Tummy tuck on large belly poses some unique challenges, which should be recognized prior to surgery to achieve the best results possible and to avoid or at least minimize the incidence of complication.
To shed light on the effects of tummy tuck on large belly, leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently posted videos and photos of a female patient who had this anatomy.
Before and after photos of a patient with large redundant abdominal skin and fat rolls along her flanks and back—“cosmetic” issues addressed during surgery.
Aside from the apron-like abdominal skin, the patient also had “bra and back rolls” caused by excess superficial fat, which sits close to the skin. This is different from the deeper visceral or intra-abdominal fat that is linked to obesity and so the only way to eliminate it is through weight loss.
To eliminate the fat rolls along the flanks and upper and lower back, Dr. Smiley performed liposuction prior to the creation of tummy tuck incision.
“I always perform liposuction along the flanks first so I would know how much skin to pull and tighten during tummy tuck,” he said.
During liposuction, Dr. Smiley created several small puncture wounds where a hollowed tube called cannula was inserted and used to break up and remove the superficial fats responsible for the “unsightly rolls” that are more apparent in tight clothing.
Afterwards, the celebrity plastic surgeon created a flank-to-flank tummy tuck incision that was made very low, slightly below the pubic hairline, so “the resulting scar is hidden by the patient’s underwear.”
Dr. Smiley said bleeding is one of the issues in tummy tuck and so all efforts are made to minimize it.
“I pre-treat the abdominal area. Epinephrine is injected prior to the creation of tummy tuck incision; this is a drug that constricts the blood vessels to reduce bleeding,” he explained.
Keeping the patient’s blood pressure relatively low, which is possible because of general anesthesia (administered by board-certified anesthesiologist), also contributes to less bleeding and reduced risk of large fluid imbalance, Dr. Smiley added.
Dr. Smiley measures the thickness of the apron-like skin he removes during tummy tuck surgery.
In his previous Snapchat posts, Dr. Smiley said he only works with board-certified anesthesiologist to ensure patient safety.
(Note: Anesthesiologists not just administer numbing medications and sedatives; they also monitor the patients’ vital signs such as blood pressure, oxygen level, and heart rate during surgery.)
Meanwhile, Dr. Smiley removed a chunk of excess skin and fat that almost reached the patient’s knee; it also had a thickness of about 2 inches.
After removing the excess skin and tightening the abdominal muscle, he closed the wound in several rows so the skin would receive no or very minimal tension, which is the key to “favorable” scar, he said.
Brazilian buttock lift is basically a butt augmentation through fat injection. It always starts with liposuction to harvest unwanted fat from two or more donor sites; this critical step contributes to the more holistic contouring effect of this technique compared with butt implant surgery.
Buttocks come in different shapes and sizes, which to some extent affect the results of Brazilian butt lift. Simply put, the right candidates have cosmetic goals that are in line with what the surgery can accomplish.
The patient has square-shaped buttocks and poor waist-to-hip ratio, which Tarick Dr. Smiley improves with meticulous Brazilian butt lift.
The surgery has a certain appeal to women with square-shaped buttocks, which lead to a less feminine figure. Studies have all pointed out the most ideal female physique has a waist-to-hip ratio of 0.7, meaning the waist circumference accounts for 70 percent of the hips measurement.
The preference for 0.7 WHR is seen across all cultures; even the world’s best artworks depict women with this physique, or more commonly referred to as an hourglass figure.
Women with square-shaped buttocks have poor WHR due to their thick waist, narrow hips, and flat buttocks.
Liposuction can reduce the waist circumference, although it is critical to pay closer attention to the flanks and lower back to create a smooth inward slope. Despite the relatively thick waist, a good number of patients with square buttocks have less dispensable fat in the area. Hence, other donor sites might be considered such as the upper arms, bra rolls, and thighs.
For “average built” patients, at least 800 cc of fat on each butt is needed to see a notable improvement.
But even with large fat volume collected by liposuction, the elasticity of butt skin will still determine the degree of augmentation. A skin that is too tight resists large expansion, and too loose the patient runs the risk of sagging appearance and cellulites if over-injection has been performed.
Over-injection must also be avoided because of the increased risk of skin surface irregularities. This applies to every patient, regardless of the “starting” butt shape and size.
Despite the anatomical roadblocks facing patients with square-shaped butt, in the vast majority of cases Brazilian buttock lift can still provide impressive contouring effects provided that the surgeon is meticulous during patient selection and is adept in the surgery, as suggested by leading Beverly Hills plastic surgeon Dr. Tarick Smiley.
The top heavy look is one of the most recognizable breast implant effects. Hence, patients who want the natural look always take into account their body frame, particularly their upper body dimension, waist-to-hip ratio, and height when selecting their implant size.
In general, the breast implant size range between 300 and 450 cc provides “smaller” augmentation that suits petite women. Also, going the conservative route favors patients with little soft tissue coverage who are prone to rippling, globular shape, and increased palpability particularly when overlarge implants are used.
Conservative-sized implants also suit athletic patients who typically have low body fat percentage that makes them prone to rippling if overlarge saline implants are used.
Due to the inherent strength of modern breast implants, most patients seeking revision surgery nowadays are not concerned with rupture or leak but want an implant exchange to upsize or downsize, as suggested by a recent survey.
