Abdominal revision liposuction poses some unique challenges. First and foremost, plastic surgeons often have to deal with skin irregularities caused by over-removal of fat, and the internal scar tissue from the previous surgery.
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently posted a Snapchat video showing a female patient who had botched liposuction that resulted in large dents below her navel, contour irregularity on the left flank, and less than optimal waistline.
The large dents and surface irregularities, according to Dr. Smiley, were primarily caused by over-liposuction or removing too much fat.
In the video, the celebrity plastic surgeon said a thin layer of fat must remain after surgery to ensure a smooth skin surface and to avoid a wide range of surgical stigmata.
To correct the ill effects of over-liposuction, Dr. Smiley performed fat transfer, which in essence is a reverse liposuction. After removing some fats along the flanks and waistline, instead of discarding them he injected them to smooth out the indentations.
To further achieve a smooth skin surface, Dr. Smiley released the scar tissue that was causing the skin to adhere to the muscle, which in turn also improved the contour of the left flank.
Moreover, he removed additional fat along the flanks to create a more hourglass silhouette (narrow waistline and wide hips).
Since revision abdominal liposuction is more complex than the initial surgery, Dr. Smiley always uses the tumescent technique combined with microcannula, or flexible hollowed tube with an outside diameter of less than 2-3 mm.
Tumescent liposuction involves injecting large amounts of tumescent fluids into the fatty area before the actual removal fat is performed. The idea is to make the fat cells swell up to pave way for a more precise, gentler extraction.
Furthermore, the tumescent fluids contain epinephrine that constricts the blood vessels and thus the amount of bleeding is reduced by up to 90 percent as compared to the “dry” or “no wetting solution” technique.
Precision is further improved with the use of microcannula during the actual extraction of fat, allowing the surgeon to remove excess fats in smaller bits, as opposed to larger chunks. For this reason, he avoids using large cannulas especially when doing some type of revision liposuction.
The female patient has presented Dr. Smiley her “wish pic” (Kylie Jenner’s voluptuous body). For this reason, he not just sculpted the four quadrants of the frontal abdomen and the flanks, but also the inner thigh and hips.
Overall, Dr. Smiley used 12 tiny liposuction incisions to meet the cosmetic goals of this particular patient; these are expected to fade into the background after 6-12 months.
The success of revision rhinoplasty surgery preparation will not just rely on the surgeon’s skills. Patient cooperation will also play a critical role on the final results and ultimately the satisfaction rate, according to the California Surgical Institute website.
The list below explains the “basics” of revision rhinoplasty surgery preparation. It is important to note that some patients may need to follow a set of highly specific instructions due to their unique anatomy or individual problem. For this reason, the safest route is to stick to the recommendations of one’s surgeon.
Minor contour irregularities and persistent fullness or swelling of the supratip (right above the tip) are best addressed after the skin has redraped completely to the new contour, which happens after 9-12 months. This “guideline” applies specifically to patients with markedly thick nasal skin, which is susceptible to prolonged swelling.
Waiting also allows the patients to be more objective on the results of their surgery and to ponder deeper on their cosmetic goals.
The idea is to have the most accurate assessment of the nose to achieve the most satisfying results possible. Nonetheless, certain deformities are best treated as soon as possible because of the zero possibility of improvement even after the passage of time.
Any medical condition that can interfere with healing must be controlled well in advance of the surgery. Healthy lifestyle and/or medications can help patients achieve their optimal health so they can handle the surgery.
- Avoid risk factors linked to increased bleeding, infection, and poor healing
Aspirin and other drugs and supplements with blood thinning properties must be discontinued 2-3 weeks before surgery and at least week afterward.
Tobacco and smoking cessation products (gum and patch) are also best avoided several weeks or even months ahead of the surgery because they are known to significantly increase the risk of skin necrosis and poor healing.
Doctors generally have preoperative information packet that explains what medications, supplements, drinks, and foods to avoid or at least limit their consumption. Furthermore, prudent patients should never hide or omit information regarding their drug use (including recreational drugs) to prevent complications and less than optimal results.
