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It is to be noted in obese persons and those with larger fatty areas, liposuction (removal of fat) can result in constrictive bands or skin folds that may appear unsightly. These irregularities are more likely to occur in the highly lax zones of the inner upper thighs, groin, upper arms, and armpits. A groove or skin fold may not necessarily be caused by inappropriate technique, but may be expected in patients with poor skin tone, as is commonly seen in the obese, those with large fatty areas, and those with stretch marks. This occurs in part because the fatty deposits that are to be removed are covered by "stretched-out" or naturally tethered skin. Removing underlying fatty deposits may leave more "stretched-out" skin than is necessary to cover the now smaller areas. To achieve a smooth, natural-appearing result, one's skin must have the ability to contract (shrink) sufficiently to fit the smaller area (after the fat is removed). Depending upon the size of the patient, many patients may be best advised to undergo a "multi-stage" liposuction-having liposuction performed in two or more separate sessions. For some patients, multi-staging may allow further contraction, or reduction can be obtained in surrounding areas in order to reduce the band or skin fold. Surgical incision or excision (cutting with a scalpel) of the band may be necessary for correction. These surgical procedures are known as thigh- or arm-reductions. These corrective procedures remove the unwanted skin by cutting (with a scalpel) and stitching (suturing) specially in layers, to prevent the layers from coming apart. Whenever tissue is cut with a scalpel a scar must result. A scar is the natural glue that binds the tissues together. Good deep scar will help reduce spreading of surface scares. Nonetheless, the surgical approach by cutting unwanted redundant skin folds that may remain following liposuction is an accepted technique that, in most cases, reveals the desired results. These procedures need to be entertained by patients who are extremely heavy in many areas (obese) or those patients who are excessive in the areas being treated by liposuction (isolated lipo-dysmorphia). Additionally, one needs understand that incisions (cuts) to remove excess tissue may involve the entire length of the skin fold, be directly over the fold, may be adjacent to the fold, or may be located in the natural creases. Now, let us discuss the tummy tuck procedure. Common words that usually mean the same thing regarding external appearance (looks) in liposuction are "tummy," "belly," and "abdomen." Medically speaking, the words "gut" and "stomach" really do not mean the same thing, and we will try not to use the words gut and stomach. Many women desire to have their tummies tucked, especially after pregnancy(ies), when the tummy (not really the true "stomach") may "stick out" or protrude. Many times, much of the cause of this protrusion is not subcutaneous fat (that "outer" layer that lies outside of the muscular wall of the abdomen and just inside of the dermis or leather layer of the skin). Many patients have a protrusion that is the result of the internal contents (stuff like guts, liver, uterus, bladder, and omental [=deep fat]) of the abdomen. For example, deep in the abdomen and protected by a muscle wall, the bowel sits in a soft "cushiony" fatty layer called the omentum. The omentum cannot be safely suctioned. The omentum fat can become gigantic as it stores fat and calories while it surrounds, protects, and encases the all-important human bowel. No liposuction can be performed in the area of the omentum; don't even think about it. Perforating the abdomen with a liposuction cannula to reach the omentum can cause an infection called peritonitis, which is frequently deadly. As of 1999, it was not possible to violate the muscular wall of the abdomen in order to remove omental fat with a tube for cosmetic purposes. Removing or damaging the omental fat could also cause severe life-threatening bowel problems, such as fiber bands and total bowel stoppages later in life. Many patients want to have their tummies tucked. The doctor and the patient then need to decide if the problem is a weak tummy-muscle wall. Or is it only too much skin or too much fat between the tummy-muscle wall and the skin's dermis (leather layer)? There are at least three important questions to be answered by the patient, doctor, and the doctor's physical examination of the patient. The tummy tuck can take place in: (1) the skin only, (2) in the skin and the fat, (3) in the rectus muscle only, or (4) in any combination of surface skin, fat, and rectus muscle (or its components). The Web site author believes that if there is a chance that a patient can exercise with properly performed abdominal crunches, etc., and can see tightening of the muscle naturally, then it may be wise to avoid muscle-tightening "stitches". This still means that the skin layer can be tightened. For our purposes, let us call a tummy tuck that only involves skin and fat a "surface tuck" and a tummy tuck that involves cutting and tightening the muscle (muscle coating or sheath or other associated components) a "deep tuck." The simplest tuck is to cut out the skin and some fat and to sew what remains back together. This is probably the safest form of tummy tuck, because the surgeon does not have to violate, cut, or tighten the deeper rectus abdominis muscle (and its rich blood supply). Tissue (body parts) cannot be cut and sewn without leaving a scar; the key, of course, is to get the finest and tiniest scar possible. There are many forms of tummy tuck, especially on the surface skin. Some of the more unique forms are ones that are performed around the belly button or in folds. Sometimes "tucks" are performed in small enough incisions that the incisions are not grossly obvious. However, these tiny tucks are usually for tiny bellies and cannot be used if lots of skin has to be removed for a noticeable effect. Most tummy tuck incisions are very obvious, depending upon the size and the amounts of tissue that have to be removed. The "deep tummy tuck" is the cutting-out and stitching of the rectus abdominis (major tummy muscle). This rectus is the main muscle that holds the contents (like bowel and liver) inside the abdomen or belly in place. As people age, and if they do not constantly exercise the rectus and other abdominal muscles by doing front and lateral "crunches," the abdominal muscles become weak and very, very thin. The thin muscles are further stretched as the contents of the belly constantly push against them, thereby making the muscles even thinner. For years, surgeons have used the technique of cutting out the muscle, stretching it, and sewing it back into place. Unfortunately, the results of this procedure are many times only a "quick fix," yielding only