Episode 33: Tummy Tuck – Hot Girl Summer Coming Soon!

Dr. Franco: All right, team. Welcome back to “Plastic Surgery Untold: Beyond Botox and Butts.” I’m Dr. Johnny Franco, also known as “Austin Plastic Surgeon.” We’ve got our celebrity cast joining us again. Today, we’re talking tummy tucks, which is one of the most popular procedures in America right now. And before we get to the good stuff, let’s catch up what’s going on with our celebrity crew here. I want to bring up a little nugget that actually happened to us a couple of weeks, because he will keep this from you guys. So I am letting Celebrity’s moment here of what he’s done, but I want to make sure that people know the real story of what he’s done.

So we were at the Austin Smiles gala, so shout out to them. And maybe we can have them, if Celebrity allowed, on the podcast one of these days to talk about all the great things they do. It’s actually…

Travis: Yeah, absolutely.

Dr. Franco: Actually, as some of you guys know, and feel free to jump in, you guys are all participants of it, Austin Smiles is actually a group started here in Austin by plastic surgeons that raises money and actually goes on mission trips to help kids with facial, hand, burn deformities, anything that the plastic surgery community can help. And then, many CRNAs and anesthesiologists, they have gone on trips to help. And so, we go to various parts around the world and help do this. So, great cause, Austin Smiles. Feel free to look them up, donate, or participate. They’re always looking for people to help.

But as part of that, they had a very small gathering, as they did a mostly virtual gathering. And one of the board members came up to me and I was trying to introduce G. Berto, Austin’s Most Beautiful Man. I was like, “Oh, this is my friend, G. Berto, Austin’s Most Beautiful Man,” and she goes, “Oh, how can I forget him? He’s so handsome.” I was like, “Wow, boom. Okay.” You’re welcome, G. Berto.

Gilbert: Yeah, she made me blush a little.

Donald: So this is all fact?

Gilbert: This is fact, yes. This happened, indeed.

Dr. Franco: And she hadn’t seen you in over a year.

Gilbert: It’d been over a year since then, yeah.

Dr. Franco: And still, just remembered you as the handsome man?

Gilbert: I guess I’m just that memorable.

Travis: Oh, my God. It’s going to be a long episode.

Gilbert: And then, I was there with…Nobody said anything about me?

Dr. Franco: No, no, no, no. No, they didn’t. No, they didn’t.

Gilbert: I thought that’s where you were going with this.

Donald: Always leave them smiling, John. Always leave them smiling.

Travis: Yeah, I didn’t even get an invite to this, so…

Dr. Franco: Yeah, it was a much-condensed list, and some people made the cut, some people didn’t.

Travis: Oh, God.

Dr. Franco: But life…Right now, 2020, got to make some tough choices.

Travis: Cutthroat in here. Geez.

Dr. Franco: Celebrity, what’s going on with you? Catch us up. Big house moves, big life moves, been all sorts of things going on in your world.

Travis: Yeah, house moves, life moves, rehabbing the knee. I think I told you guys last time, I finally did sign up for a half-marathon, so that training will start in two weeks. I’m excited about that. It’ll be at the end of February and it’s going to be Zion National Park in Utah. So it should be exciting. G. Berto, there’s room for one more, if you want to hop on.

Gilbert: Maybe. Yeah.

Travis: We’ll just see.

Gilbert: I haven’t run a race in a couple of years, but I’ll be up for it. [crosstalk 00:02:56]

Man 3: Well, maybe we should do it then. Maybe we should do it and give Franco…We can put him in a wagon and just drag him behind us.

Dr. Franco: Wow. Wow. That’s what I’m talking about. That’s what I’m talking about.

Donald: Like those moms on the trail with the baby strollers, pushing them?

Travis: That’s exactly right, but a big old baby stroller. [crosstalk 00:03:08]

Dr. Franco: I’m gonna be doing that with little baby Winston. Little baby Winston will be strolling in his stroller and I’m going to running around town waving at him. So if anybody wants to give me a Christmas present, a doggie stroller would be much appreciated. I like the little angled ones, some nice padding because I don’t want him to get hurt. Donald, what’s going on with you?

Donald: Oh, man.

Dr. Franco: Oh, that sounds great. Moving on. So today’s episode is gonna be about…

Donald: Do you see this?

Travis: So please…Donald, please…

Donald: Do you see what I’m dealing with?

Dr. Franco: No, please catch us up.

Donald: No, man. Been pretty busy. You know, I do a lot of stuff in the gaming world, and it’s a lot of business kicking up.

Dr. Franco: You say this, can you tell us what you’re doing in the gaming world right now? Because I feel like plastic surgery’s a black box to all of our listeners. The gaming world, other than, like, “Call Of Duty” or “Halo” or “Madden 2020” is a black box to me.

Donald: No, there’s a lot going on. And the funny thing is, with…

Dr. Franco: Such as?

Donald: …everybody being home…Well, I can’t speak particularly to the projects that I’m doing, because I’m signed under NDAs. But what I will say is…

Gilberto: Of course. Of course, of course.

Donald: What I will say is, I’m working on…

Dr. Franco: We’d like to talk to the people about tummy tucks, but we’ve got an NDA here…

Donald: No, no. Well, hey…

Dr. Franco: …so this is going to be the world’s shortest podcast, sorry.

Gilberto: Unbelievable.

Dr. Franco: I’m sorry to all the listeners that wasted some valuable space on their iPhone downloading this podcast.

Donald: It depends on how many of these listeners are into games, but you know. No, that’s what I’ve been up to, man, is just making games. There’s a lot of people at home, staying at home playing games, so a lot of games need to be made.

Travis: Got to ask, three favorite games quickly, of all time.

Donald: “Battlefield,” any one from the “Battlefield” series, “Legend of Zelda: Breath of the Wild,” and then “Mario,” just for old times’ sake.

Gilberto: All right, all right. I’ve got that.

Travis: Spoken like a true gamer. He knew immediately his top three games.

Donald: Oh, yeah.

Dr. Franco: I’m glad you helped him, because he had a lot of airtime there and really said nothing. And so, we heard, “NDA,” we had, “I can’t tell you any secrets.” And so, boom, boom, boom.