In the ideal scenario, lab screening, which is primarily blood work, is performed not later than 10 days prior to surgery to ensure that the patient is healthy enough for rhinoplasty and the ensuing recovery.
Revision rhinoplasty, also referred to as corrective or secondary nose job, deals with deformity of varying degree. In general, mild asymmetries such as small residual hump along the profile are best addressed after 6-18 months postop; the idea is to wait for all the residual swelling to subside.
Waiting is also ideal for patients with a markedly thick skin that makes them susceptible to protracted postop swelling in order to achieve a more favorable outcome, as suggested by leading Beverly Hills plastic surgeon Dr. Tarick Smiley.
Postponing revision rhinoplasty also ensures that the skin has fully shrink-wrapped to the new contour, and the patient becomes more “objective” in assessing the surgery’s results. Simply put, waiting prevents anyone from making hasty decision that could lead to more problems and frustrations.
However, there is no reason to wait when the issue involves gross deformities and abnormalities, especially when there is very little chance that they will improve even after all the swelling has dissipated. This is particularly true for twisted nose, collapsed appearance, and polly beak (the nose resembles a parrot’s beak due to its excessive convexity).
Function-related problems are also best addressed sooner than later to prevent further suffering.
In addition, patients with significant swelling caused by aggressive scar tissue inside the nose are best treated with steroid (Kenalog) injection as soon as possible, provided that the nasal framework is sturdy.
Steroid injection is commonly used in the supratip (right above the tip) to reduce persistent swelling, which is not uncommon in patients with thick nasal skin. However, the treatment should be used sparingly (i.e., highly diluted form and at intervals of 4-6 weeks) to minimize risk of skin depression, skin discoloration, and abnormal blood vessel formation.
In summary, the right or ideal timing for revision rhinoplasty will depend on many factors such as skin thickness, degree and type of abnormality or deformity, amount of postop swelling, stability of the framework, and presence of function-related problems. Simply put, the “usual” guideline of waiting 6-18 months is not always justified.
Corrective liposuction often deals with bumps and dents whose underlying cause may involve fibrosis (hardened fluids during the recovery process or internal scar tissue), under- or over-correction, use of large cannulas, or a combination of these factors, according to the California Surgical Institute website.
It is almost always a prerequisite to use microcannula, or narrow suction tube whose outside diameter is 2.5 mm or less, when doing some type of corrective liposuction surgery. Large cannulas, meanwhile, are best avoided because they offer less precision as they remove fats in bigger chunks.
For additional accuracy, leading Beverly Hills plastic surgeon Dr. Tarick Smiley may recommend power-assisted liposuction (PAL) in which the microcannula releases tiny, accurate vibrations to break up the fat prior to its extraction. For this reason, the technique is also highly ideal for removing fibrous fats, which are typically found in the back, flanks, upper abdomen, and male breasts.
During a corrective liposuction surgery, it becomes more important than ever to preserve a residual layer of fat right beneath the skin, with its blood vessels intact. Not only does it ensure a smooth skin surface, but it also reduces the amount of postop swelling and bruising.
Furthermore, the use of gentler liposuction techniques, which have become possible thanks to microcannulas and probes that release accurate vibrations, can also prevent excessive internal scarring.
Some doctors avoid ultrasound- and laser-assisted liposuction techniques when doing revisions because the thermal energy could increase the amount of surgical trauma and possibly the risk of bumps and dents as well.
While internal scarring typically resolves on its own as the patient moves forward to her recovery, when there is too much of this (usually due to aggressive liposuction techniques) it would be difficult if not impossible to achieve smooth results from surgery.
How long the microcannula stays in the area will also determine the surface of skin. A good rule of thumb is to move it at a relatively quick pace to prevent inadvertent over-removal of fats. When too much fat is removed, the affected area would collapse to the point that the skin would resemble a “Swiss” cheese.
