Where Did My Butt Go?

Dr. Gardner (00:00):
You go from somebody who is subconscious or consciously thinking about everything they do, what they wear. Okay, I'm going to the gym. I got to put on two spanks because otherwise I'm jiggling all over the place. It's just a transformation. So it really is like a moth to a butterfly.

Announcer (00:19):
You are listening to Alabama the Beautiful.

Kirstin (00:22):
I'm Kirstin Jarvis and I'm here with Alabama Cosmetic Surgeon, Dr. Vincent Gardner. Hey, Dr. Gardner.

Dr. Gardner (00:28):
Hey, Kirstin.

Kirstin (00:29):
You want to know what we're talking about today?

Dr. Gardner (00:31):
Absolutely.

Kirstin (00:33):
Okay. We have talked about arm lifts, thigh lifts, tummy tucks, but for a lot of people after major weight loss, the loose skin doesn't just stop at the front. You do an operation that goes all the way around to the back.

Dr. Gardner (00:48):
We do a lot of upper and lower body lifts. And so let's do the lower body lift first because most people kind of know what that is. So a lower body lift is when we combine a tummy tuck with a buttock lift. And typically when I do a buttock lift, I also do what's called an autoaugmentation. Because if we just do a buttock lift and I equate doing a buttock lift kind of a tummy tuck for the butt, meaning that we're pulling all of that loose, saggy skin, we're pulling it up. So the front and the back are different. In the front, we typically pull down with a tummy tuck, whereas in the back we pull up and it has to do with the points of attachment of the skin and soft tie to the musculoskeletal frame. And so by doing that, we're able to lift and tighten the skin of the buttocks.

(01:41):
And when we do those together, we do what's called a lower body lift. Some people call it a belt lipectomy. Technically there are some nuanced differences between those two, but we kind of, I guess, view them as the same. But that's an incision that goes all the way around the waist or at or below the belt line. And we're correcting loose skin on both the front, the tummy or the tummy tuck or the abdominoplasty, as well as the back, which is the buttock lift with the auto augmentation.

Kirstin (02:13):
Are there certain patients that benefit from splitting the procedures up versus certain patients that do better with doing it together or is it like a surgeon preference, patient preference?

Dr. Gardner (02:24):
That's a good question. There are probably some instances where it makes sense to do one separate, maybe just do the tummy tuck and then come back and do the buttock lift. I tend to like to do them together. Sometimes it depends on patient priorities, meaning that if they say, "Gosh, I really want my breast and my abdomen done at the same time," well then that's a situation where we're going to try to meet the needs of the patient prior to what I think is best. And so there are times where we will do them separately. The other thing that you have to take into account is when we do them separately, think about this, there's only so much room. So when we do a tummy tuck, if this is the front of the patient, we tend to bend the back up about 20 to 30 degrees while we're doing the tuck.

(03:14):
That means we can pull the skin a little bit tighter because we know there's going to be some relaxation of that skin. And so if we bend them up, if we've got the buttock here, that means I'm stretching or putting more tension on the buttock. And so a lot of people would argue that if you're doing the tummy and the buttock at the same time, that you're going to put more tension on the back. So when we do a tight buttock lift, what I don't want is somebody bending over because that puts a lot of stress on the incisions and could potentially cause some disruption or what we call wound dehiscence. Also, the reason I like patients to use MEFIX tape for six to eight weeks because it really reinforces the suture line and takes tension off the incision. Now, do you want to talk about the upper or do you have other questions?

Kirstin (04:08):
Go ahead and talk about the upper.

Dr. Gardner (04:10):
So the upper is when we combine a backlift with abdominal procedures. And so for instance, I have a case that I'm about to do where we're doing a circumferential upper body lift, which basically combines a backlift where again, remember on the back we pull everything up. We're going to pull the skin up and it's going to get rid of these upper back rolls that are right here. And so we do the backlift, but we continue that incision around to the front and we combine that. I combine it with what's called an open book tummy tuck. And so the incision will go all the way around underneath the breast and we're going to do essentially a fleur de lis. So it combines a regular tummy tuck, a fleur de lis tummy tuck, a reverse tummy tuck, which is where we pull skin up on the front as well as a back lift.

