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Adrian Richards: Hello, my name is Adrian Richards. Welcome to the Plastic Surgery Podcast, providing information for patients from patients. I'm a consultant plastic and cosmetic surgeon. In June podcast, I'll be talking to specialists in particular fields to get their latest updates on treatments. During the second part of these podcasts, I'll be talking to patients who've undergone these treatments to get their opinions and views on how the treatments work.
Today, on the podcast, I'm going to be talking to Lisa Sacks, who's a consulting plastic surgeon who specializes in breast and tummy surgery. Lisa's got some really interesting points to make about tummy tuck procedures.
After the interview with Lisa, I'm going to be talking to Heidi, who had an abdominoplasty and breast uplift procedure performed by myself. She's got some really interesting things to say from a patient's perspective, particularly abdominoplasties.
Hi, Lisa...
Lisa Sacks: Hi.
Adrian: ... thanks very much for coming on to talk to me. Now, you've talked to me a bit over, quietly, about some real exciting ideas you had for tummy tucks. I wonder if you could talk me through some of those.
Lisa: Tummy tucks is something very close to my heart because I believe that it's not a cosmetic operation, but a reconstructive operation. Many women who come and see me have had children and they come and said no matter how much exercise they do or how much they diet, when they sit down, they have this alien sitting on their lap. Or, if they're slim, they have this pot belly up here with an arched back.
Adrian: It really doesn't match the rest of them, don't they?
Lisa: Exactly.
Adrian: Yep.
Lisa: And when questioning women closely, one often finds that many women have lower backache. In fact, so many women who've lower backache, they think it's normal. They think it's from their pregnancy or from their childbirth. My feeling is that after two pregnancies the muscle wall on the front of the abdomen what men call a six-pack in women, that split, that happens to accommodate the pregnancy, never actually comes back together again.
Adrian: It's quite variable though, isn't it? Some people really do have quite a big bulge and other people, it's less.
Lisa: Yes, and it's got nothing to do with whether a woman is thin or fat. It has
more to do with the size of her babies. One often sees it, of course, in twin pregnancies or triplet pregnancies.
Adrian: This is a quick thing for people. You test it by if you lie flat and when they strain to get off their bed that tenses the muscles up. It's almost you can feel a little gap-like, can't you?
Lisa: Yes, yes, yes. And one does the same for the head and the shoulders to feel the gap above the bellybutton. But, if one asks a woman, "Is your tummy flat in the morning when you wake up and then by the evening you're quite bloated and look like an early pregnancy," that normally is an indication that there's muscle wall weakness.
Adrian: And the muscle is getting weaker during the day?
Lisa: It's not getting weaker, but the muscle is not toned.
Adrian: Can you improve that with exercise, Lisa?
Lisa: One can, but it has its limits. Personally, I hate doing tummy exercises
because it makes my neck sore, which probably indicates what weak tummy muscles I've got. But, women are not great for doing bench presses or sit-ups or press-ups. It's just a fact of life. Many women are far too busy to go to the gym every night, looking after their families. What I found in doing tummy tucks over the last 10, 11 years, is that by doing a full tummy tuck and reinforcing this muscle layer with a permanent stitch, the benefits to their backache, to their bowel function, even to their sex lives, is remarkable.
So, before surgery, a woman will complain about the little apron or the pouch that she has, affecting what she can wear. After surgery, they come and tell me that actually looking good is just being the icing on the cake. It's really their improved posture and their general feeling of well-being. So, this is very important. This operation can tighten the core muscles.
Adrian: OK, so just talk me through that. It's the rectus abdominis muscle, which vertical muscle; isn't it?
Lisa: It's two long, vertical muscles on either side of the bellybutton.
Adrian: They typically separate. How do you repair them in the operation?
Lisa: When the patient is lying on her back and anesthetized and the skin and fat is lifted up, one can see a gutter, an indentation where these muscles have split. It's a wide sheet of tandem. One measures what would give the patient a comfortable closing. In some women, we're closing up to 10 centimeters of muscle split. We do this really with a very thick shoelace type of nylon suture.
Adrian: Yes.
Lisa: I do it in two layers. It's gives beautiful results with an almost hourglass
figure after surgery.
Adrian: Yeah. Would you placate...? This is rectus placation. Would you do this on every patient?
Lisa: On 99 percent of my patients who've had pregnancies or in younger women who've been morbidly obese. The interesting question is if one placates the abdomen in someone who's never had a pregnancy, what happens when they're pregnant?
