Kelly R. Kunkel, MD

A well-done "donut" lift provides at best only a very modest change in the position and appearance of the areola.

The trouble with the "donut" lift is that it sounds good.  It sounds good to get a lift that results in only a scar around the areola but nowhere else.  Who wouldn't want that?

Donut lifts result in more lawsuits than any other procedure in cosmetic breast surgery.  That's because women often expect more of the procedure than it can deliver.  Most women really need much more than that minimal lift.  A donut lift results in pretty substantial tension on the scar line, resulting in a scar that spreads and an areola that is often way too large and unattractive.  

While some women are candidates for this procedure, it's not a good procedure for most.  More commonly women do better with other types of lifts.  It's true that other types of lifts result in more visible scars.  But, when the final result is breasts that look great, nipples that are well-positioned on the breasts, and scars that are not very noticeable, that's a much better result than can be achieved with most "donut" lift procedures.

Visit in person with a plastic surgeon who does a lot of cosmetic breast surgery.  Make sure the surgeon understands what you hope and expect to achieve.  Be willing to hear what the surgeon has to say about the options and the potential outcomes.

Each person who comes in for a tummy tuck consultation spends about 1.5 - 2 hours in our office during the first visit.  That's a long time.  But, it's time well spent.  

I want to make sure that I'm hearing what the person wants, and I also want to make sure that the person has a good idea of what's possible.  I have the person stand in front of a full length mirror and I draw on her abdomen, flanks, and back with markers to help make sure we are both seeing and talking about the same things.

It's pretty common for someone to have some fatty fullness behind their muscles, in around the intestines.  This is not something that can be corrected with a tummy tuck.  Most of the time these types of patients have fullness at and above the belly button.  The photographs you included suggest to me this is the case with you.  If your expectation is that your upper abdomen will be made flat with a tummy tuck, you may be disappointed.  On the other hand, some women with this type of finding really are most concerned about the lower abdominal hanging skin.  A tummy tuck takes care of that very nicely.

It's easy to be overwhelmed when visiting a surgeon's office.  Patients are often a little shy, maybe even a little embarrassed to be there.  Some offices are very busy and things are rushed.  The surgeon may only spend 5 or 10 minutes with the patient.  It's this type of situation where miscommunication is most likely to occur.  Before you undergo surgery by anyone, make sure that you talk with the surgeon and the staff.  They should have a good expectation of what you are hoping to achieve.  They shouldn't just be selling surgery to you.  They should be helping you understand the surgery and the likely outcome.  If that has not happened to you yet, make sure it happens long before the date of your surgery.  It's just too important.

It's pretty common for most plastic surgeons to see people who have lost a lot of weight.  Loose skin everywhere...arms, breasts, abdomen, back, thighs...

First, congratulations!  So much dedication and work to get there.  But...now what?

I like to have the person focus on what's most important to her.  Do that area/those areas first.  Each person is different in her idea of what she most wants to change.  

The abdomen, flanks, and back are usually addressed together, and often this is the first thing women have done.  It is possible to combine another area with this.  I sometimes combine breast lift/reduction with this procedure.  This typically creates a profound change in appearance and self-confidence.

I do not like to combine tummy tucks with inner thigh lifts.  After a tummy tuck it's common to move a little slowly for a couple weeks and to walk bent over for about a week.  But, it IS important to be moving around to help prevent blood clots in the legs.  If the inner thighs are done at the same time it becomes more difficult to move as much as you should.  I typically like to do the inner thighs at some other time.

Sometimes we'll combine arm lift and breast lift surgery.  Many combinations are possible.

Spend some time thinking about which one or two areas bother you the most, the areas that are driving you nuts.  Take care of those areas first.

Visit with someone who is recommended by people you trust, maybe your doctors or very good friends.  Ask a lot of questions and make sure the doctor understands what you hope to achieve.

Congratulations again.  Really, losing 140 pounds is a tremendous achievement!

Facelift patients and facelift surgeons don't want to have noticeable scars.  No patient wants to have, and no surgeon wants to create, telltale scars of a facelift.  

Several things contribute to how a scar ends up.  Genetics certainly play a role.  Some people are programmed genetically to heal differently than others.  Hypertrophic and keloid scars are more common in certain individuals than others regardless of how incisions or wounds are closed.  Circulation to the skin is important too.  Someone who smokes or is taking 3 medications for high blood pressure or has very thin skin may not have as good of circulation to the skin as someone who is 50 and runs marathons. However, in facelift surgery, tension on the scar line is probably the thing that will lead to more visible scars than anything else.  Tension on the skin is to be avoided as much as possible.   

There are different techniques for a facelift.  Sometimes shorter incisions that don't go into the hairline behind the ear work well.   A person who has loose neck skin will probably benefit from an incision that goes back into the hairline behind the ear.  The issue about where to make the incision on the "face side" or front of the ear is a little different.  I suspect that most surgeons, for most women, make the incision behind the tragus, the little protrusion of the ear over the ear canal.  Sometimes an incision in front of that will work better.  It's a discussion to have face-to-face with a surgeon.  Visit with someone who is recommended by doctors and good friends.  Make sure that surgeon understands what you want to achieve.  Ask a lot of questions!

Most people I see for a facelift have existing differences between the right and left sides of the face.  We use a 3-d imaging device to show each person the differences that they have.  It's important to identify these differences before undergoing surgery so a plan can be made to address them.  Some asymmetries may be addressed by adding fat in different amounts in one cheek than the other, for instance.  Sometimes the correction takes place by moving the tissues in a different direction on one side than the other.  I don't wait until the patient is on the operating table to make decisions like this.  I talk with the patient before surgery while looking at the 3-d image.  The evening before surgery and the morning of surgery I look at the photographs we took and plan the surgery.  When I place markings on the patient the morning of surgery I confirm what I saw in the photos or make some adjustments to my plan.  I'm not sure we ever achieve exact symmetry when we do facelift surgery.  But, it's key to identify the asymmetries and talk about how they might be addressed before the procedure.  

Talk with your surgeon and make sure she/he understands the things you hope to achieve.  Don't wait until the day of surgery to have that conversation; do it in advance!