Gilbert: I’ve got to ask real quick, can you get me a PS5?

Donald: I possibly could, yeah.

Dr. Franco: What?

Travis: All right, all right. We’ve got to talk after.

Donald: Yeah, yeah. See? Now, I’m important. Yeah, there it is.

Dr. Franco: Well, let’s jump into this. Let’s talk tummy tucks, because this is a cool topic. And we’ve talked a little about them as part of mommy makeovers, some drainless-type stuff and why we do that. Today, let’s just talk overall, tummy tuck and techniques, options, and what we can or can’t do. And why don’t we start with who’s a good candidate?

Travis: Yeah, that’s a great…

Gilberto: A great question.

Travis: I love it, yeah.

Gilberto: Who is a good candidate, Dr. Franco?

Dr. Franco: Boom, boom, boom. Typically, not Austin’s most handsome man. But you never know, some men do get tummy tucks.

Travis: That is very true.

Dr. Franco: I think it’s a hard call, because people want to avoid the incision, the scar, most people would rather do liposuction, if they can. So really comes down to a skin issue. And so, a lot of people come in and they’re…It’s funny because I’d say probably half of our tummy tucks are people who initially came in for a BBL or lipo and just weren’t good candidates for that, and then were just better candidates for a tummy tuck. Kind of the rule of thumb is, if you’ve got a significant skin issue, i.e., extra skin, loose skin, you’ve lost a lot of weight, pregnancy, other stuff, then you’re going to need a tummy tuck, in terms of that.

One of the most common complaints we get when people come in for a tummy tuck is just, they’ve had babies, had a C-section, they’ve got skin that folds over, that kind of tummy line, panty line. And they’ve worked out, they’ve done other health lifestyle stuff, because you can lose weight and do that stuff with good lifestyle changes and working out. But it’s sometimes hard to treat the skin issue, because some of that is genetics and it just depends how much that skin will retract over time.

Travis: So what you’re saying is, a tummy tuck is not a weight-loss procedure?

Dr. Franco: I think that’s an incredible statement, because we do a poll on our Instagram all the time when we take the skin out, how much it’s going to weigh. People will say 20, 30, 40, 50 pounds and then, unfortunately, I think a little surprised, maybe even disappointed that it typically weighs a couple pounds.

Travis: Two pounds, three pounds, yeah.

Dr. Franco: Two, three.

Travis: 1.5.

Dr. Franco: A huge tummy tuck is seven pounds, maybe. So the vast majority of people…And I think the point you’re getting to is that you really want to be as close to your ideal weight before the tummy tuck. The tummy tuck’s not going to get you to that ideal weight.

Donald: Interesting.

Travis: Completely agree with that. Also, BMI.

Dr. Franco: Yeah. And so, everybody has some different BMI cut-offs. We’ve recently changed our BMI cut-off to 33. The lower the BMI, the less risk of complications. And no question, at 35, you see a steep jump in terms of complications. And some of that just has to do with a lot of factors. If your BMI goes up, people are at higher risk for hypertension and diabetes, other underlying medical issues that they’re kind of a sequela of that. Also, just tends to be more tissue. So that’s all the medical reasons.

The second part is, the higher the BMI, the less results you’re going to see from it because most people see us do the internal corset, the tightening of the muscles. But we have internal and external fat, and we can get to this when we talk about men and tummy tucks in a little bit. But we can do a lot to treat the external fat, so the stuff above outside of the muscles, in terms of liposuction, tummy tuck, fat removal, different things like that. But tightening of the muscles is limited by what it’s going over. If you think about it, it’s just like trying to close a…If you ever stuff your suitcase and you’re trying to zip it closed, if there’s just too much on the inside, there’s just a limit to how much you’re going to get that compressed and down. Same thing when we’re tightening the muscles.

Donald: Completely agree with that. and I think before I really got into plastics and in doing plastics cases routinely, I had this complete misconception of what a tummy tuck was. I thought that you just chop off a big portion of fat that you have around your midsection and you’re done, and you just sew it up and you’re all finished. But there are tons of different techniques. There are also skin-only abdominoplasties, there are abdominoplasties where you’re repositioning the opening for the belly button. I didn’t understand what happens with the belly button. So I’m hoping that we can kind of get to the bottom of a few of these things before we’re done today.

Dr. Franco: Let’s start from the beginning, because like we’d talked about, typically, someone who’s getting a tummy tuck is someone who’s not a good candidate for liposuction. And so, you’ve got loose skin, whether it’s stretch marks, whether it’s skin hanging down. And that’s because…Not to digress too much, but so we could put it in context when we liposuction somebody, we’re taking that fat out, but then we’re dependent on that skin to shrink down and give them that shape. If you already have loose skin that’s not tight, we can take out more fat, but you’re still going to have loose skin. So you’re not going to have that hourglass figure.

So the idea is that we’re taking out that skin and we’re reshaping them. Sometimes, it’s in combination with liposuction. A lot of times with a tummy tuck, you’ll see us do liposuction back and flanks, maybe a little fat transfer to the butt, hips, do a little 3D sculpting, and then finish it off with a tummy tuck. Because now, we’ve thinned out that waistline and we can get rid of the skin and kind of really cinch people in and make that look good. And so, that’s, I think, some of the stuff you’re talking about. It’s not just cutting out some skin and putting it back together. There’s a lot of cool internal sculpting stuff we do to get people that nice “V” angle, give them that nice little internal corset and get them shaped just perfectly.

Gilbert: One of the things that I wanted to ask you about is, like, we were talking about who’s a candidate for a tummy tuck. What are some of the things that some of these candidates can do before they get a tummy tuck? Obviously, they want to get their BMI down. You’re talking about the internal corset, where we are suturing the muscles together, there are certain exercises that they should be doing to help with those things and to kind of help speed them through recovery.

Dr. Franco: I mean, I think a little bit…And I think a little beyond the podcast here, in terms of specific workout routines and exercises. But I think to your point, I always tell people, “The better shape you are going into the surgery, the better you’re going to come out,” because it’s a physical stress on the body. No matter what Celebrity and I do during the surgery, there’s still some physical stress on you during it. And maybe a similar point you’re alluding to is, one, getting your weight down, two, eating healthy. I tell people, “Don’t make big changes the week before the surgery. By then, it’s too late. Do you.”

