..Before & After Cosmetic: Body

 Liposuction

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This 38 year old gentleman is in good shape pre op but desired “a six pack abdomen”. I told him it would require a strong commitment on his part and should not be taken lightly. When he convinced me of his sincerity, we embarked on a plan to achieve his goal. First I would remove the belly fat that, while not excessive by any means, would preclude seeing the rectus abdominus muscle beneath his skin. Then he would continue his exercise program which, despite enormous effort, was not exposing his abdominal musculature due to overlying subcutaneous fat. This kind of liposuction requires considerable skill on the part of the operator since we are going “bare bones” on his sub-q fat and any inconsistencies in thickness are easily detected. I am proud of my work here and he is pleased with the result (shown on the third post op day). It will gradually improve with time as the excess water swelling is absorbed and excreted. Its amazing how the judicious removal of a few millimeters here and there can make such a big difference in our appearance. He will rejoin his abdominal work when the soreness subsides in a few days. I admire people who take care of themselves and want to be their best and this young man is no exception.

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Do you recall from the previous slide my statement that I “expect further improvement as the excess water in the wall of his abdomen is absorbed and excreted”? I am grateful to this patient for taking the time to stop in on his most recent trip to Phnom Penh. This is a treat for a surgeon whose practice is composed of many patients who come here for surgery, and must return to their home countries before I am able to get a look at the final results of my work. The water swelling which “blunted” his result at post op day 3 is now gone at 2 months post op. And you can see how marvelous he looks. The original pre op photos are included again for your convenient comparison.
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 As handsome as the man is pictured above, I am most proud of how I transformed the young lady pictured below.ellie lipoellie lipo 2 

Close inspection above her right hip reveals a slight discoloration where I

inserted the cannula. We hope it will fade…

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This gentleman is in his 60s and has kept himself in excellent shape. He only has one area that is refractory to diet and exercise; a collection of fat in his mid abdomen, the so-called “middle age paunch”. Simple stuff here: under light sedation and tumescent anesthesia, out comes the fat and he is home in two hours. Back to work on the third post-op day; the day these pictures were taken. Note the flattened belly in the leftmost post-op photo and the ink design still present on his flanks. In the middle and rightmost photos, please observe that his abdomen is slightly concave below his costal margin whereas in the pre-op photos it is convex. Bruising will fade in a few weeks and contour will improve over the ensuing months as swelling subsides and the remaining tumescent fluid is absorbed and excreted. Liposuction remains our second most common procedure behind breast augmentation.

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 Before&After_Cosmetic_Body_Slide05 Liposuction on women is subtle; more so than on men. Whereas on men, the ‘’endpoint’’ is usually the underlying musculo-aponeurosis defining the ideal male torso, going this far in women creates all kinds of problems, starting with an edgy, linear, masculinized look. This is not becoming. (viz. the bodies of so many women body builders who are overly-masculinized and not attractive.) One reason a healthy woman’s body is so attractive is because of the curvilinear silhouette she possesses. This must be maintained at all costs even if some sub-q fat is left to soften her new figure. Its where the fat is left that is so vitally important. Of course a flat abdomen is attractive in both sexes and that is one of our primary goals in men and women. This is apparent in the upper pair of photos; the pre-op and third day post op profile views. In the center pair, please note how the torso is slightly concave below the costal margin in the post-op view but is strongly convex in the pre-op view. Finally, the third set… It is more difficult to see the improvement in the straight-on view until you notice the slightly pronounced hourglass shape in the post-op photo due to the judicious reduction of her waist. I would have removed more fat from this patient but we reached the limit that could be safely removed after carefully taking the predetermined amount from each quadrant to maintain symmetry. We look forward to continued improvement in this lovely young mother as water swelling is absorbed and excreted over the ensuing months. The most common error by practitioners in female liposuction is in treating the problem areas to the exclusion of the surrounding ‘’normal’’ areas resulting in a ‘’linearized’’ post-op appearance. Surgeons who leave women with unchanged waists and straight hips, for example- a very common error displayed on websites all over the world- thereby removing their feminine curves, may think they have succeeded when in fact they have made their patients look worse. Surgeons should err on the side of accentuating a woman’s curves, not eliminating them.

Before&After_Cosmetic_Body_Slide08 You can already see a marked improvement in the body habitus of this young woman after 5 liters of fat was removed from her breasts and abdomen. At post-op day two (left) and five (right), there is still a lot of water present in those areas obscuring the final result which I expect to be even better.
Before&After_Cosmetic_Body_Slide08-20 As you can see, an hourglass figure is emerging. In creating this, I left a lot of bruising on her abdomen and flanks and she reports a little soreness still, even at day five.  If the price she and I must pay to get this kind of result is a week of soreness and bruising, we will gladly pay it. You can see some of the water leaving her breasts between days two and five, showing more breast definition. Beautifully-shaped breasts will emerge with time…
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A Work in Progress: The photos at right will remind you that this patient is presented elsewhere in this website (Topics: “Improved Shape vs. Scarring” and ‘’Breast Reduction’’). We have completed her breast reduction and are in the middle of a series of liposuction procedures. We have 2 more such procedures to go . Both the patient and myself are very pleased with our progress so far. Her entire body habitus has changed to a much more athletic and dynamic one which was one of our primary goals when we began in this former athlete.  Before&After_Cosmetic_Body_Slide09

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 Before&After_Cosmetic_Body_Slide09-20 Please compare the relative projections of breasts versus abdomen in the two profile views at left and of course the breast shapes themselves. The post op breast silhouette has a beautiful shape compared with the pre op view. Please note that the breasts are not bottomed out in any way yet the nipples point up ever so slightly, giving them a very youthful appearance in this sixty year old. In our next procedure, I will concentrate on her lower body primarily, in particular, the collection of fat at the top of her buttocks (arrow). After removing this, her buttocks will curve out gracefully from the small of her back , giving her an even more slender yet curvy silhouette.