Hence, the breast implant size and its “specific” results on each woman is one of the most important topics during consultation. Leading Beverly Hills plastic surgeon Dr. Tarick Smiley says the patient’s candidness—describing her “bust goals” in precise detail—plays a critical role in the success of breast augmentation.
Of course, it is the surgeon’s responsibility to offer his patients all modalities that will improve their discussion. For instance, some doctors offer sizers that are put inside an unpadded bra to give women an idea on how a specific implant size will look on them.
Some doctors also offer three-dimensional imaging to further improve the discussion regarding the implant size and profile, or how much it projects from the chest wall.
Meanwhile, some studies and surveys have attempted to shed light on the ideal breast size in which individual preferences greatly varied. However, most respondents favored medium-sized breasts, namely, C and D cup.
One study has even suggested that medium-sized breasts that are firm and with a 45:55 ratio, which means most of the volume is in the lower pole, with the nipple serving as the delineating mark, as the most preferred breast appearance.
It is important to note that some patients seek breast implants to enhance their shape or correct the deflated-looking upper breast pole without resulting in significant augmentation.
Breast lift and implants is a “combination” surgery to reshape the pendulous breasts and provide additional volume especially in the upper breast pole, which tends to deflate with aging or following weight loss and pregnancy.
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently posted breast lift and implants before and after photos on Snapchat to illustrate its “contouring and volumizing effects.”
During breast lift with implants, Dr. Smiley always completes one breast before proceeding to the other side. The idea is to create a template for the other breast, leading to more symmetric results.
Prior to surgery, the patient shown in the photos had significantly drooping breasts whose areolar complex, which is the ring of pigmented skin around the nipple, settled below the level of the breast crease and were hugely disproportionate.
With the severity of her breast ptosis, or sagging, Dr. Smiley performed the anchor breast lift, which involved a donut-shaped incision around the areola that extended down the midline to the breast crease. Another incision shaped like a crescent was also created along the base.
The anchor breast lift is also referred to as inverted T lift due to the shape of the incision or scar pattern.
The donut-shaped incision around the areola allowed Dr. Smiley to drastically reduce its size. To achieve good symmetry between the two sides, he used a cookie-cutter device to delineate the new smaller areolar complex.
When making the areolar incision, Dr. Smiley says “it is important not to go too deep in order to preserve the blood supply,” and ultimately “minimize the risk of healing problems and delayed recovery.”
Before and after photos of breast lift with implants
During breast lift, Dr. Smiley elevated the tissue of the lower breast pole with the use of internal sutures, and repositioned the areolar complex higher, ensuring that it would lie approximately at the center of the breast mound. Meanwhile, studies have suggested that the ideal nipple position should be above the breast crease, and there must be a 18-21 cm distance between the nipple and the sternal notch, which is the small dip at the base of the throat.
Afterwards, he positioned the implants beneath the pec muscle, instead of placing them above this anatomical layer. This technique, referred to as submuscular implant placement, reduces palpability and risk of rippling and bottoming out due to the additional padding from the muscle.
Should I have dermal fillers vs fat transfer? This is arguably the most common question of patients wanting to rejuvenate their face with the use of “volumizers,” which can be combined with facelift surgery for a more holistic, more natural result.
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley says that dermal fillers are readily available materials injected into the soft tissue, while fat transfer uses the most natural material possible—i.e., the patient’s own fat that is usually derived from the tummy and flanks, areas that typically carry “unwanted” fat cells.
Photo Credit: Restylane.com
In essence, dermal fillers and fat transfer fill in the cracks and depressions that are typically caused by age-induced facial volume loss, while facelift removes the loose skin and tighten the deeper structures.
Dr. Smiley says that patients older than 55 typically require both procedures because their aging appearance are caused by facial volume loss and soft tissue laxity (sagging).
The celebrity plastic surgeon says he prefers fat transfer to dermal fillers because of the former’s longer lasting results, averaging 12-15 years.
Fillers, meanwhile, are usually repeated at 3-4 month intervals to maintain the plump up appearance. Hence, it is safe to surmise that in the long run they are more expensive than fat transfer, says Dr. Smiley.
Aside from the “long term” cost of dermal fillers, many surgeons have suggested that fat transfer remains superior because it adheres to the core principle of “replacing likes with likes” and so the results are perceived to be softer and more natural looking.
Should there is a need to address deep depression and cracks at the time of facelift surgery, Dr. Smiley performs a simultaneous fat transfer; this is more convenient than having two separate procedures, which of course can lead to additional cost and multiple recovery.
Dr. Smiley often uses a simultaneous fat transfer to further soften the nasolabial folds, or laugh lines; and to create a smooth transition between the lower lid and upper cheek.
Failure to address the “abrupt” lid-cheek junction, Dr. Smiley warns, can lead to unnatural facelift results manifested by skeletonized eye socket and crescent-shaped bulge right below the lower lid. Simply put, fat transfer “fine tunes” the effects of facial rejuvenation surgery.
Meanwhile, Dr. Smiley typically reserves dermal fillers for first-time patients who need volumizers as a stand-alone procedure. Should they are happy with the results, they may ask for a more permanent treatment in the form of fat transfer later on.