But the more you can clean up your diet, eating healthy…Because all those things have long-term sequela, right? So it’s funny how many patients we see that have…Because this is a big portion of our tummy tuck population is people who’ve had some type of bariatric procedure. And just with the weight loss of the 50, 70 pounds, how many people tell you that, “I used to have hypertension,” “I used to be prediabetic…”

Travis: Oh, yeah. All the time.

Dr. Franco: …”I used to have this?” And with the loss of that weight, all those things have gone away and just, kind of, resolved on their own. And so, that’s obviously one extreme. But no question, working out, eating healthy, not smoking. Smoking is another huge one that they have 100% control over. And just like breast reductions on our previous podcast, a month before or a month after, that’s a dealbreaker, you come in, you’re smoking, you’ve got cigarettes in your pocket, unfortunately. But I’ve talked in our office about this because we’ve done it with COVID a little bit, is, you do the walk of shame out of the surgery center. So back to G. Berto’s college days where he did the walk of shame out of the sorority houses at 6:00 in the morning. You’re doing the same at 7:00 in the morning out of the surgery center with your little surgical bag because you didn’t have surgery because…

Travis: You were still smoking.

Dr. Franco: …you were still smoking up to the day of. COVID, unfortunately, is still an issue, and here in Texas, we’ve had spikes. So have tried to warn people, “Leading up to your surgery, be crazy, crazy, crazy about being good about wearing masks, using hand sanitizer.” And I’m not trying to get political, just from a medical standpoint. The things that you would do to prevent getting the flu, that you’d be…from getting strep, from getting other things, you have to do it because from a pure medical standpoint, myself…If Celebrity sees you, if his nurses at the surgery center check your temperature…You know, you wouldn’t go under an elective surgery with a fever, not feeling well with any type of sickness, because chances that you’re going to have a problem have gone up exponentially.

Travis: Absolutely. And…

Dr. Franco: Celebrity?

Travis: Yeah. Here in the business, we call that a cancel-ectomy. We don’t like to see that because we don’t want to cancel cases. We’re there, we’ve got the team there, Dr. Franco’s there, everybody’s there in place. We’re ready to do those cases and to get those patients treated and taken care of. And…

Dr. Franco: And we’re…Actually, that’s a big portion of your life. They’ve taken a lot of time, so it’s heartbreak for us when we have to do this.

Travis: It is, it is. And we just…We want everybody to have the best result possible and to be as safe as possible. And if we’re doing anything to not promote that, we’re not doing our jobs. So we screen everybody as soon as they do get to the surgery center. I know Dr. Franco is having his patients tested. It’s one of those things where we’re doing everything that we possibly can to make sure that it’s as safe as possible.

Dr. Franco: Did that kind of answer your question, Donald?

Donald: Yeah.

Dr. Franco: I feel like you opened up Pandora’s Box a little bit.

Donald: Yeah, it did, it did, definitely.

Travis: We even went down the COVID rabbit hole on that one, geez.

Dr. Franco: But I think some of those things were super, super important for people to understand because most people have waited a while for this surgery, have jumped through a lot of hoops in terms of doing the things to get themselves ready. And it truly, truly is heartbreak. But I do also want people to understand, if we didn’t care, we wouldn’t do it. We wouldn’t send you home. It’s easier for us to just do the surgery and be done, but that’s not how Celebrity rolls.

Gilbert: Is there more than one way to do an abdominoplasty or tummy tuck, or are there different variations to the procedure?

Dr. Franco: I mean, I don’t want to be attacked by PETA, but there’s more than one way to skin a cat. There is, and so, it kind of depends on the individual situation. One of the things…And let’s start at one spectrum and work our way up to the other. One of the questions I probably get at least once a day in our office hours is, “I want a mini tummy tuck.” And so, the question is, number one, what does a “mini” mean?

Gilbert: Subjective.

Dr. Franco: So “mini” truly means this, that you’re not moving the belly button, per se. So you’re keeping your belly button. And so…this is plus or minus, some people still tighten the muscles all the way up to the chest, other people do not tighten the muscles as part of the mini. And that’s something to ask your surgeon. Again, not right or wrong, but just different methods of doing this. Second is that because you’re keeping your belly button where it is, we do something if you are tightening the muscles where you say you’re floating the belly button. So you lift the whole skin up in unison, keeping the belly button completely attached to the skin, not cutting around it like you’ve seen us do before.

And so, we tighten the muscles. But you’ve got to put the belly button back down in the exact spot, because you’re going to look really weird if we pulled that belly button all the way down and you’ve got your belly button holding your belt up. And so, got to put it down. And the reason I’m making such a hard point about that is, that means we’ve pulled the skin…If the belly button’s pulling down into the exact same spot, we can’t take any skin above the belly button to pull that down. So if you’ve got loose skin above the belly button, a mini’s not going to help you. It helps those that just have a diastasis rectis, where the muscle is really loose and we’re going to tighten all that and maybe take a little of skin. Very few people don’t have a little bit of skin.

Also, if people are very, very, very…a select few people that just have some loose skin either above a C-section scar, below the belly button, everything above the belly button looks phenomenal, those are good mini tummy tuck candidates. A mini tummy tuck’s going to be a little longer than a C-section scar, not quite as long as all full, because remember, the length of the scar is directly proportionate to the amount of skin that we take. And I think that’s super important because the more skin we take, the longer the scar because it’s going to go further. Typically, we’re going higher and it’s going more around the belt-line area.

Does that make sense? Because I think that’s super important. Sometimes, people have a misconception that a mini is less than a C-section scar. It’s not. And it’s hard because everybody wants a short scar and stuff, but you also want a good result. And I think it’s a fine balance with some of that. And so, I’ll tell you, in our practice…when we were together, G. Berto, I don’t know if you’ve ever even did a mini with me.

Gilbert: I don’t think we ever did a mini together.

Dr. Franco: Because we’ve probably, at my practice…and we do about 500, 600 surgeries a year, I would be surprised if we do more than 3 or 4 minis a year.