Liposuction for Gynecomastia (breast fullness in men)

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This is an example of liposuction for gynecomastia. You can see that this young man had lots of breast fullness in the pre op photos at upper left. In the post op photos, he is devoid of that fullness. Pre-operatively, he was very uncomfortable in any situation where he had to remove his shirt (eg on the athletic field, at the beach or by a pool) and chose to forgo those fun activities for fear of embarrassment. He even related that he was uncomfortable in a t-shirt. Postoperatively, he is very happy and looks forward to joining his friends soon.  Before&After_Cosmetic_Body_Slide11-2

 Abdominoplasty (tummy tuck)

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This was the first tummy tuck I ever did (back in the States when I was working as a general surgeon). I hadn’t even seen one at that point. I apologize for the poor quality photos. They were taken back in 1996 before I had a digital camera or a scanner. They are photographs of old printed photos. This woman was only 25 but had been through hell before coming in to see me. She had a Cesarean section and developed necrotizing fasciitis during the post-op period. This is one of the worst things that can happen to a post-op patient and has a mortality rate of 50 %. She survived but was left with an awful scar around which she deposited fat. This operation was next to impossible to do since the abdominal wall was attached like concrete to the fascia due to scarring. Somehow I was able to get it done and even managed to give her a nice hourglass shape by tightly plicating her rectus fascia (cinching in her waste). She is pictured on post-op day two. Her staples are still in as are the drains which were removed the following day. I have rolled down her panties to show the low-lying scar which will easily be hidden by a little bikini. This may be the only tummy tuck in history covered by medicaid and if I remember correctly, the reimbursement was a whopping $200.

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This French lady kept herself very slim after the birth of her three children but couldn’t get her tummy flat no matter how much she exercised. (no one can if the problem is due to a lax fascia as it was in this case.) So a tummy tuck, not liposuction, was indicated. This was the first tummy I did in Cambodia. In those early days most of our out of town patients came from France. Nowadays the majority come from Australia, Hong Kong, Singapore, China , Canada, and of course, the U.S.

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As you can see, this friend of mine had an umbilical hernia pre-operatively which was getting angry-looking with a purple tint to the overlying skin. It was of the dangerous size; large enough to transmit a loop of bowel yet small enough for that bowel to get incarcerated and if not released in time, strangulated , leading to perforation and sepsis. Pictured one week after surgery, it is all fixed now and as you can see, I performed a tummy tuck on him concurrently. I do this combination frequently on both women (pregnancy leads to it) and on men. This friend is in the patient care profession also and as such, expected a lot which I was very happy to deliver. The scar is very prominent at one week but will fade to a thin “pencil line” with time.  Before&After_Cosmetic_Body_Slide15-2

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 The books used to teach that you can’t do liposuction at the same time as a tummy tuck. I knew they were wrong because it didn’t make sense according to surgical principles. So all the other plastic surgeons were getting limited results compared to us. As I have been doing for many years, I combined the two procedures here. The specimen I removed from his abdominal wall (all the skin and fat, hip to hip from above his belly button to his pubic area) weighed 22 KG = 48.4 lbs. I could barely lift it off the table. I also removed 4 liters of fat by liposuction. This tummy tuck/lipo combination took an hour and a half longer than my usual two hours but it was worth it as this good friend told me: ‘’It has transformed my life.’’  Before&After_Cosmetic_Body_Slide16-2

 Buttock Augmentation

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This beautiful runway model from Beijing complained that when she wore a cocktail dress, it hung straight down and that her jeans looked too flat in the back. She requested a buttock augmentation but didn’t have enough fat to do it by transfer. So I placed buttock implants of 300 cc’s on each side. She is a little too sore to stand up straight as it is only post op day 2. 23 years old 5’10” 122 lbs

 Brachioplasty (Arm Lift)

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This sweet American lady came to Phnom Penh to have a procedure by me and was so happy with the result, she ended up staying for five! Pictured above is the before and after result of one of those procedures, a brachioplasty or ‘’arm lift’’. These procedures are most commonly performed on those patients who have undergone massive weight loss of 150 pounds or more after one of the gastric banding procedures. Since this was not the case here, and her arms were very bulky (making adequate skin resection impossible), I performed liposuction prior to the resection of her excess skin (‘’bat wings’’ as she liked to refer to them). After the removal of 1000 cc’s of fat, I proceeded with the resection. If you study the ideal arm, you will notice that the forearm is actually wider than the arm in this view even though the forearm is distal to the arm. Pre-operatively, this is not the case in this lovely lady but post-operatively, I’m proud to say, it is. I had warned her that, when we removed her bandages , revealing her slimmer arms, she would shed a tear or two (of joy) and later, she admitted that, yes, she had. The after picture is quite swollen and bruised still at post-op day four (especially near the axilla) but I couldn’t resist giving you a peek. This amazing lady underwent liposuction from six locations (removing a total of six liters of yellow fat), a face lift, the arm lift shown above, and a breast reduction. All of these procedures, with the exception of the breast reduction, were performed painlessly under local anesthesia with I.V. sedation even though each one took about three hours to complete.