Adrian: Yes.
Lisa: In young woman who's never been pregnant, I use an absorbable suture so that it will have dissolved by the time they're pregnant. But, even in women who've had a tummy tuck and then become pregnant, somehow the gains of the tummy tuck are retained after pregnancy.
Adrian: That's interesting, isn't it?
Lisa: Very interesting.
Adrian: The usual advice is to wait until you've, perhaps, finished your family before having a tummy tuck. Now, just explain to me the varieties of incision for tummy tucks the mini tummy tuck and then the full tummy tuck. How do you decide what's best for the individual?
Lisa: Mini tummy tucks, in my practice, are very rare.
Adrian: Yeah.
Lisa: My personal philosophy is that if a patient's having an anesthetic, taking the time off work, going to the trouble of recovering from an operation, she wants to make it worth her while and have a good result. So, I don't generally do mini tummy tucks other than in people I who have a really minimal defect. In the majority of women, I see women who come along and think they need liposuction because their tummy's sticking out. I show them, lying down and lifting up first their feet and then their head and shoulders, that actually they don't need liposuction, they need their muscles fixed. Because if they had liposuction, they'll have less fat under the skin, but their tummies will still be sticking out because it's a muscle problem.
Adrian: Yes, often these women feel it is the excess of fat. But, in fact, their fat layer is very thin, isn't it? It's the weakness of the muscle bulging forwards.
Lisa: It's the weakness. I think that a feminine tummy needs to have a fatty layer. We certainly don't want to see the six-pack in a woman, unless she's a bodybuilder. The scar is substantial. Let's not beat around the bush about it. The scar of a proper abdominoplasty goes from hip to hip, but it should go high on the hip, arch down, right in the pubic hair and then up on the other side. That's called the handlebar incision.
What's good about that incision is that it can be hid in the smallest bikini. Not a Gstring, but in the smallest bathing suit, either one piece with high legs or a bikini. And if it's placed correctly and sutured correctly without tension, the scar might be very long, but it should give a hairline scar, a very...
Adrian: So a very light, faded scar. So, just talk me through a mini tummy tuck. Often there's a caesarean scar.
Lisa: Yes.
Adrian: That's called a phantom steel scar, isn't it?
Lisa: That's right.
Adrian: You typically remove that, don't you?
Lisa: The phantom steel scars, from gynecological surgery or from caesarean sections, are often higher, about an inch higher than I go for a tummy tuck. So, that invariably gets removed. If a person has had an appendectomy, it often gets included, as well.
Adrian: And often above the caesarean, the eye notices the patients often have sort of a bulge above this?
Lisa: That's right. That's what most women complain about. They've had their
caesarean when they were much younger. As they age they may deposit a little fat above that. The caesarean scar acts a tether and they complain of that shelf effect.
Adrian: Because it's held in, isn't it, and then they get the overhang. So, if someone's had a caesarean scar or phantom steel scar, you remove the scar?
Lisa: That's right.
Adrian: They've got a scar in a similar place, but it's extended.
Lisa: That's right.
Adrian: OK. Now, just tell me a little bit about the difference between a mini tummy tuck and a full tummy tuck.
Lisa: Mini tummy tuck doesn't go above the belly button. That's what it is. It's from the pubic triangle up to the belly button and it really just deals with a little bit of excess in the lower abdomen. It's difficult, I think, to placate the muscles with a mini tummy tuck in someone who has had two pregnancies or more, because if one does that, one ends up with a bulge in the epigastrium, that is from the belly button up to the xiphisternum. That's why I don't favor using a mini tummy tuck in someone who has had two pregnancies or more.
Adrian: So, a mini tummy tuck is normally from the pubic area to ruse tissue to about eight centimeters below the tummy button, isn't it? That tissue is removed, the tummy button isn't touched.
Lisa: It's not touched, it's not relocated, but it does get a slightly more vertical orientation.
Adrian: And often hooded on above, isn't it?
Lisa: Yes.
Adrian: OK, so that's a mini tummy tuck. A full tummy tuck?
Lisa: A full tummy tuck involves, where people always say, "Will you make me a new belly button?" The answer is no, it's the same belly button, but as the soft tissue is all released and brought all the way down, a new peep hole is made for the belly button. In most women who have this operation, the little hole that was cut away around the belly button, ends up being pulled all the way down to the top of the pubic hair. That's why the scar is so long, because we are taking a huge swath of tissue from hip to hip that in many patients can weigh over a kilogram.
