Some Notes in Regard to Tummy Tuck Surgery

Tummy tuck, or abdominoplasty, is a surgery that has some pluses and some minuses. When compared to liposuction, on the plus side there is a tightness of the front of the tummy skin, and the surgeon is able to sometimes tighten the muscles underneath. After pregnancy, these muscles pull apart in a fashion that is sort of like felt. Felt would not shrink back or “rubber band” back into its original state, but instead stays loose. When the tummy tuck is performed, the muscles in the middle of the “six pack” can be laced together with permanent sutures, and therefore the pulled-apart middle can sometimes be repaired. On the other hand, if there is a great deal of fat underneath the muscle surrounding the stomach and other internal organs, it doesn’t work very well because it’s sort of like suturing a drum head.

The downsides of tummy tuck are as follows:

1. It’s quite a dangerous operation compared to anything else in cosmetic surgery. The fatality rate (death rate) is approximately 1 in 3000.

2. You end up with a huge (about two-and-a-half-feet long) scar.

3. The belly buttons postsurgery are often a bit unnatural or very unnatural looking.

4. Liposuction at the same time is not usually regarded as safe. The reason for this is that the blood vessels that supply the area of the abdominal skin that’s to be pulled town to meet the pubic bone can be easily compromised by liposuction, and so liposuction is usually done on another occasion many months separated from the tummy tuck.

5. Liposuction if done instead of the tummy tuck can often produce a great deal of skin shrinkage and a very satisfactory result, and a recovery which is very, very minimal compared to a tummy tuck, which generally has a painful and prolonged recovery.

Remember when thinking about your alternatives between tummy tuck and liposuction it’s not a clear “yes” and “no” answer in most cases. Tummy tucks are not for everyone, because of the risks, deformity of the scarring, and other factors. Think carefully about these issues, and although the risks associated with liposuction are modest, they are still a factor too. Use your best judgment and your doctor’s advice in regard to these issues.

Liposuction Revolution!

Sushi dinner in Hawaii

Did you know that finally there is a new machine that helps liposuction surgery? We have tried almost every single new device (laser, Vaser, “Smart” Lipo, etc. etc) over the years, and they have provided minimal improvements at best. They just weren’t worth buying because they didn’t work. Since our experience extends over almost 20 years and 10,000 cases we knew they didn’t work.

Now, we have the new Power X® liposuction machine. It is a refinement of a patented design that has been around for almost a decade. The old machine broke down, and worked just a little, but the new one has been completely re-engineered by a new company and we bought one the first day we tried it. I do not spend money on devices that don’t work. Every fool and his mother is trying to sell me something because they believe we are a gold mine and foolish enough to buy any type of medical device.

This thing safely speeds the procedure up. We think we are spending 1/3 less time on liposuction; in other words, you need half the medication you would have used with the manual systems. Anesthesia medications are the most dangerous thing in the operating room, as they have the potential to cause you not only discomfort post operatively, but problems during surgery, sometimes serious ones. We have to watch carefully during the procedure to be sure you don’t get too much medication.

An additional benefit: we think it helps prevent some of the irregularities in skin quality that inevitably occur after some liposuction procedures. AND we have seen no more complications or problems post operatively than we had before.

Don’t be fooled: our experience still means a lot. Surgeons can’t start out and get great results because they have this machine. We still need all our expertise. But we think this device will improve our results, your postoperative experience, and our overall safety.

Call our office today to see how you can benefit from the LIPOSUCTION REVOLUTION!

Everything You Wanted to Know About Breast Implants but Were Afraid or Ashamed to Ask

Seattle Port at Night

Did you know that the most important factor in predicting your result with breast implants is the type of breasts you have before the surgery? I always check the breasts and make sure that we don’t have an unusual problem. Some breasts are very, very saggy and need a lift before doing implants. It used to be that the surgeons generally performed the lift and the implant at the same time, but opinion is shifting on this issue because the complications are so high if these two procedures are performed together. All kinds of problems, including nipple areolar area skin death, occur. And the general opinion now is that it’s better to do a lift in one procedure and wait four to five months before inserting an implant, if necessary.

Other breasts are different than the “standard model.” Some breasts are long and skinny, and these breasts deserve special treatment before performing the implant. Sometimes they need a reduction. Sometimes they need a procedure that makes them look more like normal breasts before doing the implant.