(04:59):
And in this particular patient, we're going to do a mastopexy or a breast lift at the same time. And that's because she doesn't really have any fat to lipo so we can spend our time just cutting out excess skin as opposed to also doing liposuction.

Kirstin (05:15):
So the first time I ever heard anything ever about an open book abdominoplasty was you speaking about it at a conference. And I came back to the office and I was like, y'all, he does this thing called an open book tummy tuck. Have y'all ever heard of this? Is this a Dr. Gardner thing or is this widely used for major weight loss patients?

Dr. Gardner (05:36):
Good question. So I heard about it several years ago and I actually kind of tracked down the guy that started doing it. He's an Australian physician and he actually trademarked open book tummy tuck. So when I gave my talk on it, because I had never seen an actual talk on it, I gave one at our yearly conference a couple of years ago and I gave him credit of course for trademarking the open book tummy tuck. But I don't think it's something that's widely done, but when you have an interest in massive weight loss, which I do, one of my favorite things to do is to remove skin after weight loss, then I think it's definitely something you want to have in your armamentarium to get rid of this extra skin. And it's really neat because you get to combine both horizontal and vertical and the vertical or the horizontal not only on the lower abdomen, but also in the upper abdomen. So it's a very powerful procedure as far as removing excess skin.

Kirstin (06:36):
Yeah, it works well. After you have a patient who has a big weight loss, how does someone know if they need a 360 body lift and not just a tummy tuck?

Dr. Gardner (06:49):
Well, a lot of patients will come in asking for the 360 or the body lift or the belt lipectomy. So some people already know. And some people, they don't see their butt and they don't try to look at it in the mirror. And so they don't really care about what they look like from the back. So I try not to make recommendations that are going to make somebody conscious of something that maybe doesn't bother them. So I never say, "Hey, why don't we do your butt at the same time?" Because they may not think that their butt looks bad. So I will make recommendations and when I'm kind of pulling on skin and trying to, I may subtly say, "Well, does anything else bother you?" So a lot of people come asking for it. Some people, when they say, "Well, gosh, what else could we do?"

(07:39):
Then I will bring it up and talk about it. But I think there's a lot of candidates. If you have drooping sagging on the backside, the buttock or the back, then you're going to be most likely a candidate for a back lift or a buttock lift. And again, I like to do an auto augmentation. I do it almost on every patient because if you pull up skin and don't do an auto augmentation or come back and do a BBL, a lot of times you're going to end up with a very flat buttocks. And most women do not want a flat buttocks. They want curves, right?

Kirstin (08:16):
Curves are cool. Okay. How stable does your weigh need to be to know before you're even a candidate for surgery? So do you want somebody who's completed their weight loss journey or can they still be actively losing a little bit of weight?

Dr. Gardner (08:31):
So when I was doing bariatric surgery, we always told patients, "You need to be stable for at least a year before you consider skin removal surgery." Now that I'm on the other side of that, I don't think you need to have a year of stability. Obviously the more stable somebody is, the better long-term they're probably going to do, but as long as you have hit what I call your nadir, meaning you've lost as much and you're at your goal weight or pretty close within 10, 15 pounds of your goal weight, then I think it's very reasonable to go ahead and have surgery. Now, I do caution people that if you gain significant weight after your procedure, you're going to have a different result. And if you lose significant weight after your procedure, you may have a different result. So let's take a breast reduction. If you do a breast reduction on a patient and they lose 50 pounds after that, they may have had a C cup after the reduction.

(09:26):
They may end up with an A cup after they lose weight. And that also depends on where people gain and lose weight because some people gain and lose it in their breasts. Others say they don't, doesn't matter what they weigh, their breasts are the same. So it's just dependent on the patient. But yeah, we don't make them wait a year like we used to. I think as long as they're stable and I think if their mindset is such that, hey, I'm in this for the long haul, then I'm comfortable doing skin removal surgery on them.

Kirstin (09:56):
For the right candidate, or somebody who is a great candidate for surgery, does it matter how they lost the weight, whether it was GLP-1s or bariatric surgery or the old-fashioned diet and exercise?

