Pittsburgh-based Dennis Hurwitz, MD, FACS, draws international focus on his innovative procedure

Soon after People magazine’s Nov. 17, 2003, issue hit newsstands and landed in subscriber mailboxes, phone lines at the Hurwitz Center for Plastic Surgery in Pittsburgh all but melted as callers swamped the switchboard. The reason: They’d just read People’s cover story describing a relatively new body-sculpting procedure developed by center owner Dennis J. Hurwitz, MD, FACS, to transform former fatties into svelte stunners by means of a single, cost-effective operation.

People wasn’t the only nationwide media outlet to showcase Hurwitz’s groundbreaking procedure. There were reports in other prestigious publications, along with guest appearances on a slew of television programs, including Montel and Inside Edition.”

However, his surgical innovation might have generated scant notice outside medical circles were it not for his decision to retain a New York City-based public relations agency to promote it nationwide.

“It’s not a common practice among plastic surgeons to retain advertising, publicity, and marketing consultants, but I think it’s something more of us are going to have to do to stand out from the competition and be able to help consumers make better-educated choices,” he contends. “It used to be that word of mouth was all you needed. If you did good work, your satisfied patients would tell their family and friends, then word would get around, and new patients would seek you out.”

Hurwitz believes word of mouth in bygone days was effective because consumers tended not to invest the time and energy needed to research the providers and become educated about what it took to deliver a good result. Now, however, Internet-equipped and sophisticated-thinking consumers do that and more—as a matter of routine.

That’s what convinced Hurwitz to retain a PR agency. He says he pays the firm and others like it between 5% and 10% of his annual gross revenues for publicity, advertising, and additional forms of external marketing.

“It’s an investment that’s paid huge dividends,” he says, noting he also has a book coming out this spring called Total Body Lift.

Academic Orientation

Cosmetic procedures make up the bulk of Hurwitz’s practice today. On the reconstructive side, he sees a relatively sizable share of cleft-lip and cleft-palate cases. It’s understandable, in light of his former position as head of the craniofacial center at the University of Pittsburgh, where he performed his plastic surgery residency training back in the mid-1970s; he has been a member of the teaching staff there ever since.

Interestingly, Hurwitz’s continuing involvement with reconstructive plastic surgery proves to be a strong selling point in the eyes of prospective cosmetic surgery patients. Many of them find it reassuring that Hurwitz is a top reconstructive physician with an ongoing university connection. The opposite also holds true: His reconstructive patients take comfort in knowing that he has a reputation for excellence in cosmetic work.

“Both sides of my practice support each other in terms of the marketing message,” Hurwitz says, adding that he’s not bashful about letting his patients know that his extensive and cutting-edge reconstructive skills make him a better cosmetic plastic surgeon, and vice versa.

The career of Baltimore-bred Hurwitz—a University of Maryland Medical School graduate who interned at Yale–New Haven Hospital—began in academia. It wasn’t until 6 years later, in 1983, that he entered private practice. In 1996, he returned to full-time academic practice to help establish a cosmetic surgery center at the University of Pittsburgh. He again entered the private sphere in 2000, but he continued his relationship with the University of Pittsburgh as a clinical professor of plastic surgery.

In his role as teacher, Hurwitz brings to the classroom a perspective intended to help his students and residents accomplish great things in relatively short order.

“I try to instill in them the notion that they need to find an avenue that will allow them to be the very best they can be as plastic surgeons,” he says. “For me, that avenue is the stimulus of being involved on a daily basis in academic medicine.”

Long Procedure

The most challenging cases Hurwitz sees these days are those involving contouring of patients who’ve experienced massive weight loss. Common among such individuals is the presence of rolls of loose, sagging skin just about everywhere from the collar bone to the knees, but particularly in the region of the abdomen, buttocks, and thighs. To address this condition, Hurwitz developed a procedure he calls The Total Body Lift (TBL). It consists of a circumferential abdominoplasty, a lower-body lift, an inner-thigh lift, a reverse abdominoplasty, a backroll removal, and a breast reshaping. All are performed in a single surgical session that takes as little as 7 hours to complete (although 9 hours is more the norm).

“It’s a long procedure, but because it’s so mentally stimulating, the time seems to fly,” he says. Throughout the TBL surgery, Hurwitz handles just the cutting, liposuctioning and repositioning; assistants perform most of the suturing. It’s a lot more efficient that way, he says.

“As soon as I’m finished with one section of the body, the assistants step in and close up, while I move on to the next section, and so on until the entire procedure is completed,” Hurwitz explains. “Since suturing is the most time-intensive part of the surgery, it expedites matters to have that task performed by assistants so that I can concentrate on the most critical elements.”

The amount of time required to complete a TBL is the reason Hurwitz schedules only one a day and—with the occasional exception of a simple breast augmentation or tummy tuck as a warm-up—nothing more.

“That’s all I can physically endure,” he says. Hurwitz thinks the procedure could be shortened to perhaps no longer than 6 hours. That, however, will require his team to develop a steadier rhythm as they work.

“If we get to the point where we’re not waiting for suture material, not waiting for instruments, we can trim some minutes off our time,” he postulates.

Comprehensive Approach

Hurwitz began developing the TBL procedure in 1998 in response to pleas from referring physicians and patients. At the time, the then-lead bariatric surgeon at the University of Pittsburgh announced plans to make stomach bypass surgery—forgive the pun—staple of his practice. Accordingly, he advised Hurwitz to expect from him many referrals of patients with severely sagging skin.