Adrian: There are techniques to minimize the length from that, to sort of bring the tissue in from the sides. I mean I certainly, I know you do try to minimize the length of that scar as much as possible.
Lisa: Yes.
Adrian: Something I found useful, I would like you to comment on, is I often
plan this scar with underwear on.
Lisa: Yes, yes. I often say to these patients, "Please bring in a bikini bottom that you have at home." Most of them blush and admit they haven't worn a bikini for 20 years. So, they come in with a bikini bottom on and we plan the scar to fit into the bikini.
Adrian: The trends moved a bit, isn't it? It used to be much more highwaisted.
Lisa: There's a terrible fashion at the moment with very, very low hipped trousers. It seems to be more common in younger people, but since this fashion has arisen, I know that I have to be very careful with where I put the scar on the hip. I ask patients to let me know what type of trousers they wear. But, older patients, I don't think this has caught on very well. The important thing, for me, about this operation is the belly button. The belly button scar has to be very, very aesthetic, because the belly button can be a terrible giveaway. In a patient who is old and may have had a bit of a fat tummy, the belly button stock gets stretched. I think a very important part of this operation is to stitch down the belly button stock to the muscle layer at the time of the placation, so that one gets a very sculptured, concave belly button.
Adrian: That's a nice, sort of, almost like a saucer going down, isn't it.
Lisa: Exactly. You want to give them a lovely tummy with a belly button of a thin person. Often one sees a tummy tuck where the belly button stock hasn't been shortened, and the belly button looks like peephole in a door.
Adrian: Yes. So, tell me, we talk a lot about what's the best tummy button, vertical, transverse. What's your feeling?
Lisa: I go through phases of using different techniques, but patients always tell me they want a smiley belly button, because in a distended tummy the belly button is usually covered with sagging tissue. I always say, "It's sad and hiding away." I have used various shapes. I have used diamonds. I have used triangles. I have used hemicycles. The important thing is to really try to close it in an aesthetic way and to not have too much tension, otherwise one gets an obese scar around it.
Adrian: Absolutely. So, it should really look sort of natural with a nice...
Lisa: Completely, yes. Completely natural.
Adrian: OK. Just a word on recovery. I mean it is, as you say, it's a sizable procedure. How long do patients stay in the hospital? What is the recovery period like, Lisa?
Lisa: In the United Kingdom, this is an impatient procedure and they stay in for two nights. It's very interesting because in America they do this as an outpatient procedure. So, it's quite different culturally in different countries. Patients stay in for two nights. I tell them that they need approximately three weeks off work. I follow them up at one week. By their third week visit, they can drive themselves to the clinic. The first week is the toughest because they are in a bent over position and very, very slowly the skins elasticity accommodates the amount of tissue that we've taken off.
Adrian: In accord, any sort of compression garment?
Lisa: I put compression garments on the patient at one week, sometimes I leave the drains in for that time. I don't put compression garments in the first week because I want the blood supply of the flaps to become established. Many patients are embarrassed about coming for this procedure thinking it's a cosmetic operation. When I have a consultation, I spend a good deal of time explaining to patients that this is a reconstructive procedure. They all worry about if they should take time off work. I tell them that in fact, this is a gynecological procedure and they shouldn't feel guilty about taking sick leave for this.
Adrian: They are often surprised that we can give people sick notes, saying that they have an operation, unspecified operation, and that was obviously, out with a sort of a holiday, an issue for some people isn't it?
Lisa: Yes, yes. It's interesting, many women feel that they need to take holiday leave to have anything likes this done. But, so long as one educates them and they realize that it is not a cosmetic operation and if they hadn't sacrificed their body for child birth, they wouldn't be needing the surgery. So, I think, it's a reasonable payback time for women who have had children.
Adrian: I see. One of the tricks I have learned to help people straighten up is, I ask them to stand against the wall and then sort of walk their hands up the wall. Do you find that useful?
Lisa: I have never tried that. I am going to try that next week.
Adrian: It works quite well, Lisa. So, anything else you would like to talk about, mention about tummy tucks being a very satisfying operation?
Lisa: Yes. Many patients want to know if I am going to combine liposuction with tummy tucks, and I think this is a very, very interesting point. Tummy tucks together with liposuction are the only two really dangerous procedures in plastic surgery. Liposuction, one can get fat embolus, which means blood can get into a vein and cause a stroke.