Travis: Yeah. I would agree with that. I did one just the other day with one of the other really good guys in town, and it was just the perfect patient for a mini tummy tuck. The patient just had some loose skin right above her C-section scar, and it was just right there. She was in phenomenal shape, her BMI was probably 18. She looked like she had washboard abs, just with some extra skin. And she had a little bit of diastasis that we ended up plicating…or the surgeon ended up plicating just below the belly button. And then…

Dr. Franco: I thought that maybe you scrubbed in. [inaudible 00:17:56]

Travis: No, but to your point, the people that qualify or that are good candidates for that mini abdominoplasty…

Dr. Franco: Because I mean, what would you say? And for tummy tucks, do you see maybe 1 out of 10, 1 out of 20…

Travis: Oh, probably…

Dr. Franco: …is a mini?

Travis: …1 out of 20, if not less.

Dr. Franco: Because the problem is, if you did a mini and then you’re not happy, there’s a really significant amount of time that has to go by before you can revise this, because again, trying to protect that belly button. And it always comes back on plastic surgery blood supply, making sure that that belly button’s going to heal well. And so, now, you’ve got to weather the storm for a while. And then, plus, you’ve gone through all the recovery.

Travis: Absolutely. But you did touch on one thing a second ago that I think the listeners would probably love a little bit of expansion on…

Dr. Franco: Just give the people what they want.

Travis: …that diastasis….Right? That diastasis recti. What is that? And I think that is a huge part of a tummy tuck that I didn’t understand before I got into plastics. So maybe you could elaborate on that a little bit?

Dr. Franco: Oh, yeah. You know, I think this is a huge part. And in our videos, we call it an “internal corset” because we’re just trying to get rid of the fancy terms and make this something that people can relate to. But basically, those muscles get stretched and pulled to the side. And that’s why, sometimes, you see people who are really fit, they don’t have a lot of fat and their belly bulges. And sometimes, they come in for liposuction and I’ll push them in front of the mirror and be like, “Hey, you see how you touched those muscles right away? That’s because that’s the internal stuff.” And it’s really kind of cool when we do a tummy tuck and we lift that skin and you can actually see that gap between the muscles where those muscles have been pushed out. And that’s pretty dramatic and that’s one of the most satisfying portions of the tummy tuck is pulling those muscles back together and just re-lining that up.

Travis: And when you say “the muscles,” you’re talking about those rectis muscles that are right in the middle of those six-pack, eight-pack ab-looking muscles, right?

Dr. Franco: Right. And if somebody’s not sure exactly what we’re talking about, then go to @celebrityanesthesia. And in the mornings, he’s usually running without a shirt, and…

Travis: Every day.

Dr. Franco: …you can see exactly where those muscles are. And so, I think that would be a good diagram for you to be able to know where they should be in a perfectly-chiseled man.

Travis: Oh, God.

Gilbert: But it’s not just men, right? I mean, some of those muscles, they kind of separate [crosstalk 00:20:10]…

Dr. Franco: Oh, no. I mean, he’s got a girlish figure, too. Some hips, those shaved legs. No, yeah. No, I think it’s a good representation…

Travis: It makes me faster.

Dr. Franco: …of either sex. Though, a good point, Gilbert. Good point, good point.

Gilbert: Pregnancy can cause that a lot, or lack of exercise of the core and stuff can weaken those muscles and cause them to separate, right?

Dr. Franco: No question. Pregnancy’s probably the most common, but no question, extreme weight gain, anything that simulates that can cause those to come. So it’s pretty rare. I honestly can’t think of the last tummy tuck, whether mini, full, whatever, that I didn’t tighten the muscles, because it’s so rare that somebody doesn’t…Who doesn’t say, “I want my belly flatter and my waist smaller?” I mean, I could use mine a little flatter and smaller.

Travis: And once those ab muscles are pulled together, they actually function like they were supposed to function again. So a lot of women that we do tummy tucks on, you tell me that they’d come back and say, “I feel like I can finally do a real sit-up again. I finally have that ab and core strength that I used to have pre-pregnancy.”

Dr. Franco: Here’s a little quiz for Celebrity, Donald, and Gilbert. Why do you get the four-pack, six-pack, eight-pack? If this is a straight-line muscle, why do you get those little bulges? Why do you get those muscle bulges?

Donald: Well, the straight line is not actually the muscle. That’s the linea alba that…

Dr. Franco: In the middle.

Donald: In the middle, yeah.

Travis: I was going to say that.

Dr. Franco: Right. You’ve got the linea alba in the middle, that’s good. But then, you still have the broadband linear muscle going down because that’s your pulley. That’s what makes you flex, just like your workout machines. So why do you get the little blocks of muscles?

Travis: I would say because they’re pulling from different angles.

Gilbert: It’s hypertrophy of the muscle from working out.

Dr. Franco: But only in a few little spots?

Gilbert: I mean, if you’re only getting in a few little spots because you’re not working out hard enough.

Travis: No, no.

Donald: I would think it’s because of the different sections of…

Dr. Franco: Well, it’s actually…Yeah, there’s something called inscriptions, and those are what section them off. So there’s actually a cool little fascia band. So you’ve got the linea alba down the middle, and then, so the fascia comes around and over them, but it actually enwraps that whole muscle. And that’s what we use to pull these muscles together, but it’s segmented in little blocks. You actually have a transverse inscription, and that’s why those muscles get bulged. You actually have a tight band that separates the little compartments of the muscles as they come down, and that’s why you can see the six or eight-packs, as in my case.

Travis: So they’re not breaking through the fascia, is what you’re saying, like, when you are repairing them?

Dr. Franco: No, no. You don’t want to open the fascia. The fascia’s what [crosstalk 00:22:44]…

Travis: Well, I’m not the doctor. I’m making sure, yeah.

Dr. Franco: No, no.

Travis: I’m not going to be in there.

Dr. Franco: No, no. No, please. Please, please, don’t break the fascia. The fascia’s there for support, thank you. Thank you, Donald. “Battlefield 3.”

Donald: Yeah, exactly.