In gearing up to accept postop erative stomach-bypass patients, Hurwitz found that the cosmetic techniques available to help the formerly obese were limited in scope and largely ineffective. The most glaring deficiency, in his estimation, was the patient’s need to undergo multiple surgeries over a period of 18–36 months.

“These patients want a good result, but they don’t want to go through a protracted ordeal to achieve it,” Hurwitz contends. “Multiple surgeries are disruptive to their lives—they have to put their careers and relationships on hold, which is unfair. They also pile up a lot of extra expense by having to undergo multiple surgeries.”

Hurwitz says it occurred to him that a comprehensive approach would be just the ticket for rectifying the shortcomings of traditional surgical strategies. Drawing on his training in craniofacial surgery, he came up with the protocols for the TBL.

“Craniofacial surgery is an organized approach to dealing with complex and multiple deformities, from the top of the skull to the neck, in a risky, highly technically difficult single operative session,” he says. “It entails lengthy operations that require an extraordinary amount of planning involving different disciplines. The techniques of craniofacial surgery provided a clear view of what needed to be done in the development of the TBL procedure.”

Favorite Instruments

Necessary first and foremost for successful TBL surgery is an intimate familiarity with the operating room and its support staff, Hurwitz reveals. Accordingly, he performs the procedure in one—and only one—hospital.

“The support staff  knows what I want,” he says. “And that gives me the comfort level I need to proceed efficiently.”

Depending on the patient, Hurwtiz might undertake TBL liposuction with conventional power-assisted instruments or by means of ultrasound emulsification. He also likes to use several sizes of vertical underminer to help release tissues down the length of the thigh.

“I always try to select the approach that’s going to be the most gentle to minimize trauma while optimizing prospects for the preservation of connective tissue elements and vasculature,” he says.

To aspirate the released fatty tissues, he prefers a vented cannula system of Vaser® LipoSelection™ because of its reputation for gentleness. His second choice is a Tulip® syringe system.

As for the incisions, “I strongly believe that they should be made with cold steel rather than electrocautery,” he says. “I have access to electrocautery and occasionally use it in other cases. But in this type of surgery, a major principle is closing tissues under high tension to promote optimal healing. That’s difficult to achieve if the tissues you’re working with are burnt.”

Hurwitz prefers to close with deep permanent sutures in sizes 0 and 1. He likes to use absorbent sutures in the dermis.

A concern with the TBL procedure is that its longer on-table time increases the risk of post-surgery complications; these include infection and thrombophlebitis. Hurwitz’s desire to minimize this risk is what drives his quest for a shorter OR session through further improvements in workflow efficiency. He also strives to minimize this risk by limiting the patients he accepts for surgery to those least likely to experience complications: generally, adults under the age of 40 and weighing no more than 200 pounds.

So far, his risk-management strategies appear to be working. An outcomes analysis Hurwitz published in 2004 showed that the incidence of complications among his single-stage TBL patients were no greater than those among any multistage patient he saw during that same time period. Specifically, none of his TBL patients had to be readmitted to the hospital because of complications (although, on average, they received one extra unit of blood transfusion).

Looking ahead, Hurwitz expects that the TBL procedure will become less unusual as other plastic surgeons adopt it in response to consumer demand.

Meanwhile, he’s working closely with his hospital to establish a center of plastic surgery excellence. The goal of such a venture would be to better prepare TBL patients for surgery through nutritional and educational services, then provide them a place to stay for several weeks after the surgery so they can have direct access to physical therapy, lymphatic drainage, therapeutic massage, and other interventions aimed at helping to improve outcomes, reduce pain, and speed healing.

“My interest is to better serve the patients,” Hurwitz says. “That’s what I’ve tried to do from my very first day in practice. I think any plastic surgeon who makes serving patients his or her primary consideration is going to have the necessary foundation for a very successful practice.” n

Rich Smith is a contributing writer for Plastic Surgery Products.

Critical Maneuver

Pittsburgh-based plastic surgeon Dennis J. Hurwitz, MD, FACS—who developed the Total Body Lift—claims that this procedure is currently the only workable strategy for simultaneously changing the appearance of the upper and lower abdomen, the inner and outer thighs, the buttocks, the upper back, and the breasts.

The comprehensive, single-stage procedure begins with the patient lying stomach-down on the operating table. A large segment of skin above the buttocks, up to the mid-back and along the thighs, is removed to bring up the lower body. Later, skin is removed from the upper back, Hurwitz says.

A critical maneuver involves turning the still-anesthetized patient so that skin removal from the thighs can continue. This removal extends to the abdomen, thereby rendering a circumferential abdominoplasty, he explains.

At this point, the upper abdomen is advanced and positioned into its new location under the breast. (Incisions are made under the breast to conceal the scar.)

While the patient continues to be supine, the sagging skin above the genitalia is smoothed and contoured. Finally, the breasts are reshaped.

Anywhere from 10­–30 pounds of excess skin are purged in the course of the operation, Hurwitz notes. At the conclusion of the 7- to 9-hour surgery, the patient remains hospitalized and is discharged 24–72 hours later. At home, bed rest with brief walks and calf message is ordered for the first 3 days, after which time light activity can be gradually reintroduced. After 4–6 weeks, the patient may resume normal daily activities. While healing, however, the patient must wear elastic support garments to protect the incision sites and ensure proper recovery.