Adrian: Liposuction combined with a tummy tuck, or just liposuction.
Lisa: Liposuction alone, in general. In an abdominoplasty alone, is the operation in plastic surgery most likely to cause a deep vein thrombosis and a pulmonary embolus.
Adrian: Just explain what that is, a DVT.
Lisa: A DVT, a clot in the legs, and that's both from being immobile during the operation and after surgery, but also because abdominal cavities close down by the muscle repair and it may make the veins returning blood to the heart a little bit more sluggish. Of course, we have stocking on the patient, stockings and pumps on the legs, and we take every precaution, like stopping the contraceptive pill before, and stopping HRT.
None the less, combining a tummy tuck with liposuction, I feel, is compounding the risk. So, the only liposuction I do, is what I call etching, which is above the belly button, I do a little bit of liposuction to make an indentation, as one sees in a thinner abdomen.
Adrian: Would you ever consider liposuction of the flanks?
Lisa: At the time of surgery?
Adrian: Yeah.
Lisa: If it was a small volume, but normally I say to patients, "Let's see how you go and we'll consider it another time." I generally don't like to combine liposuction with abdominoplasty.
Adrian: Yeah. I mean, I would absolutely agree with that. That's my position.
Lisa: I think safety must come first.
Adrian: Absolutely, and obviously these are often ladies with children and young families, so I think safety has to be paramount.
Lisa: Yes. I don't have a body mass index that is [inaudible 17:28] of like in the National Health Service. I am happy to operate on someone up to a body mass index of about 35 or 36. I don't want to operate on people who have got a lot of intra-abdominal fat, because I can't get a proper muscle repair. But, if I can see that most of the protruding stomach is due to muscle weakness, I am happy to operate.
Adrian: What is your attitudes towards smokers?
Lisa: That's another good question. My practice is a non-smoking practice. I
don't smoke and the patients must not smoke either. There are well documented studies that smoking increases infection with surgery by 30%.
Adrian: And delays healing.
Lisa: Exactly. It's the nicotine. One puff of nicotine closes down the blood vessels in the wound edges. I wouldn't drive a car that had a high risk of accidents, so why do I want to operate on a patient who I know has a 30% higher risk of an infection? I tell my patients this is a team effort. I expect them to stop smoking before surgery: four weeks before and four weeks after.
Adrian: So, you're fairly strict then.
Lisa: Very strict.
Adrian: Thank you very much for taking the time to come and see us.
Lisa: Thank you.
Adrian: This information is available on your website.
Lisa: That's correct.
Adrian: Great. So, people can look you up and download the information as they need it. Thank you very much, Lisa.
Lisa: Thank you.
Adrian: I appreciate that. [music]
Adrian: I'm here this afternoon with Heidi, who had a joint procedure: a breast uplift, which she talked about in a previous podcast, and a tummy tuck. Heidi, would you just tell me a little bit about what brought you in and how you found the consultations here?
Heidi: OK. After having three children, I had stretch marks. I'm an avid user of the gym. I'd done everything that I could possibly do to tone my tummy up, lose weight, and whatnot. But, I still had very loose, creepy skin that would fold over my jeans. I could hide it well to a certain extent in clothes, but I was massively aware of it all the time. It just made me feel uncomfortable. My tummy button had collapsed. I just wanted to know if there was anything that I could do about it. A friend of mine had recommended Aurora Clinics to me. So, when I came, I must admit immediately I felt comfortable. The nurses were really lovely and very welcoming.
There was just no pressure from the time I came in to, I think, the fourth time that I came to chat. There was absolutely no pressure about going ahead with the procedure. I was given lots of information, lots of pictures to look at, and people to contact who had had the same procedure.
That, again, made me more confident about what I could achieve and what I could achieve realistically as well. I knew I would still have stretch marks on my tummy, but they wouldn't be loose. They would be on a tough, firm skin. Nothing folding over. So, in that respect, it was very good. I was very happy.
Adrian: I think from other people I talked to, the tummy tuck does take longer to recover than most sorts of surgery. That's particularly because the muscles are often repaired. Can you tell me how the procedure was and how you recovered, Heidi?
Heidi: Certainly. My muscles weren't repaired as I thankfully did enough legwork at the gym for a few years. So, I didn't need that. However, it did take longer to recover than I expected. Although I was told how long it would take to recover, it still doesn't click in your head. You are indisposed for a while. You do need care at home. You do need someone to help out with things.