Dr. Franco: So, a little nugget there. Next video, we’ll show you guys. Tune in at Austin Plastic Surgery where I’ll show you some inscriptions. Kind of cool, just dropping some little anatomy nuggets on you guys. But moving on. So tightening of the muscle, getting the full abdominoplasty. One of the questions with the full abdominoplasty, which is where we go all the way up, typically take the skin from the belly button all the way down to the pubic line area, and then get everything into a good spot here. And so, the question is…a lot of times, is whether you do liposuction with the tummy tuck or not. In the vast majority, yes, we do.

Because there’s areas like the back flanks, and I tell people, “You want to look absolutely fabulous, coming and going.” And so, the love handles typically is an area that we don’t adjust with a tummy tuck, because we don’t want the incision to go endlessly far. We want to do what we need, but only do what we need and then liposculpt the rest of the body, so that we can get that in. There are some areas where you have to be careful in liposuction, especially above the belly button and in that mid-central area, because we do want that skin to heal well. Again, it goes to blood supply.

Gilbert: Blood supply, okay.

Travis: The name of the game…

Dr. Franco: All right, the name of the game in everything.

Travis: …oxygenating those tissues.

Dr. Franco: You know, got to get that stuff to heal. But I do think there’s some fancy stuff we can do with the liposculpting, fat transfer, other things to really get that belly into a good spot. And I think that either Travis or Austin’s most beautiful man brought this up earlier, that it’s not just the removal of the skin. But a lot of times, we get a little bit of hate on our Instagram about why the skin is bunched where we suture it together. And I think people don’t realize if you think about it, just from a pure geometry standpoint, right, the line on the bottom is much shorter than the big arched line on the top.

And so, we can just pull this down. But then, you just have kind of a flat line going all the way that goes much further. You’ll also still look really square if you just pull stuff down, right? That’s not changing the shape. So if we’re working really hard to tighten those muscles on the inside, then we’ve got to do the same with the skin so we can show off all the hard work we did on the inside. So it’s doing that V, so we bunch it. So we tip…purposely V that skin in and try and bunch it in, so that way, you get that nice curve and little silhouette, much like G. Berto. Do you know what I’m talking about?

Gilbert: I do know what you’re talking about. I used to help you with some of these cases.

Dr. Franco: Exactly. And we used to do our little tricks, where we just kind of push, mark, push, mark. And that way, we can get that in and get that nice, perfect shape so that the skin does bunch out. But just sort of like we had talked about on our previous episode, it’s pretty amazing how that stuff just smooths out over time, and you can do some of these little plastic surgery magic tricks to make everything look just perfect.

Travis: So we talked about the mini tummy tuck, a little bit on the full. Is there any other…?

Dr. Franco: A little bit? I feel like we’ve been talking a lot.

Travis: Well, is there any other ones that we haven’t talked about?

Dr. Franco: There are some other ones in terms of this, and most of them are just…It’s all spectrum, so the mini, then the traditional or full. Then, some people, of course, do with or without lipo, so those people, we can be semantic about it, tend to be broken up as well. And then, there’s things like a circumferential body lift or a 360, and that’s where the incision goes all the way around. Some people will do what’s called an extended tummy tuck. I don’t get too much into that with our patients, it kind of goes where it needs to go. But the extended would be kind of going around towards the back, but maybe not all the way around.

People who need a 360 or circumferential tend to be someone who’s lost over 100 pounds and just has excess skin all the way around. So those are definitely options. A lot of the portions stay the same. You’re still tightening the muscles, still limiting…Typically, if you’re doing a circumferential, probably very limited liposuction in those areas, as you are making a lot of incisions. And typically, their issue, it’s just a skin issue and not a fat-removal issue, in terms of that. There are some more…Again, focusing more in terms of stuff like massive weight loss, some people like call it a fleur de lis tummy tuck. Again…

Travis: Oh, getting a little French action.

Dr. Franco: Yeah. No, no. And you know, it’s something that I don’t think is used all that often, but again, sort of like mini, it has its time and place. And I know you…I think you’ve one or two with us, Celebrity. And I know a few other docs at the surgery center do them occasionally, again, just in the right person.

Travis: Exactly. And it’s patient-dependent, and definitely google it. It’s a fascinating procedure, and the way that the incisions go and everything, kind of, comes together is not your traditional tummy tuck. Again, reserved for a special patient population.

Dr. Franco: Because the fleur de lis, just for those of you that don’t want to google it and want to stay on the podcast…

Travis: Sorry.

Dr. Franco: …which we would appreciate, it has a vertical addition that goes up-down the midline towards the belly button. So we do some less undermining, but also helped…sort of like we’re doing the internal corset, bringing that in. Because there’s a limit, sometimes, to how much we can cheat that skin in to give the shape. And sometimes, we need to do some things like that. There are some other fancier…or not fancier, but new or different variations of that where they don’t do the vertical right down the midline and they do them on the side. And I think some of those semantics are a little beyond this podcast, but there are other ways to treat if you just have a massive amount of weight and depending on your specific situation.

Gilbert: One of the things I’ve found really fascinating, Dr. Franco, is how with your full abdominoplasties, you don’t have any drains. In my training, I remember assisting some of the plastic surgeons, and they used to use a lot of drains for the abdominoplasties. How do you get around that?

Dr. Franco: Yeah, we do something called progressive tension sutures, and not something popularized or created by me. Actually, a father/son combo in Dallas actually came up with this idea, and it really works very, very, very, very well. And see, the idea is that people think that there’s just a fluid build-up because of a tummy tuck. Our body naturally makes this fluid because that’s how we distribute the nutrients throughout the body. So what we’re doing is, we’re re-closing off that skin and putting it back in the space so that the body can absorb that fluid like it normally would. And that’s the idea.

I tell people, “Think about your driveway.” If you did a good job and it’s perfectly smooth, the water and the rain just run off and doesn’t collect and everything. It’s there, but it just gets managed. If you’ve got a big old pothole, then that fluid collects. And if we don’t do something to get that skin down to reattach, it’s not able to handle that extra fluid, and then you get what’s called either a seroma or hematoma or something else, where you get a fluid collection, and then that has to be drained. So there’s no right or wrong method. The reason that I do it is, I’m a big proponent, as…and you’ve heard Celebrity and I talk about this, of early ambulation and getting people moving.

