The ABCs of Abdominoplasty

Keri Stephens:

Hello, and welcome to the Plastic Surgery Practice podcast on the MEDQOR podcast network. I’m Keri Stephens, and I’m joined by my co-host Alison Werner. We’re the co-chief editors of Plastic Surgery Practice. Today, we are excited to have Dr. Alex Zuriarrain back with us to discuss one of the most common cosmetic procedures, abdominoplasty, Dr. Zuriarrain is a founder of Zuri Plastic Surgery in Miami, where he specializes in aesthetic procedures of the face and body, including facelift, eyelid surgery, rhinoplasty, breast augmentation/reduction, abdominoplasty, liposuction, and the Brazilian butt lift.

Keri Stephens:

Dr. Z, thank you so much for joining us. In a previous episode, we spoke to you about the Brazilian butt lift, focusing on the need for better communication with patients about the risks associated with BBL procedures and how you’re using ultrasound technology to improve patient safety. Like I said, today, we’re going to focus on abdominoplasty. You wrote an article for the website titled, From the Battlefield to OR, Abdominoplasty Is Still In Evolution. And we wanted to get a bit more in depth about this conversation around the topic. You mentioned in the article, abdominoplasty had become the fourth most common cosmetic procedure in the US by 2019, with more than 140,000 operations performed this year. So from what we know, what are the most common reasons patients are seeking out this procedure? And what are you hearing in your practice?

Dr Alex Zuriarrain:

Yeah, abdominoplasty is a very, very significant part of my practice. I have a lot of patients coming, pretty much from all walks of life, that are interested in improving the abdominal contour that they currently have. They’re not satisfied with the shape that they have. They feel sometimes very square, very boxy. Or they’re having a lot of abdominal protuberance, either from history of massive weight gain, massive weight loss, or multiple pregnancies that really bring them into my practice, looking to better themselves, looking to feel better about how they look, how they feel. And so that’s why I think it’s really become such a popular operation.

Alison Werner:

Well, you talk about how the procedure has advanced since its inception to treat truncal wounds in World War II, but you write that the technique still falls short of perfection. So where is it falling short at this point?

Dr Alex Zuriarrain:

Yes, I think since that World War II era, where we were using these procedures really for life threatening injuries or reconstructive efforts, it became a cosmetic operation that became pretty standard in its technique and its approach. But we’ve all been trying as plastic surgeons to up the ante, to push the ball forward when it comes to what kind of cosmetic result we can get that doesn’t leave the stigmata of any scarring, that doesn’t leave any evidence behind that you’ve been there as a surgeon, that you’ve made an incision, that you’ve done all of these techniques to improve the appearance.

Dr Alex Zuriarrain:

We’ve got a lot of work to do still, I believe, in trying to advance some of the technologies that we’re using to do this procedure, in particular suture materials, the addition of liposuction, the addition of other radiofrequency devices that I’m now using in my practice to enhance tissue contraction, for example. We’re doing more high definition abdominoplasty now than ever before. And really, the suturing techniques have really improved, and the quality of the scars and the overall results have changed dramatically in the last 30 to 40 years.

Alison Werner:

Okay. And so when you talk about high definition abdominoplasty, what does that mean? What does that look like?

Dr Alex Zuriarrain:

It’s a combination of liposuction with abdominoplasty and now, now more than ever, the addition of radiofrequency skin tightening modalities that have come onto the scene probably in the last five to six years, where we’ve been able to use these technologies to provide more enhanced definition. One of the biggest problems with abdominoplasty in general is if you went 30 years ago and looked at the before and after photos in the archives of plastic surgery, you would see abdomens that looked very flat. There was no contour to them. There was no central contour, no oblique contour. Yeah, you would get rid of all of the extra skin, and that was a huge improvement and a huge leap forward. But you could really tell somebody who had a tummy tuck done versus someone who didn’t because the result wasn’t natural. And so now what we’re doing is we’re pushing the envelope and really making these abdominoplasties look extremely natural, with very good definition. And the South Americans really pushed this concept of adding liposuction to the abdominoplasty procedure, in Brazil, Argentina, in South America basically, where they’ve really helped us as American plastic surgeons, really refine our techniques.

Alison Werner:

Okay. So that’s liposuction abdominoplasty. I know another technique that you mentioned in the article was combining monsplasty and abdominoplasty. How does that come together?

Dr Alex Zuriarrain:

Yeah. So the mons is an area difficult to treat for any plastic surgeon, depending on the amount of skin laxity that the patient has. These are predominantly in patients that have lost a significant amount of weight. We’re talking about more than 50 pounds of weight loss, where there’s a lot of skin sagging, and the mons area is an area where a lot of this extra skin accumulates. And for a lot of women, their concern is, well, you do this beautiful abdominoplasty, and then you have a very heavy mons. You have a very thick mons that if they wear the yoga pants that all the women like to wear nowadays, that they’re not going to have the kind of cosmetic result that they’re going to be comfortable walking around Whole Foods Market with their yoga pants on. So that’s an area that we’ve done a lot of improvement on, to liposuction those areas, to pull the skin tighter, to do techniques to fixate the mons pubis to the abdominal wall to prevent it from sagging after the abdominoplasty. And patients are very appreciative of that because their results are superb.