relatively temporary results. When you cut out the muscle, the only thing (following natural healing) that can take the place of the cut muscle is scar tissue. Scar or fibrous tissue is the glue tissue by which we all heal. Usually, and as has been proven in scientific studies, the scar tissue can never be as strong as the original tissue it replaces; even after a year, only 80% of the normal strength is found on scientific bursting tests. Before you consider a "deep tuck," ask your surgeon to explain what in his/her physical examination of you proves that your tummy muscles are weak. It should be an easy determination that only involves finger pressure. The Web site author recommends that patients tighten their tummy muscles by doing stomach crunches, up to 200 a day, before considering a "deep tuck." Disclaimer: Do not exercise like this if you have any back (or similar) problems without first asking the medical advice of an orthopedist, physical therapist, or personal trainer, as the case may be. The Web site author believes that in many cases, "deep tummy tucks" are lazy people's way out, especially if the true problem is weak tummy muscles. Once a surgeon puts a scar in the rectus abdominis muscle, that muscle may even tear or stretch during proper exercise. By having a "deep tummy tuck," a patient may be burning her/his bridges. That patient may then not be able to get the effect that would have been gained by proper exercise in the first place. Five or ten years after "deep tummy tuck" surgery, when the rectus muscles and scar fibers have been weakened further by time and chronic stretching from within, another "deep tuck" may leave the patient at the point of diminishing returns. Why all the trouble when combining a liposuction with a tummy tuck? The board-certified plastic surgeons in the United States, as a group, have by been shown by Florida Board of Medicine statistics and their own statistics and literature the unfortunate reputation of having the highest death and serious complication rates for liposuction, when compared with all the major specialties of medicine known for practicing liposuction. This may in part be due to the fact that plastic surgeons favor multiple procedures, such as the abdominoplasty (tummy tuck) in combination with the liposuction. Beware of doctors recommending many procedures and of the concept that "if you buy three surgeries, you will get one free"; it may be a recipe for increased problems as well as increased costs. Liposuction is most safely performed as a "closed" procedure, in which the surgeon does not open up a "big hole" in the patient. During the Florida Board of Medicine's formal hearings on cosmetic surgery in the 1999 and 2000, Dr. Weber addressed Board members regarding issuing a ban on the special combination of liposuction and abdominoplasty surgery citing the above reasons. The Board implemented the ban. During the ban's time period the death rate for in office cosmetic surgery in Florida declined by near 50%. When liposuction is performed alone, usually only a few germs (which live, naturally, in our hair pores) get into the liposuction entrance-wound tunnels. The human body may be better able to defend against infection in a situation in which only trauma as a result of a liposuction is present. Unfortunately, when a combination tummy tuck is done along with a liposuction, additional germs enter the wounds of the tummy tuck. Maybe they come from the knife or from laser-cutting hair pores. Whatever the cause, germs can have free access to all the tunnels that may have been made throughout the belly as a result of the combination "tuck" and liposuction procedure. It could also be that the tissues of the tummy tuck, which normally would have a good blood supply, may get into trouble, because liposuction does disturb the blood supply to the tissues around the location where the tummy tuck was sewn. The author believes that both of these conditions have contributed to the severe, dangerous, and deadly results that have occurred with combination procedures involving liposuction plus tummy tucks. Again, patients should be fully informed of the added risk of the combination procedures before "signing up" for surgery. Combining liposuction with tummy tucks makes two ordinarily safe procedures more risky. Depending upon how one compares that scientific data, that extra risk may border on outright dangerous. There exist reputable plastic surgery journal articles have contained recommendations against the performance of a liposuction in combination with abdominoplasty. Many board-certified plastic surgeons have ignored these published warnings and have continued to perform tummy tucks in combination with liposuction. Unfortunately, even with the passing of time, it appears that the risk of death and serious problems related to combination treatments has not lessened as expected. What does the Web site author suggest as one of the safest paths to follow? The author suggests that it is possible that liposuction be performed on the abdomen first to see whether the tissue tightening occurs near the surface as well as fat reduction below the skin. The author would, of course, only perform the liposuction once he has performed a physical examination showing that there is sufficient fat to remove and that there is sufficient chance that the surface skin tissues will contract. However, some patients have tight surface skin with varying amounts of subcutaneous fat underneath, with most of the protrusion being the result of weak tummy muscles. If this is so, then the author recommends the use of abdominal crunches, posture training, and exercise programs, provided that the patient does not have any back problems or other orthopedic problems. If there is appropriate fat on the abdomen, the author recommends performing the liposuction followed by a vigorous program of abdominal exercise and compression over the several months. If there is much excess skin, a "surface tummy tuck" is performed at least one month after the liposuction. Should there be a necessity for removal of an excess skin, then the tummy tuck would then be recommended. The "tuck" is best scheduled several months after the liposuction so that the surgeon may determine whether or not maximal surface contraction has occurred. The more limited recommendations work well in the vast majority of patients. Doing the tummy tuck at a later time tremendously reduces the dangers that exist during combination procedures (procedures that are performed all at once). Additionally, the costs charged by less aggressive surgeons who split the procedures may be less than or equal to the cost of a combination procedure performed by more aggressive doctors. Sometimes a little investigational homework by a patient can save a lot of future physical or economic difficulty.
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