Adrian: In what way are you indisposed?
Heidi: There is a certain amount of pain. I think even after having a general anesthetic anyway, it does take a lot out of you as you are tired. I had to be very careful about moving about. I absolutely made sure the first week I did absolutely nothing. I stayed in bed. I let my darling husband run around after me, and friends, to make sure that I healed really, really quickly.
Adrian: You stayed two nights in hospital, didn't you? The first week...
Heidi: The first week I just stayed at home in bed, and that was it. I just read, listened to music, and totally looked after myself. Just walking to the toilet even, you just have to really be careful, take your time, and look after yourself.
Adrian: You kept your ankles moving, didn't you, Heidi?
Heidi: I did. I kept moving my legs. That's one thing I could do. I wore the support stockings as well and the corset that I was given. Also, in bed, I made sure that I was slightly propped up and that my legs were elevated as well so that my tummy wasn't pulled. It is a little bit sore, and you don't want it stretched out. That's what I did at home.
Adrian: I think that's the point, that the tummy skin is quite tight. It needs to be tight actually, so you've got a flat tummy. Straightening up is difficult in the first week or so, isn't it?
Heidi: It is because it's not a natural position for your body. It's not been used to it. It will get used to it. It just needs time to heal in that position. But, even after the first week I made sure, even walking around. If you're moving your ankles and legs, then just slowly walking to the toilet or bathroom, that's keeping you moving. That helps with the healing process as well.
Adrian: Brilliant. So, take me through then the subsequent weeks: the second, third, and fourth week. How did they feel?
Heidi: Much better. I could do more. There is a lot of swelling. I don't think everyone's really ready for that, although I was told about it. You need to make sure you've got lots of very comfortable, loose‑fitting clothes because nothing will fit you properly. There was one day when we went to visit friends where I did do too much. I walked too much. I knew it afterwards because I became quite light-headed. My tummy swelled up a little bit more. You have to make sure you either wear the corset, some hold you in tights, Spanks, or something like that to support you. It does help a lot.
Adrian: Then you're at six weeks now. Tell me how are you feeling now, and what's the scarring like?
Heidi: I feel fantastic, actually. I have to admit. The scarring is amazing. It's just a very thin line. It's a little bit red in parts, but mostly it's completely healed. My tummy area above still feels a little bit numb, but that's slowly going.
Adrian: Tell me about that, Heidi. Which area is numb?
Heidi: Not around the scar, actually. It was more around the tummy button, your actual stomach area. It just feels as if you've been to the dentist, and you've had some litocaine injected. That's what it feels like.
Adrian: That should improve as the nerves grow in. They take about a month to get going. Then they grow at approximately the speed of hair. It will come back.
Heidi: That sounds exactly on the ball, actually, because it has just slowly gotten much, much better. It doesn't feel painful in any way. I'm back in my tight jeans. Marvelous! Everything fits really, really well. I'm back to work doing everything that I'm to do normally back at home. I've even been to the gym, taking it easy mind you. Yeah, I just feel completely normal. Even better than normal to be honest, because I just feel great.
Adrian: Brilliant. For anyone thinking of this sort of surgery, a tummy tuck abdominoplasty-type procedure, Heidi, what would be your words of advice to people?
Heidi: I would advise to make sure that this really matters to you, that it is something that you really want done. It's not something that you go into lightly. I am over the moon that I've had it done because it's made a huge difference to me. No one would probably notice a huge difference while I'm in my clothes, but it's just given me so much self-confidence. It's amazing. It's something that I don't have to worry about anymore.
Adrian: Brilliant. Thank you very much for taking time to talk to me today. Good luck.
Heidi: Thank you very much. It's been a pleasure.
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Adrian: That will do for today. Thanks for listening to the Plastic SurgeryPodcast, providing information for patients from patients. For further information and to leave feedback, please visit the Aurora website at www.aurora-clinics.co.uk. If you'd like to schedule an appointment with one of our surgeons, please call 01844 214362 or email us on info@aurora-clinics.co.uk. We're very keen to get feedback. If you're considering any of these treatments and you'd like me to ask one of the resident experts about any topic, please email us or send us an audio file, which we can play on the podcast.
I'm Adrian Richards. Thank you for listening to the podcast, and thank you to all of our guests.
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