Keri Stephens:

Yeah, that makes sense. And one of the points you make in the article that really struck me was that while most people requesting abdominoplasty do so for cosmetic reasons, whether that’s to enhance their appearance or self-esteem, abdominoplasty with muscle repair for people who have recently given birth can go a long way to prevent future health problems. What kind of health problems are you talking about?

Dr Alex Zuriarrain:

Yeah. Abdominoplasty has both a cosmetic and a health benefit. We’re talking about health benefits regarding decreasing the amount of adipose tissue that a patient has overall. This is what we call parasitic fat. It’s a literal term in medicine called parasitic fat. And I think it’s a great description of what this fat is doing to the human body when it’s just sitting there, and it has no purpose whatsoever. It’s flacid tissue. It increases your chances of diabetes. It can increase your chance of heart disease. Your body is having, and especially, specifically your heart is having to pump at an increased rate in order to perfuse or to oxygenate all of this fat that is really just hanging there and not doing anything for you. So beyond the cosmetic benefits of abdominoplasty, there are huge, huge health benefits that I think a lot of patients don’t know about.

Dr Alex Zuriarrain:

And you see these, again, in the massive weight loss patients where we do a procedure called a panniculectomy, which is very different from an abdominoplasty, whereby in a panniculectomy, we basically just cut off a huge piece of tissue, but there’s no cosmetic intent. It’s basically completely functional in its purpose. It’s to rid the patient of basically bad skin eruptions, rashes, skin breakdown in the mons pubis area. And it’s strictly just for functional purposes. But the abdominoplasty goes much further than that in regards to its cosmetic goals.

Keri Stephens:

That’s interesting. And now, for those looking for less invasive options to treat the abdominal area, what are the options that have the best outcomes?

Dr Alex Zuriarrain:

Well, this is the crossroads that all plastic surgeons and non-plastic surgeons who evaluate patients for cosmetic procedures, this is what they need to understand. You cannot do enough exercise to get rid of loose skin. That is never going to happen. So if you go to somebody, some medical professional, some healthcare practitioner who tells you, “Just go ahead and exercise. I want you to go to the gym, and I want you to be on a strict diet plan,” call it whatever you want, intermittent fasting or keto diet or whatever you want to do. Skin is skin. Skin does not respond to exercise. That is putting your patient on a very unfortunate and very frustrating path to no result in terms of their abdominal shape, abdominal contour and their skin laxity. Those patients, if they have enough skin laxity, they need a tummy tuck. That needs to come off.

Dr Alex Zuriarrain:

There’s no cool sculpting in the world, there’s no external radiofrequency devices, there’s no cavitation, there’s no fancy massages, there is no hocus-pocus that’s going to get rid of loose and flaccid skin. And I think a lot of people are afraid to say that. I think a lot of plastic surgeons don’t want to say it frankly and honestly because they don’t want to scare patients away from their med spas, where they’re doing a lot of other procedures that are “helping with this problem,” but we all know it’s not going to work.

Dr Alex Zuriarrain:

So now, the contrary is there are patients that are on the fence. There are patients that they have some skin laxity, but they don’t have a ton that would warrant a tummy tuck. In those examples, you have liposuction with the addition of radiofrequency devices for tissue contraction that can be of benefit. But honestly, Keri and Alison, there are no non-surgical options that are worth skin tightening. There’s nothing out there. I haven’t seen anything that is worth it.

Alison Werner:

Yeah. And you mentioned in the article radiofrequency. How does that play into it?

Dr Alex Zuriarrain:

Yeah. Let’s say that you’re on the fence. Let’s say maybe you had one pregnancy, and you just have a very small amount of skin right above the mons pubis. And you could get a little pinch out of it, but maybe it’s not that much. But you’re just not happy with it. You don’t like it. You don’t feel comfortable wearing a bikini. So nowadays, instead of just, “Hey, let’s try to do some liposuction and put you in a compression garment for three months and do some massages and hope and pray that your skin is going to retract and it’s going to look smooth and flat,” we can now use internal radiofrequency device that you do at the time of surgery.

Dr Alex Zuriarrain:

It enters the same exact port that you use to do the liposuction, that you pass your liposuction cannula through. It’s a one time treatment. And it’s very effective because it’s getting underneath the skin, and you can turn that machine on and get some decent tissue contraction out of it. Now, is it going to make everything perfectly flat? No, it’s not. Is this magic? No, it’s not. But it could be great for certain patients that don’t need a tummy tuck.

Alison Werner:

Right.

Keri Stephens:

Right.

Alison Werner:

Well, you also mentioned ultrasound. Is that kind of falling in the same parameters there for its use?