Dr. Gardner (10:09):
To me, it doesn't matter. There probably are some nuances. I think the slower you lose the weight, the more likely you are going to have some good skin retraction. But again, that's not even a given because people have stretch marks. And as we know, stretch marks are where we actually tear the dermis. And so that's a long-term problem that is best served by trying to cut out those stretch marks. But to me, it doesn't matter how they lose it. I think consistency and as long as they're getting adequate protein intake, that's the key because if they're not getting adequate protein intake, that's when they're going to have problems with wound healing. So that concerns me more than anything. So somebody that has lost weight, and there are a lot of people that do it as a combination, meaning that diet and exercise, they've had either a Roux-en-Y or a sleeve gastrectomy and they hit their wall and then they said, okay, then I started on GLP-1s and I lost another 50 pounds and now I'm at my goal weight.

(11:13):
So to me, it doesn't matter. I do think that the protein intake is super important and I like for people to get 90 to 100 grams of protein daily post-op to make sure they can heal their wounds. And I've had a few patients over the years where their wounds have literally popped open and on further investigation found that they're not eating protein. And again, you're not going to heal your wounds long-term as well if you don't have good protein intake.

Kirstin (11:44):
Along those same lines with recovery, let's talk about the recovery from a body lift. We know like you do, tummy tucks, arm lifts, thighlifts, things like that. This is to me a lot bigger operation. Would you agree the recovery's a little bit more intense in something like this?

Dr. Gardner (12:01):
Yeah, it is a bigger operation. I don't know that the recovery's more intense. I mean, I think that really depends on the patient. So many of these patients do really, really well because they're just so motivated. They've spent years getting their weigh off. And so most of these patients that are going to have these type of operations are super motivated. They're going to do whatever and they're so excited to see their new shape that most of them will follow the rules. We have some great post-op pain medicines now in the Journavx, which is the new one that we use. We don't obviously make anything from it, but it's a great product, so I talk about it. And it is a non-narcotic pain medicine that has really transformed I think our post-op recovery. Now we haven't been using it for a long period, but in the short term it's really helped. And I think that is a significant change for post-op pain, and I think patients are really appreciating it.

Kirstin (12:58):
Sometimes we talk about recovery in when do I look good? When do I feel good? When can I get back to doing things? So after somebody has something like a 360 body lift, upper body lift, when would you say they could get back to their normal lives?

Dr. Gardner (13:13):
So I think the key is whether or not we do an abdominal wall muscle repair. If we do a diastasis repair, then I'm not going to let them do any heavy lifting, straining, vigorous activity for six weeks. And the reason is we want that to really scar in because if we don't, we're just relying on sutures and sutures can break and you can get some dehiscence of that repair, which means that the wound may still be intact, meaning the incision's intact, but the muscles are starting to pull apart. But if we give it typically six weeks as a minimum, most patients will have scarred in sufficiently to the point where they're not going to be able to pop that open. And I always tell them when they start back in the gym, start off slow. Don't go try to lift the gym the first day.

(13:58):
And if they'll work their way back up, most patients do really well. And as far as that goes now, submersion, if they have implants, six weeks. We don't want to risk getting an implant infected. And otherwise, I don't like for anybody to get submerged unless we know their incisions are completely healed, meaning no scabbing, no crusting, completely healed before they submerge. And so typically that's probably going to be three or four weeks.

Kirstin (14:25):
Okay. What are the trade-offs for this type of surgery that people need to go in knowing? We talked a little bit about scars. Are there drains? Are there other compression or anything like that that they need to know about?

Dr. Gardner (14:38):
So typically, well, yes, they're going to be scars and they can have quite a few scars, but in my experience, patients that have lost significant weight are very accepting of scars if they get the shape that they want. So when they get rid of that skin and they get a much better shape, they tend to make peace with the scars. The other thing is we hadn't talked about is we can do a lot with scarring post-op. Now, if they do taping and compression for that six to eight week period, their scars are going to look much better. But say they'd get a scar that didn't quite heal the way we wanted to. One, we can always come back and revise it. Well, that is a procedure where we cut it out and start over. The other side of that is we have lasers, we have IPL, all sorts of lasers and lights that we can treat these scars with to try to get improvement.

