A man in his 60’s who has gynecomastia and significant weight loss. The only way to tighten loose skin is to remove skin, leaving a visible scar on the chest in exchange for a normal contour in clothing. Our patient is shown before and again, 4 years after bilateral gynecomastia excision with free nipple grafting. He is pleased by his contour in fitted shirts and bicycle jerseys, but, as we see with most gynecomastia patients who need skin excision, he does not feel comfortable taking his shirt off at the beach.
An early follow-up on a Fleur de Lis abdominoplasty in a man in his early 40’s who has lost 80 lbs with a keto diet. He has a large hernia of his umbilicus which was corrected at the same time by his general surgeon. A new umbilicus ( neoumbilicus) was created at the time of his surgery. “Fleur de Lis” refers to the pattern of skin excision which includes a vertical component. Many patients with significant weight loss have a horizontal excess of the upper abdomen which requires a vertical excision to tighten it. A vertical scar is the tradeoff. Our patient is shown before and again, just 2 months after his surgery. Scars are typically the thickest and reddest at 6 weeks after surgery and then will fade and improve over the next 2 years. Swelling of the abdomen also takes 6 months to fully resolve after an abdominoplasty. A dramatic early improvement is seen.
Update: A 9 month fu showns resolution of swelling and a dramatic improvement despite the gain of 5 lbs since surgery. Scar continues to fade and improve. And the new umbilicus that we created looks natural.
A mother of 2 in her later 50’s who had a lap band in 2007, that was removed in 2014 and then had an endoscopic gastric sleeve in 2014. She has lost 100 lbs and been at a stable weight for the last 2 years. She is bothered by fullness and laxity of the abdominal skin and would like to be able to wear fitted clothing.
She is shown before and again, nearly 7 months after an extended abdominoplasty with the removal of nearly 5 lbs of skin. She was 5 feet tall and 139 lbs before her surgery. She is thrilled with the improvement of her abdomen and loves catching sight of herself in a mirror now when she walks by in her fitted clothing. Exparel was used to limit her need for narcotics after surgery, and progressive tension sutures were uses to decrease her risk of seroma formation. Her scar is placed low, in a thong position, where it is most easily hidden by clothing.
As is typical in a patient with significant weight loss she continues to have some looseness of the skin of the
upper abdomen, but not enough in her mind to trade it for a vertical scar ( Fleur de Lis abdominoplasty)
A mother of 3 in her early 60’s who has lost significant weight after an endoscopic gastric sleeve 2 years before. She is bothered by the “pouch” of her abdomen that makes it difficult to wear fitted clothes. She is shown before and again, 6 months after an extended abdominoplasty.
A woman in her late 30’s who has lost more than 120 lbs with diet and exercise and is bothered by the appearance of her abdomen, She is currently 5’ 7” and 200 lbs, giving her a BMI of 31.32, She is shown just before and again, 17 months after an extended abdominoplasty with the removal of more than 5 ½ lbs of skin. We could provide additional tightening of the upper abdomen with a midline excision ( a fleur de lis pattern) but she does not wish to have a visible scar in this area. She is thrilled now to fit better in her clothes.
A woman in her mid 50’s who has lost 148 lbs after a gastric bypass more than 15 years before through an open upper abdominal midline incision. She had had Coolsculpting treatment of the abdomen 3 months before coming to see me, but didn’t report any improvement. Of course cryolipolysis is s treatment for fat, and her problem is excess skin, so the lack of improvement is not a surprise. It is always important to make the diagnosis before selecting a treatment.
Our patient is now seen 18 months after her abdominoplasty. The scars have continued to fade.
A mother of 2 in her late 30’s who has had a gastric bypass and has lost 85 lbs. Her case is complicated by having been a recent smoker. She is 5’ tall and 155 lbs, giving her a BMI of 30.27. She was encouraged to not smoke for 2 months before and after her surgery. She is shown before and again, 7 months after an extended abdominoplasty. She had some initial problems with healing in the lower abdomen, but responded to dressing changes and protein supplementation. She is thrilled with her the new shape of her stomach and can now wear normal clothing.
A woman in her mid 30’s who has lost 128 lbs with diet and exercise. She is bothered by the appearance of her abdomen.
She is 5’7” and 200 lbs, giving her a BMI of 31.3.
She is shown before and again, 6 months after an extended abdominoplasty, with the removal of more than 5 ½ lbs of skin. She is thrilled with her improvement, and no longer worries about how to hide her loose abdominal skin in clothing. As is typical after this much weight loss, her skin is not as elastic and her abdomen is not as “tight” in the upper portion. When patients are significantly heavier there is a horizontal excess of skin in the upper abdomen that could be improved further with a vertical excision, known as a Fleur de Lis abdominoplasty. This trades a vertical scar which would be visible in a two piece bathing suit for a tighter appearance. She is pleased with her contour improvement and does not wish the additional scar in this area.
A man in his late 50’s who had a gastric sleeve performed endoscopically by the bariatric service 3 years before and reduced his weight from 385 to his present weight of 257. He is 5’9”. He was bothered by a feminine appearing chest and hanging skin
of his arms. He is shown before and again, 11 months after bilateral brachioplasty and bilateral gynecomastia excision with free nipple grafting.
Details: 210 gms of skin were excised from his right arm and 224 gms from his left are. 920 gms of breast tissue were excised from his right breast, and 918 gms from his left breast, and 400 ml of fat was aspirated from his right breast and chest, with 400 ml of fat also being aspirated from his left chest. An accurate placement and size of the new nipple is critical, and
The diameter of the nipple
was made at 25mm, and the new placement of the nipples was marked with the new nipple plane located 0.33 times the distance from the sternal notch to the pubis, and the internipple distance being 0.23 times the chest
Discussion: Studies show that the risk of infection and wound healing complications increases above a BMI of and with His BMI of 37.67 we can expect a nearly 3 fold increase in these issues. As expected, he had small areas of skin separation and infection that delayed his healing, and we can see some inconsistent healing of his free nipple grafts. Scars will typically continue to fade and improve in the arm area after brachioplasty for 3 years. Despite this he
now has a normal chest and arm contour and is comfortable wearing fitted shirts. Although gynecomastia surgery in patients with lax skin trades a visible chest scar for an improved contour, he feels comfortable now taking his shirt off
at the beach. Having a hairy chest and some slight looseness of the skin helps to camouflage the scars better.
A mother of 2 in her early 30’s who has lost 180 lbs after a gastric bypass. She is bothered by a drooping and deflated appearance of her breasts. She is shown before and again, 8 ½ months after bilateral augmentation mastopexy. She had Sientra 355 cc round textured moderate profile implants placed in a partial subpectoral position along with a “J” mastopexy on her right side and a vertical mastopexy “lollipop” incision on her left.
Texture was chosen to decrease lateral shifting of the implants and the thicker more “form stable” gel of the Sientra implant was chosen to help keep more fullness in the upper breast. Scars will typically continue to fade and improve for 2 years after surgery.