Occasionally, corrective liposuction entails the use of fat transfer, which essentially is a liposuction in reverse. Doctors collect donor fats from one area of the body, remove all the impurities, and re-inject the highly purified fats into the area with skin asymmetries caused by over-correction.
While revisions often produce good results, it is important to wait for at least six months or until all the swelling has resolved, the internal scar tissue has “soften,” and the skin has shrink-wrapped around the new contour.
Medical literature suggests the revision otoplasty rate has a wide variance, from 0.6 percent to 11 percent. Nevertheless, most patients who need it only require minor corrections involving asymmetry (i.e., “noticeable” difference in the projection between the two sides), under-correction, and scarring.
However, there are various ways to achieve long-lasting and more predictable results from otoplasty and thus minimize the revision otoplasty rate.
Leading Los Angeles plastic surgeon Dr. Tarick Smiley has explained his techniques that help him achieve high patient satisfaction.
- Remove the “offending” cartilage
Some surgeons simply excise some skin and rely heavily on internal sutures to pin back the ears. Dr. Smiley says this “approach” may not provide long-lasting results because the cartilage—a firm but flexible tissue that holds and determines the ear shape—has a rather “strong memory.”
To achieve results that can persist long term, Dr. Smiley highlights the importance of removing and/or “weakening” a small amount of cartilage, in addition to the use of correct suturing techniques.
- Wait until ear growth is near complete
While otoplasty can be performed as early as two years of age, waiting until the patient reaches five offers some unique advantages since during this period ear growth is near complete (about 90 percent). This makes it easier for surgeons to assess the ideal projection of the ear, and deliver results that will most likely last a lifetime.
- Importance of scar placement and wound closure
The incision must lie precisely at the ear-scalp junction for optimal scar concealment. Furthermore, it should be closed in several layers so the skin surface will receive no or very little tension, leading to more “favorable” scarring.
Medical literature suggests that a good number of patients seeking revision otoplasty want to hide or at least improve the appearance of their scars.
Poor scarring from otoplasty is sometimes linked to infection, which can be avoided by taking antibiotics, performing proper wound care, avoiding tobacco products and aspirin (and other blood thinners), and reaching one’s optimal health prior to surgery.
Revision BBL, which is an acronym for Brazilian butt lift, poses unique challenges although with proper patient selection, correct timing, meticulous surgical execution, and 100 percent patient participation (e.g., avoiding direct sitting at least three weeks postop), good results can be achieved.
Renowned Los Angeles plastic surgeon Dr. Tarick Smiley has recently posted a Snapchat video to demonstrate the challenges of revision BBL and the corresponding ways to “counteract” them, ultimately delivering an improved “backside” in terms of shape and size.
The female patient shown in the video not just complained about the minimal improvement of the buttocks from the two previous BBLs, but also the indentations around the abdomen, which was previously used as a donor site.
In BBL, the donor sites refer to areas treated by liposuction to collect the “unwanted” fats, which are later purified and re-injected into the patient’s backside.
Dr. Smiley said the visible indentations in the abdomen were caused by a combination of under- and over-liposuction.
In the video, the celebrity plastic surgeon was shown using a microcannula, a stainless steel tube with an outside diameter less than 2.5 mm, allowing him to remove smaller bits of fats. Large cannulas, meanwhile, were not ideal for revision liposuction because they give little control as they suction out fats in larger chunks, he explained.
Aside from using microcannulas, Dr. Smiley was also seen injecting a small amount of fat to further smooth out the indentations in the patient’s abdomen.
Dr. Smiley said it is of critical importance to maintain enough fats beneath the skin during liposuction to preserve a smooth surface and avoid “surgical stigmata” usually in the form of dents, bumps, and sagging appearance.
After removing the excess fats through microcannula liposuction, and making sure that all the abdominal indentations from the previous surgeries were eliminated, Dr. Smiley then proceeded with the revision BBL.
With proper purification and re-injection of the “best and healthiest” fats, Dr. Smiley said that up to 70 percent of injected volume is expected to survive long term in the buttocks.