(15:27):
And so a lot of times scarring can be a minor issue on the back end if you've done the things, again, if you've done the homework and you've put in the time working on scar gels, taping, compression, your risk for scarring is going to be less. And then if there is scarring that you don't want, we can mitigate that with lasers, lights and potential minor revisions if we need to.

Kirstin (15:55):
So let's talk about the payoff. We've done the surgery, we've gone through the recovery, we fixed our scars. For somebody who's been living inside of their leftover skin after weight loss, how does their life change day-to-day?

Dr. Gardner (16:10):
It can be a phenomenal difference. Again, we say life-changing and I think it really can be because you go from somebody who is subconscious or consciously thinking about everything they do, what they wear. Okay, I'm going to the gym. I got to put on two spanks because otherwise I'm jiggling all over the place. It's just a transformation. So it really is like a moth to a butterfly and patients are just different. And I've had so many, and even if the patient won't tell me, I had one lady went to the restroom and her husband was sitting there and he just looked at me and said, "Gosh, you have no idea how different she is now because she just is so much more outgoing. She draws attention to herself, which she never would've done before because she was so self-conscious about the extra skin. So these are my favorite patients and that's why because they're just happy.

(17:05):
They're happier. And even if they have some minor scar issues or whatever, they're still much happier and just grateful to be on the other side of things. So yeah, love these patients.

Kirstin (17:18):
How do results hold up over the years?

Dr. Gardner (17:22):
Very well. Now the problem, and I tell everybody this, the problem that we have is they have different skin. When you have stretched out skin, you have different skin. And that's the biggest concern. And one of the for instances is when we do a tummy tuck, we pull them really tight. Like I said, we bend the table up, pull as much as we can, and they're super tight on the table. Sometimes within even months, some of that skin loosens up a little bit. Now, they still look fantastic when they're standing, but when they bend over, guess what? They may have some laxity in that abdominal wall skin. Has nothing to do with the surgery. It has everything to do with their skin quality. The fact that they have no elasticity and their collagen is shot means that they're just going to have some loose skin.

(18:10):
And that frustrates people because they're like, "Well, I look great when I'm standing, but when I bend over or I'm sitting down, I've got this little pooch." And I'm like, "Well, first off, we all have that." And then my example is your elbow. You have loose skin. I have loose skin on my elbow. Well, guess what? When I bend my arm, there's no loose skin. But when I straighten it up, there's loose skin. And that's the same concept with your abdomen. You have to have some loose skin because otherwise you wouldn't be able to stand back up if it was tight. But it does make a difference in elastin collagen, those are the keys. And so unfortunately you just have different skin when you've lost weight. Same thing with pregnancy. If it's been stretched out, it's been stretched out.

Kirstin (18:54):
These kids. Okay. Is there one specific thing that you would tell someone, maybe something you want somebody to understand before they commit to a body lift?

Dr. Gardner (19:07):
Just prepare to be happy. I mean, again, that's kind of funny, but what I mean by that is I think that it's one of the best decisions that patients can make because it's not necessarily, yes, it's about removing the skin, but it's ultimately about improving their self-esteem. And when we feel good, we express that every way. We smile more, we're happier because we have confidence and we feel good. And if you can gain that or give that to somebody by just removing excess skin, it's a beautiful thing. I mean, yeah, they're going to have some scars, but like I said, their self-confidence goes up. And that's the main reason we do what we do is patients just feel better after the procedures, whether it's a facelift by Dr. Kohler or a body lift, breast lift, whatever it is, our goal is to improve your self-confidence and make you feel better about yourself.

Kirstin (20:05):
I love it. All right. Do you have a burning question for Dr. Koehler or Dr. Gardner or me? You can leave us a voicemail on our podcast website at alabamathebeautifulpodcast.com. We'd love to hear from you. Thanks, Dr. Gardner.

Dr. Gardner (20:19):
Thanks, Kirstin.

Kirstin (20:20):
Go back to making Alabama Beautiful.

Announcer (20:25):
Got a question? Leave us a voicemail at alabamathebeautifulpodcast.com. To learn more about Eastern Shore Cosmetic Surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama The Beautiful on YouTube, Apple Podcasts, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram @easternshorecosmeticsurgery. Alabama the Beautiful is a production of The Axis, T-H-E-A-X-I-S.io.