Dr Alex Zuriarrain:

Yeah. Yeah. There are ultrasonic devices as well. There are laser devices as well. They all have their pros, their cons. Radiofrequency is great because the degree of heat that’s produced is typically not in the degrees that would cause a burn, a tissue burn, which can in some cases lead to pretty bad complications, if you could imagine a burn after lipo. So we want to use devices that we know are going to cause improvements, but are not going to cause complications. And so the FDA is good at that. The FDA in the United States is very good at monitoring these technologies, keeping a close eye on them, looking at their statistics, looking at their complications. And they’re happy to pull these devices off the market in a heartbeat if there’s a trend for negative results.

Alison Werner:

Okay. What are some of the other important trends in abdominoplasty that really stand out to you today and in your practice?

Dr Alex Zuriarrain:

Yeah. A lot of it has to do with muscle plication and whether or not to fix the muscles or to bring the muscles together is done in every surgery, every tummy tuck. Is it only done in particular tummy tucks? And in my practice, I’ve really found that doing a muscle plication is extremely important, even for the patients that only have minimal muscular separation. They get much better cosmetic results. And what you use in order to repair these muscles has also come a long way. There used to be techniques of individual suture placement with permanent sutures. And now there’s a trend towards sutures that take a very long time to reabsorb, but they do eventually disappear and you don’t have any foreign body left behind, which is very nice. They’re extremely strong and durable, and they provide great results.

Dr Alex Zuriarrain:

But you take a poll of different plastic surgeons, not only in this country, but across the world, and you’re going to get a lot of different techniques on how some surgeons do their belly buttons. What suture material do they use? There are a lot of claims to fame, like the Beverly Hills belly button or the Miami belly button. Everybody thinks they’re a belly button expert. And so yeah, that is a part of abdominoplasty that is always evolving, that certain doctors, plastic surgeons are always pushing that envelope because everybody wants a very natural umbilicus. They want a belly button that has no scar around the outside, that you cannot perceive that the person had a tummy tuck. And so I think that’s … Part of the conversation that we had at the beginning was what are the advances, and that continues to evolve every day.

Alison Werner:

Okay. With all that being said, what really excites you when it comes to performing abdominoplasty procedures in your practice? What has happened in the last decade or five years that has really stood out to you?

Dr Alex Zuriarrain:

I just think it’s the ability to produce results where people can’t always tell whether the tummy tuck was done or not. And I think to me, that’s the greatest compliment is when I have a patient come back and tell me, “Hey, I had this surgery, and nobody’s gawking or looking at me to see if they can see a belly button scar, or they’re not looking at me strange. None of my family members have really given me any negative feedback at all. Everybody thinks it looks so natural. And the incisions are so thin and clean, and the scar placement is so low, and I can hide it under my bikini.”

Dr Alex Zuriarrain:

That’s what excites me the most, especially for patients that have had a huge journey regarding gastric bypass surgery and they’ve lost 100 pounds. You do a circumferential abdominoplasty on them, and the results are intense. They’re amazing. They really, really change. And they’re so grateful. Before I got on the podcast, I had a patient that just came in for a followup from last week. And she was in tears of how grateful she was for her transformation. And most of my patients say, “I wish I would’ve met you 10 years ago because I would’ve done this a long time ago.” But it takes a lot of courage to get it done.

Alison Werner:

Absolutely.

Keri Stephens:

No, I think that’s great. Actually, one of my neighbors, I just found out had a tummy tuck. She had the mommy makeover. And I have to say, she looks incredible. So whatever y’all are doing is working, for sure. Just as a last question, what advancements do you have your eye on when it comes to this procedure?

Dr Alex Zuriarrain:

Yeah. I think we still need a lot more work on the tissue contraction technologies. I think they’re really in their infancy right now. There’s a lot to learn about how to improve tissue contraction, how to get more reliable results, in my opinion, more universal application for them. And then again, at the same time, just keeping in mind that when you start pushing the envelope, like in anything you do in medicine or in science, you have to be careful the speed in which you try to make these advances because there will be complications along the way. So I do think we need a lot more long-term studies related to these devices to really strategize and tailor the technologies to get us where we need to go in that realm.

Dr Alex Zuriarrain:

The suture materials, I still also think need a lot of evolution. They have come a long way since World War II, but they still have a long way to go in my opinion. And yeah, I think that’s where we’re at. That’s where we’re at nowadays. We also need better weight loss modalities, I think as well for people. People have a really hard time losing weight, and body mass index and this surgery go hand in hand.

Keri Stephens:

Really? Okay.

Dr Alex Zuriarrain:

They’re very closely related because we know that obese patients, they’re not going to have the same type of cosmetic result. They’re going to have more visceral fat content. They’re going to have more complications. They’re going to have more infections, more blood clots. And we need a better way to get better weight loss done safely.

Keri Stephens:

No, that’s interesting. Okay. Dr. Zuriarrain, thank you so much for joining us again and for your interests into trends in abdominoplasty. And to our listeners, be sure to check out Dr. Zuriarrain’s article on the Plastic Surgery Practice website. Until next time, be sure to subscribe the MEDQOR podcast network to be alerted to future episodes. And to keep up with the latest plastic surgery industry news, visit plasticsurgerypractice.com. Until next time, take care.