Another problem is the question of a person with slightly saggy breasts who might not want scars on her breasts. In this case, we offer a lift first, but many of these individuals like a fairly large implant, and this will lift the nipple to some degree. They accept a somewhat more “natural” look, which is a little bit saggy, rather than having scars on their breasts. We frequently insert these through the armpit, through an incision which for saline implants is only about an inch long or less.

There are many breast augmentations that are performed above the muscle and many that are performed below the muscle. The theory about the above-the-muscle implant is that it produces a smoother upper curve of the breast. However, if you have rather reasonably full breasts that aren’t too saggy, an over-the-muscle implant is much easier recovery process and produces a very predictable result in our hands. Additionally, below-the-muscle implants over the long term may produce several undesirable effects. These include the breast falling off of an implant that is riding high under the muscle, and while this is acceptable in some cases, in others it’s not. A second complication which is very common is over the two to three years after getting your implants below the muscle, the activity of the muscle pushes the implant down and out. So the implants become saggy sooner rather than later.

We always recommend good bras for our breast implant patients, and in particular, we like Bali brand “Minimizer” bras, which have broad straps and full support and full coverage. Stretchy, “sports-type” bras are generally not as good because they just don’t supply the support, even though perhaps some manufacturers and individuals think that they’re very supportive.

Each breast project is an individual effort based on your particular idea of the size that you want, and we size you very carefully in the preoperative period. Your breasts also determine what kind of result you’re going to get, and the surgical technique also is very important. We perform breast augmentations through the belly button, under the muscle, through the armpit, above the muscle, and also use areolar incisions at times where this is the best option or the patient wants this. The crease at the bottom of the breast can also be used as an entry point to insert the implant. However, this is probably less desirable in many cases because the scar is visible in a lot of situations.

So your consultation will take you through the process and we will check the size you want, tell you the limitations that exist because of your breast type, and make a recommendation based on your individual needs and desires.

Breasts Are All Different, So You May Need a Special Procedure To Make Yours Look Better

Mt Rainier February 2012-by Dr. Yoho

By: Robert Yoho, M.D.

Putting an implant in your breast is not always the answer to give you a better breast look. Implants work beautifully for breasts that are generally formed well, but in some cases shouldn’t be used at all, and in other cases should be used after a primary surgery to get the breasts in a shape that can accept an implant and stretch out over the implant properly and produce a normal-looking, round, pleasing breast. 

Note that many of our patients like different looks in their breasts. Some patients like rather large breasts and they don’t mind having a bit of a demarcation in the upper pole of the breasts. Others don’t like this look at all and want a much more sloping look. Different effects can occur based on whether you have a lot of breast tissue or very little breast tissue and whether the implant is placed above or below the muscle. 

Other people have breasts which are different than the average, such as long, narrow breasts, which are called “tubular” breasts, and these need special treatment. The general pattern is to do a special reconstruction surgery or lift and then four to six months later use an implant if needed to create a larger volume breast. A little bit of volume can be added with fat transplant, but this is nowhere near the volume which is possible with implants.

The practice of putting an implant in along with a breast reconstruction at the same time adds so many variables that very few surgeons can do this with any degree of predictability. Indeed, one of the most famous breast surgeons in the country wrote an article saying that this should never be done and that all breast reconstruction should be done prior to implant placement, which should be delayed at least four to five months. He showed pictures of his own cases where the whole nipple areolar complex had died during the process of attempting to put the implant in and reconstructing the breast at the same operation on the same day.

So we need to evaluate you individually. Your breasts are a certain kind of project; it may be a complex project or it may be an easy project, but please come in for your own complimentary consultation and we’ll tell you exactly what to expect. Note that every breast operation has the risk of imperfection in its results, but things can almost always be improved by a secondary procedure or even a third procedure. We have performed breast reconstructions where we haven’t “gotten it right” until the third procedure, and the patients have been very good about letting us continue to operate at intervals of four months. In many of these cases, the patients end up with a very satisfactory result and breasts that look fantastic compared to their breasts preoperatively.


Breast wishes,

Robert Yoho, M.D.

Dr. Yoho’s Approach to Facial Rejuvenation

A family vacation moment, nothing to do with facial fillers!

One of the fantastic things that has happened with facial cosmetic surgery is the introduction of “hyaluronic acid” fillers, including Juvederm® and Restylane®. These fillers can help make a 45- or 50-year-old face look 10 or 20 years younger in some cases. The wife of a friend of mine recently was looking so fantastic that I had to ask her why, and she said she’d had 14 syringes of Restylane® placed in her face over the last 9 months. She looked like she was 27 and she is in her late 40s! The Restylane® had replaced the facial fat loss that she had undergone as a natural aging process, and because she had been using excellent skin products as well, she didn’t need a facelift or anything more aggressive than filler. Her lips were naturally full without being overdone and her cheeks, brow area, and the sides of her face all looked very youthful.

