GRAPHIC CONTENT Mommy Makeover - Plastic Surgery - Dr. Juris Bunkis
Speaker 1: Okay, here we are in the operating room. The gal we saw earlier is having a Mommy Makeover, and first of all we're going to aspirate these little excesses that she has in her top of her hip and her flank areas. We start by injecting some fluid which will cause the blood vessels to constrict, and allow us to take out more fat and not have much bleeding. This is just the injection of tumescent fluid.
If you look at the literature back in 1983, I wrote a paper about blood loss from liposuction. I was the first one to recommend that local anesthetic be included with the fluid that's injected. This is also helpful when she wakes up. She won't have as much discomfort. We use the Power Systems machine, PAL machine for our liposuction. This works like a jackhammer does. It vibrates at the tip. That helps to break up the fat. You can see the fat coming out. It is just yellow. In about one minute, this little bulk will be gone, and we can flip her over and do the front side.
Here you can see we've finished the one side and this is concave. This is still convex. This is the backside obviously, but we are taking it off the sides because if you don't, when you finish the tummy tuck, the belly's really, really flatter on the side to have these little things to look like Mickey Mouse ears. Even though we're in Southern California, we're not that fond of Mickey Mouse.
Now you can see when we're done, she's got a nice waist. This is kind of concave in here and that's what we're trying to achieve. We're going to flip her over and start the front.
Here we are in supine position ready to go. I'm glad you were able to see her before surgery, because when she lays down like this, she honestly doesn't look that bad but when she was sitting up you saw how droopy her breasts were and how much extra she had in her tummy. Here you can see how nicely her sides have been sculpted out.
We're going to start with her breasts. What we're going to do is inject a lot of local anesthetic. We're going to make a circle around the areolus and that's the part we're going to keep attached to the breast, take out the rest of that skin inside this triangle, put in the implant, move the areolus up to here and close the skin together in a fashion like this. We'll show you that as we go along. Can I have a local anesthetic please?
Okay, the first thing we do is mark around the areolus, and we use these things called cookie cutters to give us the size and shape that we want and to make sure they're the same on both sides.
Speaker 2: Sorry.
Speaker 1: As you can see, we are taking a rather large circle, not all of her areolas, her areolas comes out to here. We are going to sew this into a very small hole, and by putting a larger areolas into a small hole, there is no tension on the sides. The scar tends not to spread.
Okay, we are opening the implants now. We use allergan implants. These are cohesive gel at SRX, extra high profile implants. We open them early and but them in an antibiotic solution until we are ready to use them. Okay, we made our initial cuts, and as you can see, this is the part of the areolas that is going to stay attached. All of this skin is going to be disposed of. We start by just taking a thick piece of skin, leaving just a little of the white dermis behind. We are not removing breast tissue, and we are not changing the volume with this technique.
Okay, as you can see, we have taken the skin off the part that we are going to denude. I have lifted this flap up, and the nipple is going to fit underneath here. The nipple will be moved a couple of inches up to about this spot. That's how that works. Now, we are getting ready to put in the implant. What we do, is we dissect down to the bottom where the muscle is. You can take a look and you will see the muscle here. This is the edge of the pectoralis muscle. What we do is we start at the section underneath the pectoralis. Once I am under the muscle, this is the muscle, I put a uterine sound, I call it the crow bar, inside and very, very quickly I dissect my pocket. This takes me less than a minute and the pocket has been dissected.
Okay, the next thing we are going to do is put in some pain pumps. These are catheters that are connected to a reservoir which contains local anesthesia. By doing so, we can avoid the need for narcotics after surgery, because with the catheters in place, she gets a little infusion of local anesthesia every minute, and there is very little discomfort. This is what the catheters look like. This is what the mechanism looks like. We take it off and the pump stays inside. We will leave this in for about three days. After that time, the worst of the pain is over, and we do not need it any more.
Now that the catheter is in, we are going to slip in an implant. This is our silicone implant covered with a little brown betadine, which is an antibacterial thing. Implant is in and now all we have to do is close this. The implant is in and the drain has been secured. We are going to line up the skin flaps. We hold them temporarily with little towel clips, and then we will be replacing those with sutures. As you can see, the shape of the breast is coming together. The areolus is going to come up into this new opening up here.
Okay, these are the two cookie cutters that we used. This is the initial one. If you remember, we try to take a large piece of areolus and we are going to put it into a small hole. This will expand a little bit after we cut it. If you have a larger areolus and a small hole, there is no tension on the edges and you get a better scar around the areolus. Now that we have replaced all the skin [inaudible] with deep sutures, we haven't closed the skin yet, we are going to make an opening for our areolus. This kind of leaves a mark on the skin. I just make a cut where the mark is and that is where we are going to slip our areolus into.
Okay, the opening for the areolus has been cut. We have removed that skin and we are just going to inset this the same way. We will just hold it with the towel clamp until we are ready to start sewing it. We are now ready to kind of finish up all the sewing here.
We have finished the breast part. As you can see, she has nice round, full breasts. The implants move very nicely. Now we are going to be focusing on the abdomen. We are going to start by injecting a whole lot of local anesthetic. We are going to make an incision around the naval. What that does is separates the skin surrounding the naval from the naval skin. The naval stays there and never moves, but everything else is going to be lifted and shifted downward. This incision, where the naval came from, we are going to try to pull that hole past the incision down here. So, there is going to be an incision around here when we are done and one along here.
