Bariatric surgery was a miracle for Malia McAndrew. The assistant professor of history at John Carroll University lost 160 pounds in the year after doctors at the Cleveland Clinic Bariatric and Metabolic Institute performed the procedure.
By March 2010, she was carrying 170 pounds on her 5-foot-10-inch frame. But the joy of conquering a lifelong weight problem was tempered by a heartbreaking consequence: Obesity had stretched her skin so much that it did not snap back as the pounds fell away. In fact, McAndrew had so much skin hanging from her abdomen that she still thought she was overweight.
"It took me a long time to realize that it was skin — that as much as I exercised and ate right, it wasn't going to go anywhere," McAndrew, now 32, recalls.
In December, Cleveland Clinic cosmetic surgeon Dr. Silvia Rotemberg removed nine pounds of excess skin from McAndrew's midsection with a lower-body lift. It's just one of the body-contouring procedures available to address everything from flabby upper arms to skin and muscle irrevocably stretched by pregnancy and weight gain. Some of the surgeries rate among the most requested in Cleveland and across the nation, according to local cosmetic surgeons and 2010 statistics provided by the American Society for Aesthetic Plastic Surgery. And the reasons for their popularity extend beyond the tighter bodies they yield.
"They improve the patient's self-esteem and confidence," Rotemberg says. "That's what you're really trying to achieve."
One of the most popular body-contouring procedures is liposuction, which eliminates bumps and bulges, such as saddlebags and love handles, that are resistant to even the most stringent diet and exercise regimens. According to ASAPS, liposuction ranked second only to breast augmentation in all cosmetic surgeries performed last year. Dr. Gregory Fedele, of The Art of Plastic Surgery in Beachwood, estimates it accounts for up to 50 percent of all body-contouring work he does.
The area to be treated is injected with a saline solution containing a small amount of epinephrine, which shrinks the blood vessels and helps prevent bleeding, and a local anesthetic such as lidocaine. The fat is then suctioned through one-fourth-inch incisions with a thin, hollow tube called a cannula. If the fat cells are harvested carefully, they can be isolated and injected into areas of the body where their volume is actually needed, such as the breasts.
"One of the more recent trends has been fat grafting," says Dr. Hooman Soltanian, director of breast plastic surgery at Case Western Reserve University School of Medicine and University Hospitals. Dr. Bahman Guyuron, chairman of the plastic-surgery department at Case Western Reserve University School of Medicine and University Hospitals, says precious stem cells with rejuvenating properties are mixed with the fat cells present in our bodies.
"It is amazing what they do," Guyuron says. "They increase elasticity of skin that has lost its collagen and elastic bands. It even reduces sun-related color change."
One grafting technique that's generated a lot of media buzz in recent years is the Brazilian butt lift, which bestows J.Lo-like curves upon those in need of what Dr. Steven Goldman, of Beachwood Plastic Surgery & Medical Spa, delicately refers to as "gluteal refinement." The fat collected by reshaping the outer thighs, hips, lower back and upper buttocks via liposuction is prepared and injected into areas where "more projection" is desired.
"It's not really about making a bigger bottom," Goldman stresses. "It's about making it rounder. You're trying to optimize contour to make it look youthful and attractive."
Following liposuction on the menu of the most wanted body-contouring procedures is abdominoplasty, generically known as the tummy tuck. The surgery eliminates that abdominal pouch of fat and loose muscle that just can't be starved or exercised away, along with the accompanying loose skin.
"It's very common after childbirth and also after menopause," says Dr. Lu-Jean Feng, of The Lu-Jean Feng Clinic in Pepper Pike. She has developed a "painless, drainless tummy tuck" that greatly decreases postoperative discomfort with a series of nerve blocks. Horizontal and vertical sutures inside the body eliminate the need for a traditional drain in the horizontal bikini-line incision by preventing muscle, fat and skin from moving around and causing accumulations of fluid.
"If it accumulates, it accumulates in smaller pockets that are easily absorbed," she says.
Fedele markets the tummy tuck with the breast lift — No. 8 on ASAPS' list of the most performed procedures for 2010 — calling the duo "the mommy makeover." Soltanian says breasts that sag and droop after pregnancy, breast-feeding, weight loss and/or decades of birthdays can be raised and firmed by repositioning the nipple and breast tissue and removing any excess skin. The operation requires an incision around the areola and, in more severe cases, a vertical cut from the areola to the crease under the breast and a horizontal cut in the breast crease. "The scar would look like an anchor or inverted 'T,' " he says.
Goldman advises women who want to replace lost breast volume to opt for breast implants.
"Very few women at age 38 have the same breast volume they had when they were 20, even if their weight has been stable and they haven't had kids," Goldman observes.
Soltanian sometimes combines the breast lift with the brachioplasty, or upper-arm lift. It removes the flabbiness that develops as people age or lose weight — an issue that keeps them out of sleeveless tops and even forces them into a larger shirt size — through an incision that extends from the elbow to the armpit on the arm's underside. While less popular than liposuction, the tummy tuck and breast lifts, it is a surgery Dr. Mark Foglietti, of the Cosmetic Surgery Institute in Beachwood, says his patients find rewarding. "It's instant gratification," he says.
His own technique for doing the surgery, dubbed the tab-flap method, removes skin in small increments rather than in one large segment, allowing for better monitoring of tightness and appearance.
"It's a safe way to do the upper-arm lift without accidentally removing too much skin, a common complication," he explains. The technique, he adds, also prevents what he calls "Michelin Man deformity," circular bands around the upper arm where the skin has been stretched too tightly.
Similar to the upper-arm lift, the thigh lift can combine liposuction with surgery to slim thighs and tighten skin that slackens as the years pass or the pounds disappear. The incisions are hidden in the creases where the legs join the torso. But Fedele says some people require incisions that continue down the upper inner thighs. In some cases, Foglietti adds, the incisions extend through the sides of the outer thighs into the mid-buttock region.
At the most aggressive end of the body-contouring spectrum is the lower-body lift, often referred to interchangeably as the belt lipectomy. The surgery, which Rotemberg says typically takes six hours to perform, removes sagging skin from the abdomen, outer thighs, buttocks, hips and waist. She describes an incision that completely encircles the body at the bikini line or, in the case of the belt lipectomy, at the waist. "With the belt lipectomy, you get a little narrowing of the waist because of the scar position," she says. The procedure is most frequently performed on people who have lost 100 pounds or more.
Although the upper-arm lift, thigh lift and lower-body lift are near the bottom of ASAPS' list of the most popular procedures, local cosmetic surgeons report they are doing an increased number of them as more Northeast Ohioans undergo bariatric surgery or rededicate themselves to living healthful lifestyles. But doctors stress that no body-contouring procedure is a substitute for diet and exercise. In fact, they describe the best candidate as a nonsmoker who has any health issues such as diabetes or high blood pressure well under control and is maintaining a healthy body weight — ideally, Feng says, with a body-mass index that is less than 30.
"When your BMI is over 30, there is a greater chance of infection and potential complications," she explains. "Fat people don't heal well."