And so, anything that hurts is going to keep people from moving. Without the drains, people tend to move a little bit more because they don’t hurt, they don’t have something that they’re carrying around. And the goal is to prevent problems. And so, that’s why I love it. I think people have this false idea that it makes a massive difference in terms of the way they look. Celebrity and Gilbert, correct me if I’m wrong, but I honestly don’t think other…Unless you can find the drain-hole spot, there’s not a real visible difference six months from now in someone that had a no-drain tummy tuck or a drain. It’s truly for those first couple weeks of getting people moving and being more comfortable.

Gilbert: Yeah, I would agree. It’s hard to sometimes even see your little liposuction ports.

Travis: Sure, I agree with that, too. I think the biggest thing is patient comfort. Most patients do not want a drain coming out of them, because now, they’re walking around with some foreign body sticking out of their side. And again, drains aren’t a bad thing, and if they need to be put in…And sometimes, we do put in drains. We’ll do it for some breast cases. Even some tummy tuck cases end up with a drain because again, if that patient was not coagulating quite as well as we wanted to, or had a little bit of excess fluid or bleeding, sometimes we have to put one in to prevent the development of a hematoma long-term. But for the most part, I would say 99% of your tummy tucks are drainless at this point. Would you say that?

Dr. Franco: Oh, yeah. Yeah, at least. But to your point, if you need a drain, you need a drain. I think in the past, the old plastic surgery, just everybody got one. And now, we’re being a little bit more selective. If somebody needs it, they need it, if they don’t, they don’t. And it’s just part of the whole protocol, how can we improve patient outcome, but also patient comfort? How can we get people moving, how can we get them out of narcotics? What are we doing that’s causing that pain, what can we do to decrease it? If we need to do something, we will. But if we don’t and we’re just doing it out of habit, let’s get rid of it.

And I think that’s a big change in all of medicine. It’s hard to teach…What’s the old saying, “It’s hard to teach an old dog new tricks?” And so, I think medicine is slowly transitioning. And some of it, you don’t want to be too cowboy-ish about it, you want to make sure there’s good evidence-based medicine on it. But we also want to keep moving forward and try to find a happy balance there.

Travis: That’s one thing that I love about healthcare right now is I feel like people are actually challenging the status quo and questioning, like, “Why are we using a drain on every single patient?” I was told that in training, but what’s the evidence show? Why are we doing this? We need to be able to substantiate these claims and the reason that we’re doing things. Like, for me in anesthesia, why is every patient coming in…why am I giving them 250 mics of fentanyl and 2 of Dilaudid before, for every single case? There’s got to be a better way to do it that’s more patient-centered and evidence-based.

And I think that that’s how we’re all constantly trying to improve our areas of practice, just like G. Berto talked about going to a class for filler and where he’s depositing and looking at it exactly with a cadaver. Because always trying to constantly improve our services and what we do on a daily basis just helps with a patient’s…their level of satisfaction in our results.

Dr. Franco: I mean, do you think it’s actually possible for G. Berto to get any better at injectuals?

Travis: Actually, that’s a good question. Probably not.

Dr. Franco: I mean, who knows? Who knows?

Donald: He’s teaching the classes.

Travis: That’s right, that’s right.

Gilberto: That’s the next step, Donald.

Dr. Franco: Other things I want to talk about…because the big question is incisions and where that’s going to be. Because I think people who follow us on Instagram or social media, TikTok, LinkedIn, anything, Austin Plastic Surgeon, will see that sometimes we’ll do things because I want the incision to be as low as possible so that you can still…My goal is to get you back into a two-piece if that’s what you want to do. If you want to wear a one-piece, wear a one-piece. If you don’t want to wear a bikini, don’t wear a bikini. But I want you to be able to have the choice to do whatever you want to do. And so, trying to get that incision as low as possible so that people aren’t self-conscious about it.

So that’s one, and people say, “Oh, that’s easy.” But the challenge becomes, too…and Celebrity brought this up earlier, is the belly button. Because if we’re taking that skin out from over the belly button, it may or may not reach all the way down to that incision. So sometimes, you’ll see a tiny little line or a little T from that incision, and that’s the opening from the belly button. Because remember, it’s still your belly button, we cut around it and then pull that skin down. But if that skin doesn’t reach all the way where we’d made that opening to release the belly button, we’ve just got to close that back up. So I hope that makes sense for people, sometimes why we have a T, sometimes why we have to do some different things. But it’s all in unison of trying to get the scar hidden as much as possible.

Travis: And then, once you pull that skin down and you have their old belly button underneath that stomach that you’ve now pulled tight, how do you pull that belly button through a new opening?

Dr. Franco: I think that goes to one of the arts of plastic surgery, right, because belly button, I feel like, is the telltale sign of different plastic surgeons and their tummy tuck. And you can almost tell a tummy tuck from one person to another based on the belly button because a lot of the parts…We’ve said this many times, and I wholeheartedly believe this. It’s not just the party line. I think there’s a lot of incredibly talented plastic surgeons in Austin. I think for the population of Austin, I don’t know if they realize how lucky they are. In terms of the medical physicians as a whole, for the size of the city and the sub-specialists and the specialists that are available in this city, it’s absolutely amazing.

My aunt is coming here in two weeks to have a heart procedure done, all the way from West Texas. And so, it’s just amazing, the access to such specialized medical care in Austin, and plastic surgery is not missed out on that, even outside of just aesthetics. We’re talking microsurgeons, transgender, other stuff that’s available here. And hopefully, we can get them on the ‘cast soon.

Gilberto: Yeah.

Travis: Yeah, that’d be great.

Dr. Franco: Thank you, Celebrity. That’s a pun to you.

Travis: I’ll call my people.

Dr. Franco: But you know, the way I do it…and there’s a bunch of different ways, is I actually like to create this little flap, because my goal is…I think the perfectly round belly button, none of us have a round belly button. And there’s actually a great study that maybe we’ll talk about. Maybe Celebrity and I or G. Berto and I can talk about this study that showed the ideal belly button, and they basically…I wish I had thought about this. I would have loved to have done this study for my internship. They basically went to a bunch of colleges and took pictures of belly buttons of these female co-eds, and then showed people and said, “What’s your favorite belly button?” And that’s how they came up with the ideal belly button. So…

Travis: Wow.

