Your concerns are valid, and frankly they are not all that uncommon, especially when we are dealing with people in the bariatric (post massive weight loss, women and men) population or in ladies who are post-pregnancy and had very large babies or gained large amounts of weight rapidly during pregnancy. The reason for this is that those are the groups who are the most likely to have had significant stress on their skin and subcutaneous tissues, and thus pronounced and unrecoverable damage to those tissues. It's not that your surgeon (or any of us, really) wants to blame yours (or any of our patients') tissues for this kind of thing, but the reality is that while these operations remove excess and lax tissues, we will still be left with significant damage in the remaining tissues. There are a couple of specific things that I think you should know about that damage and how we have to go about addressing it. First, a couple of words about the nature of what we're seeing. The two main things that happen in our tissues when we gain weight, or subject them to some other expansile force, are that they grow and create an absolute increase in the amount of tissue (or number of cells) that is present, and they stretch mechanically, often to the point that they become damaged. Then, if and when those forces are relieved (loss of weight, surgical or otherwise, or delivery of baby(ies)), the changes in the tissues remain. The excess growth does not go away or "get absorbed" by the body, and the damage that occurred remains and doesn't heal, no matter how much exercise we do or topical balms, salves, creams, or other potions that we apply. No other modality works reliably either. Thus, we can shine lasers, infrared light, electrical or radio frequency energy, or ultrasound at these damaged tissues, and for the most part it is fruitless. This is because that damage is actually a wholesale fracturing and tearing of the collagen and elastic fibers in those tissues. Stretch marks are the visible manifestation of that very real physical change that occurs in the skin. Much the same way as an elastic waistband on a garment can become stretched and "sprung," such that it no longer recoils, the exact same thing happens in our tissues when they lose their elasticity. And this isn't something that can be regained by those specific tissues. Every square centimeter of your abdominal skin has been affected to some degree by this process; albeit some parts of the abdomen worse than others based upon the distribution of forces sustained. But, the point is that even with removal of large amounts of the excess tissue, and tightening of the laxity, there is still damaged tissue left behind. We're stuck with it, and we have to do the best we can. We can tighten those loose and damaged tissues maximally in the operating room, and even though they may look pretty good on the table, the reality is that in many instances we still are dealing with severely damaged tissues, and they may not hold tension and ultimately undergo the mechanical phenomenon called "stress relaxation," and they can become loose again. This is not the surgeon's "fault" necessarily, any more than we can "blame" this on our patients. It's just the reality that must be accepted with this situation. The last thing to know about this damage is that it doesn't just occur in the skin. The subcutaneous tissue, also called the adipose tissue, is not just fat. There are fat cells, or adipocytes, in it, but the thing that is often overlooked is a very elaborate network of fibrous supporting tissues called the superficial fascia system ("SFS") which holds our fat "together" and prevents things from just sliding all around on our bodies. Just as the cells of the skin grow and reproduce in response to stretching forces, and the elastic fibers in the dermis of the skin undergo this fracturing and damage, so do the fibers in the SFS undergo these changes, and that contributes greatly to the sagging, bulky appearance that loose "skin" has after weight loss and pregnancy. And, the same damage that exists in the remaining skin after tummy tuck, will be in the remaining subcutaneous tissues as well, and this is a large part of the reason why things may look loose again, even after a valiant attempt at tightening them in surgery. The other thing that I want you to know about this type of surgery is that there is a limit to how much we can tighten tissues and how much can be removed at a single setting in the OR. Removal of excessive amounts of tissue, and/or placing them under too much tension - especially when large parts of them have been "undermined," or separated from their native blood supply as done typically in tummy and body contouring operations - is very dangerous and can result in losses of large amounts of skin and subcutaneous tissues. This is because excess tension on tissues crimps blood supply and can result in necrosis, or tissue death. Any plastic surgeon knows this, and they have probably already seen it at some point in their careers and want to avoid it under all circumstances. Additionally, removal of excessive amounts of tissue in one body area can result in distortion or disfigurement of structures in that area or adjacent ones. I think your surgeon likely did what he or she had to in order to mitigate this part of the risk by doing a fleur de lis procedure. This is not a commonly performed version of tummy tuck on those without massive amounts of tissue to be removed, so it would appear that you underwent arguably one of the more aggressive forms of body contouring procedure from the standpoint of how much tissue can be removed and how much tension can be placed in a single setting. So, again, it may well be that at that moment, in your surgeon’s judgement, the excess tissues were maximally removed and the maximal amount of tension tolerable was applied to your tissues. Postoperatively, things have loosened to some degree for many of the reasons I mentioned above. This is nobody’s “fault” - not yours, not your surgeon’s. Lest you think that I am indiscriminately protecting my colleague in an “old boys” style, I am not. I acknowledge your concerns, and they are valid. Your pictures clearly show recurrent/residual laxity and excess of your abdominal tissues, and I can understand how you don’t like that. However, your pictures also show nicely healing wounds without any evidence of loss of tissue or huge open wounds being packed until they heal, too, and unfortunately that sometimes happens. Given the two options on either side of “perfect,” in my opinion, your surgeon picked the right one, if any “fault” can be assigned, and left a bit more laxity as opposed to taking too much off too aggressively, especially in a fleur de lis case. While admittedly maybe not our first choice of situations, it is always better and easier to come back another day and take a bit more tissue off than having to deal with the results of forcing the issue during the first case and taking too much. Again, your concerns are valid, but you are still somewhat early in the recovery phase, and your tissues have almost certainly not finished healing and settling. They may still contract more, or they may loosen more. In either event, we don’t want to plan, or even discuss, revision while things are in flux and we are “shooting at a moving target.” My best advice is to be patient for a little while longer and give things a chance to fully heal. Then be very open in your communications with your surgeon about your concerns, but hopefully you will now be armed with a bit more solid information about how all of this works, and your relationship won’t feel so adversarial. We surgeons don’t undertake these major operations on people without at least some bit of feeling that we’re in it to make our patients happy and meet their goals. Most of us are our patients’ biggest cheerleaders and want nothing less than the best results from our surgery for them. If you do wind up needing, or better said, wanting, a revision, hopefully now you will go into that process with a little better insight into how all of this works, and you and your surgeon can recognize that you are really on the same team - your team! Best of luck to you.