Here you can see where we did this liposuction and how nicely this curves her sides. We made our incision around the naval. I always put a suture in the bottom part of the naval, because once you completely go around it and separate it, it is easy to turn it 90 degrees by mistake. Now, we are going to make an incision across the bottom and get ready to elevate the skin. We have injected local anesthesia and you can see how relatively dry it is. We do all of this dissection with the cautery machine. We cauterize as we go. You can see how relatively dry this is. We have very, very little blood loss. Over the course of this operation, we probably will not lose more than an ounce of blood. We continue this dissection down to the muscle. Once we reach the muscle, then we start lifting the skin up towards the rib cage.
Here is the abdominal wall muscles. We just [inaudible] up on top of the fascia until we get to the naval and then we will go around the naval. As you can see, we have dissected underneath the skin all the way up to the xiphoid, where the chest starts, and we freed this flap up. I think I can show you when I touch the muscle here. You see how it jumps. There is a gap between the two rectus muscles that happens from having children. We call it a diastasis recti. Part of every tummy tuck of Mommy Makeover is to sew those muscles back together again where they were before children, and this will drastically flatten the appearance of her abdomen. We use a relatively large thread for this as we are pulling very, very hard to get these muscles together. You can see how lax she is here. When we finish this, it will be tighter than a drum.
We are going to sew all the way down to the pubic bone, and we will lift that flap up again. We are going to sew from the naval up to the chest. Connect the muscles that were repaired all the way to the top. Before we close, we shoot a little bit of local anesthetic into the muscle, because the muscle is what really, really hurts after surgery. It is not the skin in fact. Again, notice how dry we are. We have lost very, very little blood and that is a combination of a few things. First of all, at the head of the table is our anesthesiologist, and he keeps the blood pressure artificially low in the range of 80/60 or 70/50. You just bleed less when your pressure is low. The other thing is giving this local anesthetic. This has a drug in it which causes the blood vessels to constrict. When we are finished here, we are going to pull this extra skin down and close it. This part is kind of fun to see. This is her excess skin coming off.
The center peaks up a little bit because we have to go around that naval, but most of this scar will be low enough so that she can wear, you know, those little slim jeans, or whatever these young people wear. I talked to her about her little tattoo here and it's going to need a face lift when we are done. Part of her tattoo is going to be in our little specimen here. Take a little extra fat underneath, because this upper flap will be sutured down into her upper groin. That area is very thin compared to her upper belly. You just have to make them match. Just as we did with the breasts, once we get this piece off, you line everything up with little towel clamps. Those do not leave any marks. A minute later, we will be replacing those with sutures. With towel clamps, you can see real quick, and I can adjust it left or right if necessary.
I may as well introduce you to the rest of the team. My scrub tech is Jen. It is a great pleasure to work with her. I have worked with the same scrub tech for every, every case I do, and when you become like partners, you know each others hopes. Of course, you must be Sophia's circulating nurse. As Dr. Seuss said, "Where is the navel?" What we are going to do, while we are up here, I think we are going to make a little hole up here, go down there and find her naval, and pull it up to the surface.
Speaker 2: Can I have another PES?
Speaker 1: Before we finish closing this, we are going to put in the same pain pump catheters that we put in the breasts, and that will make it much, much more comfortable for her afterwards. We put in the pain pump catheters. We put in the drains, and now I am feeling where her naval is underneath here. Right over the naval, I will make a little elliptical incision and we'll go down and find the naval. Once I pull it out, I know exactly where the bottom is because that's where my stitch is, and that's how we are going to close her up. Let's finish the deal.
Up here, Janice is putting some glue on the incisions. We use the glue to protect the wound from bacteria and so forth. With this glue in place, it is very unlikely she will get an infection. The beautiful part of it is that within a day or two she can take a shower. That is a big advantage over the old tapes we used to use. You can see that there's some puckering along the incision, and that is because the lower incision was about one foot long going straight across and the upper incision is at least one foot and one-half because it goes in a circle. Within four months, every one of those puckers will be gone, her breasts will be perky, her stomach will be flat, and she is going to look real good. This is how we do Mommy Makeovers at Orange County Plastic Surgery, Orange County in California, that is.
This is the lady that we did today. If you remember, on the backside, we suctioned this bulge, and that's so that when we are done, they have a thinner waist and they don't have a bulge on the side that looks a little like Mickey Mouse ears. From the side, you can see how droopy her breasts were, and you can see how her abdomen bulges. It is very similar to the lady whose before and after pictures we will show. This lady's before and after obviously we will not have for another year. You can see how she looked before we started her case.
This is a 34-year-old lady who had a Mommy Makeover, and this kind of just shows us what to expect with the patient that we did today. You can see that she has a droopy, droopy breast. This little bulge is not so much a skin excess as that muscle being lax. You saw during the case how we tighten the muscle. We took out the excess skin. You can see how flat and tight she is, and how youthful her breasts look, and overall, how much better she looks. She has a little bulge in the side here, and we suctioned that out as well.