Dr. Franco: …I would have loved to have been the intern on this study.

Travis: Wow. Franco’s dream job.

Gilbert: I know. Anything for sciene, right?

Dr. Franco: Here I am, like, working with mice and in a lab, and somebody’s taking pictures of college students’ belly buttons. I was like, “I missed out.”

Gilbert: All in the name of science, all in the name of science.

Donald: Somebody had to do it.

Dr. Franco: “I’m just doing research. I’m just doing research.” But so, I love to create this little flap because we can pull the belly button down. And I actually cut the belly button short so that it pulls the skin down because I want the incision scar to be below the level of the skin so that you only see the normal skin on the outside. Also, by not making it a perfect circle, it actually breaks up the lines to the eyes. And so, you don’t see the incisions as much. It’s funny because I don’t think people realize, our eyes are basically a bunch of light beams that it fills in the gap. And if you can break that up, it’s less obvious to our eyes and brain. And so, it’s some of the reason that we do Z-plasties and other things that break up perfect lines so that the eyes have a harder time seeing it.

Gilberto: Interesting. A little nugget for you [inaudible 00:37:08].

Travis: Dropping nugs today, man. Yeah.

Donald: Look at this. He’s like a little artist over here.

Dr. Franco: You’re welcome, you’re welcome.

Donald: Geez.

Dr. Franco: But there’s lots of great ways to do it, and lots of people have different…some diamonds I’ve seen people cut, some lines to keep it very thin and then pull it down. There’s some times you can do some tacking sutures on the inside to pull that skin down. So to G. Berto’s point, there’s a lot of different roads to success here, but most people have a few tricks and nuggets to really do some nice things. And we do spend some time on it because I think it’s super important.

Donald: Do you do the upside-down V or whatever?

Dr. Franco: Yeah. It’s a U, thanks for watching. But…

Donald: Upside-down…

Travis: Or whatever, yeah.

Travis: Hey, V, U…

Dr. Franco: And so, sometimes U, I cut out a V…

Donald: … to [inaudible 00:37:46].

Dr. Franco: …pull it down short, de-fat a diamond on the inside so that way, it takes…de-fat some of that up to Scarpa’s because above Scarpa’s is a different blood supply than below. Just some more anatomy nuggets for you guys. You’re welcome. What other questions about tummy tucks can I answer? Because we’re down to the home stretch here.

Donald: Just about recovery, because it’s just like…

Dr. Franco: Ooh, boom. That’s a good one. Thank you, Donald.

Donald: Well, are you know.

Dr. Franco: Great segue there.

Donald: That’s what I do.

Dr. Franco: You know, I think recovery’s a big one. Especially in tummy tucks, I tell people, “You do too much too fast, you get yourself into trouble.” And I can’t stress that enough, you got to have somebody to help you, got to have somebody that’s going to take care of you because moms and farmers want to do too much too fast. Life goes on and they’re just not used to letting somebody else help them. So, got to let people help you, just putting a little bit of time in those first two weeks of letting yourself recover, staying in a flex position. It’s not like the old days that I want you in bed for two weeks, we actually stress that you get up and walk the night of. But giving yourself a chance to recover is huge.

I typically tell people, if you can give yourself three weeks to recover, I think that’s ideal. It’s changed a little bit with the work-from-home. So I think working from home on a laptop, stuff like that, two weeks is super reasonable. But again, we’ve talked about it, if you’re…And Celebrity can touch on this, but if you’re on narcotics, if you’re on any type of things like that, you shouldn’t be making any important decisions.

Travis: Yeah, absolutely. I always tell people, “Don’t make an important decision within 24 hours of getting a general anesthetic, and I normally say, “Don’t change your will or sign any legal documents within 24 hours of a general.” But also, you know…

Dr. Franco: It’s so funny that Mary tried to get you to change some stuff right after your surgery. And it’s just like, when you got your calf implants, she was like, “Hey, change this will.”

Travis: “Sign this life insurance policy.” No, no, not quite. The other thing I was going to talk about is, what we do during the procedure and post-op, to set people up for a good post-op course, and I know we touched on it last time in our podcast, and I kind of tease…Okay.

Dr. Franco: You mean when you said, “There’s no spoiler alerts,” but then, you said, “I’m going to tell you exactly what it is,” which is exactly a spoiler?

Travis: Yeah. So…

Dr. Franco: Okay. Just clarifying.

Travis: …alert, I just spoiled it. We may or may not be getting an ultrasound. And what’s nice about that ultrasound is, it allows me to see through the skin, basically to have almost X-ray vision, if you think about it like that. And it allows me to put a small needle and going and place local anesthetic in a perfect little area that is going to bathe those nerve roots that enervate or give signal to that area, your brain’s signal to feeling in that area. What we try to do is develop this local band of anesthesia basically around your midsection, which we do through what’s called a tap block, which is a transverse abdominis plane block. And we can use a large amount of local anesthetic to fill that space up.

And what it does is, we use one of the long-acting local anesthetics you’ve heard us talk about on here a few times, Exparel. And we’ll mix that with a little bit of shorter-acting local anesthetic, so it starts working a little bit faster during the case and immediately post-op. And then, hopefully, that Exparel, if it’s placed properly and if it degrades over time like it should, we should get up to about 24 to 72 hours of local anesthetic relief in that area. And again, what we’re trying to do is just make patients more comfortable without having the side effects of taking all those narcotics.

Dr. Franco: And I think these are all the little nuggets that people don’t realize, the extra steps, right, the Exparel, the blocking of these muscles. I think Exparel has been a dramatic jump forward.

Travis: Completely agree.

Dr. Franco: I don’t if we were already using Exparel when you and I were working together, G Berto.

Gilberto: We were, yeah.

Dr. Franco: Because before that, and Celebrity probably remembers this too, we had the pain pumps, which are great, but the problem was, they were a little user catheter-dependent. And because they were made to be these tiny little catheters, if they got pulled out, there was no way to put them back in. If they got clogged, if they…whatever, right? And then, also too, they were just laid on top of the muscle. There wasn’t a way to get deep down into the nerves that you’re talking about like we can now with the Exparel. So they help, but I don’t think to the same degree, because the key of these nerve blocks is getting right next to them.