We also like facial implants, particularly cheek and chin implants. These are essentially permanent fillers. The facial lifting that these two implants produce is exceedingly natural in most cases and is more and more being used by Hollywood for virtually all of the actors and actresses.

We believe that the facial fillers, which are reputed to last only a year, last much longer if larger volumes are used. Our pricing is reasonable and we encourage our patients to have a consultation for facial fillers. If you use less (at least 5cc’s) many times a more temporary result is produced although it can still be very attractive.

We (as is standard practice) do face lifting along with eyelid surgery, facial fillers, and facial skin resurfacing. When multiple procedures are desired, all of these procedures are typically done at once in one procedure to produce the best possible result. We use local anesthetic plus our unique sedation process to give you the most comfortable experience during the procedure.

While the facial fillers have very minimal recovery, the other procedures of course do require more “downtime” and we will counsel you individually about your needs during your visit to Dr. Yoho’s office.

Wonderful New Device Has Been Invented to Improve Liposuction Results

Have you heard of the abrasive cannula that is used by all the advanced liposuction surgeons these days? This cannula helps us spread the fat around and make the surface much more even after liposuction. What we do is at the beginning of the case, we use this special instrument in order to abrade and loosen the fat after insertion of the local anesthetic. Then the fat is suctioned and the patient is checked while standing. Any areas that are improper or irregular are marked with a sterile Sharpie marker and the patient is then put back on the operating table and sedated again so they don't remember or feel anything during the case.

The special cannula is again used and sometimes a bit more suctioning is performed. After this, foam and the specially designed compression garment is applied and the patient is allowed to wake up and given fluid to recover. 

We hope this detail isn't too technical for you. Some patients would rather not hear about it, but we think that this helps some people learn more and understand more and have a better feel for what is happening during surgery.

X Marks the Spot:  A New Gynecomastia or "Man Boob" Removal Technique

Dr. Yoho recently attended a medical conference for advanced cosmetic surgery in Buenos Aires, Argentina. There he learned an excellent technique for improving the results in gynecomastia surgery. Dr. Blugerman, just like Dr. Yoho, aggressively liposuctions the area around the problem using a special local anesthetic. After this is performed, instead of making an incision in the lower part of the nipple of the areola right at the junction of the skin, an X is incised right through the middle of the nipple areolar area. Oddly enough, these come together and look fantastic after the surgery, rarely causing problems of any kind, and in most cases making much smaller incisions and leaving no scars.

That said, remember that fluid buildup and sometimes a little bleeding into the area is not that uncommon with gynecomastia surgery. Be prepared to follow up closely with Dr. Yoho when you have your "man boob" improvement procedure, because occasionally this fluid needs to be removed postoperatively in order to get the best result possible and avoid complications such as infection.

The "Gummy Bear" Implant is a Failed Implant

Unrelated to Gummy Bears or implants

The claim with the gummy bear implant is that if ruptured, the silicone on the inside will not bleed into the surrounding tissues. This is a patently false proposition, because those of us who have taken out gummy bear implants which have been ruptured have seen the silicone spread in just exactly the same way that a gel implant or an ordinary silicone implant's contents will leak out of the implant shell. So therefore this is not an advantage. 

The other advantage claimed for the gummy bear implant is the lower capsular contracture rate. This is a falsehood, because the gummy bear implant is naturally as firm as if the patient already had a Class II capsule or a quite firm breast. Therefore, the Class II capsules aren't counted in the statistics, and this distorts the perception in the studies that the gummy bear implant is superior. 

We think the gummy bear implant is too firm to be very natural and not a good choice in general for anyone. We like gel implants. We don't believe they have a higher capsule rate than saline implants, and their only problem is their expense. A new device that allows us to put them in more easily and damage them less is a great help to their placement. This is the "Keller Funnel", and we have had a great deal of satisfactory experience with it in easing the insertion of our implants, using a smaller incision for the implant's placement, and lowering the chance that we will distort the implant shell in some way, thus leading to a higher chance of rupture later in the patient's history. 

Please feel free to come in for your consultation in Los Angeles or Visalia in regard to these issues and chat about the various options in regard to silicone and saline implants.