisfaction survey was sent by direct mail and by email with a request for completion online through Constant Contact (Table 5). Anonymity was ensured for all patients to encourage candor. Nonresponse bias is always a consider- ation with satisfaction surveys, yet the 58% response rate compares favorably to recent aesthetic surgery surveys pub- lished in the Aesthetic Surgery Journal.21,25A standardized validated satisfaction survey for body contouring surgery similar to the Breast-Q for breast surgery would be valuable for future analyses.26
In my experience, patients frequently criticize the “unnatural belly-button” and the “surgical, flat as a board” appearance of many tummy tucks they have seen. These are frequently their primary hesitance with the abdomino- plasty procedure. One of my objectives has been to create a more authentic-appearing abdomen so that patients would be more satisfied with their results. The survey demonstrat- ed a 97% (81% excellent, 16% good) satisfaction rating to the question: “How natural looking is the appearance of your abdomen?” A slightly less positive response was elicited to the question,“ How would you rate the appear- ance of your belly-button?,” with 87% (59% excellent, 28% good) rating it favorably. I believe that the overall high level of satisfaction with results, reported at 93% (78% excellent, 15% good) provides support that this objective is being met.
CONCLUSIONS
Ten key elements of a well-executed abdominoplasty pro- vide a unified, anatomically accurate recreation of the abdomen. This technique relies heavily on extensive use of progressive tension sutures placed specifically to enhance the native anatomy (AD-PTS).
The incorporation of these elements 10 years ago has led to a perceptible improvement in the aesthetic quality of my abdominoplasty results. Overall satisfaction was high (93%). In particular, better anatomical accuracy is support- ed by the high level of patient satisfaction (97%) regarding the natural appearance of their results, as consistently dem- onstrated in the patient photos included.
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Supplementary Material
This article contains supplementary material located online at www.aestheticsurgeryjournal.com.
Disclosures
The author declares no potential conflicts of interest with respect to the research, authorship, and publication of this article.
Funding
The author received no financial support for the research, authorship, and publication of this article.
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2. Huger WE Jr. The anatomic rationale for abdominal lipec- tomy. Am Surgeon. 1979;45:612–617.
3. Taylor GI. The superiorly based rectus abdominus flap: predicting and enhancing blood supply on an anatomic and clinical study. Plast Reconstr Surg. 1988;81:713–724.
4. Lockwood T. High lateral-tension abdominoplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96:603-615.
5. Matarasso A. Traditional abdominoplasty. Clin Plast Surg. 2010;37:415-437.
6. Nahai FR. Anatomic considerations in abdominoplasty. Clin Plast Surg. 2010;37:407-414.
7. Laverson S. Improving abdominoplasty results: recon- struction of the linea alba sulcus by direct fat excision. Aesthet Surg J. 2006;26:682-686.
8. Bruner TW, Salazer-Reyes H, Friedman JD. Umbilical hernia repair in conjunction with abdominoplasty: a sur- gical technique to maintain umbilical blood supply. Aesthet Surg J. 2009;29:333-334.
9. Pollock TA, Pollock H. No-drain abdominoplasty with pro- gressive tension sutures. Clin Plast Surg. 2010;37(3):515-525.
10. Nahas FX, Ferreira LM. Concepts on correction of the musculoaponeurotic layer in abdominoplasty. Clin Plast
Surg. 2010;37:527-538.
11. van Uchelen JH, Kon M, Werker PMN, et al. The long-
term durability of plication of the anterior rectus sheath assessed by ultrasonography. Plast Reconstr Surg. 2001;107:1578-1584.
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13. Nahas FX, Ferreira LM, Augusto SM, Ghelfond C. Long- term follow-up of correction of rectus diastasis. Plast Reconstr Surg. 2005;115:1736; discussion 1742-1743.
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15. de Castro EJP, Radwanski HN, Pitanguy I, Nahas F. Long-term ultrasonographic evaluation of midline apo- neurotic plication during abdominoplasty. Plast Reconstr Surg. 2013; 132(2):333-338.
16. Rosen A, Hartman T. Repair of the midline fascial defect in abdominoplasty with long-acting barbed and smooth absorbable sutures. Aesthet Surg J. 2011;31:668-673.
17. Pollock TA, Pollock H. Progressive tension sutures in abdominoplasty: a review of 597 consecutive cases. Aesthet Surg J. 2012;32:729-742.
18. Antonetti JW, Antonetti AR. Reducing seroma in outpa- tient abdominoplasty: analysis of 516 consecutive cases. Aesthet Surg J. 2010;30:418-425.
19. Matarasso A. Treating all aesthetic units of the abdomen during abdominal surgery with emphasis on the mons pubis. Presented at: the New Frontiers in Aesthetic Surgery Meeting sponsored by the American Society for Aesthetic Plastic Surgery, Dallas, TX, May 18, 1999.
20. Bloom JMP, Van Kouwenberg E, Davenport M, Koltz PF, Shaw RB Jr, Gusenoff JA Aesthetic and functional satis- faction after monsplasty in the massive weight loss popu- lation. Aesthet Surg J. 2011;32:877-885.
21. López Tallaj L, de Gervais J. Umbilical restoration in abdominoplasty: a simple rectangular technique. Aesthet Surg J. 2003;23(6):464-466.
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23. Lee SJ, Garg S, Lee HP. Computer-aided analysis of the “beautiful” umbilicus. Aesthet Surg J. 2014;34(5): 748-756.
24. Lockwood TE. Maximizing aesthetics in lateral tension abdominoplasty and body lifts. Clin Plast Surg. 2004;31: 523–537.
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26. Gryskiewicz J, LeDuc R. Transaxillary nonendoscopic sub- pectoral augmentation mammaplasty: a 10-year experience with gel vs. saline in 2000 patients-with long-term patient satisfaction measured by the BREAST-Q. Aesthet Surg J. 2014;34(5):696-713.
Breast Augmentation – Sizing
Aesthetic Medicine Dubai | 22 September 2019
Wardrobe
Bring in different types of outfits to try on with your sizers. You want to make sure that you are comfortable in your casual dress as well as your cocktail dress. Plain baby-doll t-shirts work best.
Personality
Think about your personality (outgoing or shy) and how you want to be perceived by the public. Then, make sure that you convey this to me. Breasts that are larger than what what would be portionate may suit your style. On the other hand, you may lean towards looking great in a cocktail dress without attracting unwanted attention at work.
Fitness
Factor in your exercise routine. If you are a runner or serious athlete, you will want to choose implants that won’t interfere with your fitness routine.
You’re In Charge
Although I will be your guide, I don’t dictate what size you should be. It’s a collaboration. However, there may be a situation when I don’t recommend going with the size you want. If that’s the case, you may want to have further discussions to make sure you understand the reasoning behind this.
Be You
Don’t pick your implant size based on how it looks on a friend. Even though you and your friend may seem similar in terms of body size, there are other factors that must be considered. It’s natural to think “My girlfriend has 350’s so I should get the same size because they look perfect on her.” But the important words are “…on her.” If you are open to different implant options, it’s more likely that you’ll find the one that is just right for you.
Know When Enough is Enough
Remember that you are picking the size of your breasts not just for this year but for many years to come. If you choose an implant that is too big, you may have issues with back pain and sagging later on. Ask any of our breast reduction patients and they will tell you that much bigger isn’t always better!
Bring A Friend
You may find that you would enjoy bringing a friend or spouse with you when you try on sizers. Our staff is great at guiding you in this process but sometimes it’s fun to have someone else there who knows you well. Also, there is a large quantity of information discussed during your consultation so it’s nice to have an extra set of ears.
Aesthetic Medicine Dubai