Travis: And that’s one thing that’s huge about Exparel, and you’ve heard me talk about it in the past, it’s that bupivacaine molecule that’s inside of a little liposome. So it slowly degrades over time, but it doesn’t travel through tissue like normal local anesthetic does. So for me and Dr. Franco, we have to be basically right next to that nerve in that little neurovascular sheet to deposit that local anesthetic right along it so it ends up slowly breaking down those liposomes and delivering that local anesthetic over time.

Dr. Franco: And we don’t want to give people the wrong idea. You’re still going to be sore, you’re still going to know you had surgery. But all these things have made worlds of difference from the old days, and this is why you can get up and walk that night of and do some of those things.

Travis: And I always tell patients too, if you’re a 10 out of 10 pain-wise, my goal is to get you to a 5 out of 10. If you’re a seven, I want to try to get you to a three or a four. We’re working to go in the right direction. I cannot make you pain-free. That is not something that is ever going to be on the table after you have any type of surgery. I don’t care how good your surgeon is or how good the anesthesia is, you will never feel like you do walking through the door to have surgery.

Dr. Franco: The last thing I want to touch base on, just because I think it’s super important, tummy tucks, some of the things we worry about are DVT blood clots, and that’s why we’re stressing all these things we’re doing to get people walking and moving faster. Some cool things that one of our surgery centers does and that we’ve incorporated into our practice is sending people home with compression devices, the actual compression devices that you have during surgery. But you know, the technology’s just gotten better. It used to be these big machines you had to attach up, they were at the foot of the bed, just wasn’t practical.

Now you have these tiny little battery-powered things that you can put on, you wrap around the legs and they basically squeeze the calves when you’re in couches. Again, not a replacement for getting up and walking, but again, just all the extra things to make sure that we’re being super safe and decreasing some of these things that we worry about. The other thing we’ve started is a different blood thinner that we’ve started the day after. It used to be that the patients had to give themselves shots and some other things that were a little bit harder. I don’t want to give myself a shot, just not the most fun things in the world. And technology, pharmaceuticals have gotten better. and some of this has made the recovery easier for patients and safer, too.

Travis: Totally agree.

Dr. Franco: Anything else to take us home before we do a little behind-the-bovie?

Travis: I think that kind of rounded it out.

Gilberto: Yeah.

Gilberto: Yeah.

Donald: That was it.

Dr. Franco: Any behind-the-bovie nuggets anybody would like to share?

Gilberto: I thought the one you said earlier, about the actual weight of the tissue not being as much as people think, I can’t stress it enough, it’s not a weight-loss procedure. You’re taking care of skin, you’re tightening that skin, you’re tightening those abs back together. That’s the real true beauty of a tummy tuck.

Dr. Franco: Agreed, not a weight-loss procedure. I think one of the other cool things is, we always say “tightening the muscles,” but to…Somebody had mentioned earlier the fascia, the strong covering around the muscle, that’s what actually holds it in. We actually try to purposely grab just the fascia and not just the muscles, because the muscles would cause us pain, and bringing that together. So we say “suturing the muscles together,” but we’re actually using that strong covering around the muscles to bring them together and hold them into a good spot.

And then, sometimes, people ask us about that suture we use. It’s actually a suture that dissolves over the next six to nine months, because truly, after two or three months, once those things have completely scarred in, those sutures aren’t really helping much. At that point, the body’s healed and it’s just scarred in and set. To go back and take out those sutures isn’t going to make any difference. And so, just letting them dissolve so that there’s no foreign bodies on the inside.

Gilberto: I think one of the things that’s kind of interesting is how you position the patient when you’re bringing the skin together and you…

Dr. Franco: Ooh, that’s a good one. That’s a good one.

Donald: …and you sit them up in a, kind of, flex position to suture the skin. And they, kind of, leave almost, kind of, hunched over a little bit and gradually, over time, as the skin stretches, they can become a little bit more erect.

Dr. Franco: Yeah. No, I like that. It’s called a Fowler position. Anybody know what the original Fowler position…? So for those that don’t want to use medical terms, it’s called “beach chair.” So to get what we’re saying, knees up, bent over a little bit. Fowler position? Celebrity, you’re not old enough to ever have had to do the Fowler position for something. Anybody? This is a really nerd kind of nugget.

Donald: It’s above my head.

Travis: I don’t know, man.

Dr. Franco: Well, why don’t we come back to it on the next podcast? So we’ll…

Travis: All right.

Dr. Franco: …leave a little nugget because it has nothing to do with plastic surgery, was used…probably been 50, 70 years since we used this treatment, but Fowler position came from an initial method to treat something else. I’ll leave you with that nugget. Back to…No, actually, let’s do a little quote of the day.

Gilberto: Let’s do some quote of the day.

Travis: I’ve got one…

Gilberto: Oh, perfect.

Travis: …if you want it.

Gilberto: Yeah, please.

Travis: Okay, this is from Helmut Schmidt. And it says, “The biggest room in the world is room for improvement.” There you go. I thought that was topical because we’re talking about improving patient outcomes and doing things in a better way, in a very conscious way, and thinking about why we’re doing things the way that we’re doing them, and challenging the status quo and looking for evidence-based practice to back up our practice changes.

Dr. Franco: Cool. No, I like it. I feel like G. Berto’s the shining example of this.

Travis: Oh, 100%.

Donald: Always room.

Gilbert: Always room for improvement.

Dr. Franco: Well, I want to thank everybody for listening to the greatest podcast in the world, as voted by us, “Plastic Surgery Untold: Beyond Botox and Butts.” Thanks to all of our guests for joining us, for dropping some knowledge today, it’s appreciated. Don’t forget to follow us on your favorite channels. We’re available on iHeart, wherever you get your favorite podcasts, “Plastic Surgery Untold.” Thanks, you guys. See you soon.

Gilberto: Bye.

Travis: See you, guys.

Donald: Boom.

About The Author

Dr. Johnny Franco
Episode 32: Breast Reduction – The Art of Lifting and Shaping the Breast!Episode 34: Is Zoom Neck a Thing?


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