Episode 59: Thursday November 17

Belly buttons are little, but they are a big deal, especially in tummy tucks. How can you get a great belly button appearance after your surgery?

Today we talk to special guest Dr. Bradley Hubbard @bradleyhubbardmd, board certified plastic surgeon in Dallas Texas, who has studied the belly button exhaustively. He shares his tips and tricks with Dr. Salvatore Pacella @sandiegoplasticsurgeon, Dr. Sam Jejurikar @samjejurikar, and Dr. Sam Rhee @bergencosmetic on how to feel comfortable wearing that two piece after that mommy makeover.

Dr. Hubbard graduated from Upstate Medical University, where he was chosen for the Alpha Omega Alpha Medical Honor Society and graduated cum laude. He completed his plastic surgery residency at the University of Missouri, receiving the Most Outstanding Resident of the Year Award, and the Excellence in Resident Teaching Award. He completed an additional year of training at The University of Texas Southwestern Medical Center in Dallas, specializing in aesthetic surgery. As a member of the renowned Dallas Plastic Surgery Institute, Dr. Hubbard focuses on adult aesthetic and reconstructive surgery.

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2022.11.17 S03E59 DR BRAD HUBBARD HOW TO MAKE A GREAT BELLY BUTTON

[00:00:04] Dr. Sam Jejurikar: Welcome everyone to the latest edition of Three Plastic Surgeons and a microphone. As always, I'm Sam Jejurikar in Dallas. Joined by my two two co-hosts. To my immediate right is Sam Ree at Bergen Cosmetic, located in Para New Jersey and Dr. Salvato Pacella at San Diego Plastic Surgeon. Today we have a very interesting and very specific topic by the guy that actually taught me everything I know about belly buttons.

And that's Dr. Bradley Hubbard, who I'll introduce here in a second. But Dr. Hubbard is an amazing plastic surgeon in Dallas. Before we get to Dr. Hubbard though, first we're gonna just take care of some some house cleaning, Dr. Uh, So

[00:00:43] Dr. Salvatore Pacella: this is our disclaimer. The, the show is not a substitute for professional medical advice, diagnosis, or treatment.

The show is for informational purposes only. Treatment and results may vary based upon the circumstances, situation, and medical judgment. After appropriate discussion, always seek the advice of your surgeon or other qualified health provider with any questions that you may have regarding medical care, and never disregard professional medical advice or delay seeking advice because of something in the jail.

[00:01:09] Dr. Sam Jejurikar: So today I wanna introduce Bradley Hubbard. I've had the pleasure of being a partner with Dr. Hubbard at Dallas Plastic Surgery Institute for the least. Has it been 10 years? Brad? I don't remember the exact year you joined. No, I got. Yeah, been about, been about 10 years and we've been really good friends for that time as well.

Brad has built an incredible aesthetic surgery practice in Dallas. He's incredibly well known. It takes months and months and months to get in to see him. So if you're lucky to get in to see him, take your appointments and patients know Dr. Hubbard as an amazing plastic surgeon. But I wanna talk about some other aspects of Dr.

Hubbard before we actually get into the meat of the thing, the meat of it. So, so a few years ago we we realized that Dr. Hubbard has quite the personality. And so his office every year does an amazing Halloween spread where they'll actually show, showcase the office staff as well as different aspects of Dr.

Hubbard's personality. And I think this was the first year Dr. Hubbard's office actually did this in the pandemic. It was, it was my personal favorite when when Tiger King was really the rage, this is when Heartthrob Bradley Har kind of made his introduction to the plastic sugary community of the world and also Dallas, Texas.

And this is still my all time favorite. Um, I George

[00:02:23] Dr. Bradley Hubbard: Castanza there,

[00:02:23] Dr. Sam Jejurikar: I think this is, this year's. Dr. Dr. Dr. Hubbard as Austin Power, kind of showing off his playful and goofy side. But there's another aspect of Dr. Hubbard, which I think people need to know about. Dr. Hubbard at Dallas Plastic Surgery Institute is the ultimate prankster and A few years ago I let it be known that my patients call me Sam, or they call me Dr.

Jay or Dr. Jejurikar, but for, it just drives me nuts when they call me Dr. Sam. I'd always sort of held onto this notion that Dr. Dr. First name was sort of a name for like a guitarist or a pediatrician, but not really like a plastic surgeon. So a few months ago, I walk into my office on a clinic day and there's this giant banner hanging up which I subsequently learned.

Dr. Hubbard pays a hundred bucks to make every time he does that, said Dr. Sam plastic surgery. And I saw it. I quickly just got irritated by it. It was down within about a minute. But it was filmed during that time. Haha, he got me. It was great. A month goes by, I walk into the or he made another one of these signs and now it's hanging up in the or.

But he's carefully had it positioned so that these sterile surgical instruments prevented me from actually doing anything with it. So I had to operate the whole day with this, this sign up. Ironically though, the prank, although it was epic, backfired just a little bit because as the date went on, other plastic surgeons kind of came by, saw this.

One of them in particular got pretty jealous of the whole thing. Just the fact that I had a banner advertising my practice in the or. So it stayed up for a while, kind of became a thing in that or where people would sign it. And then one day it mysteriously disappeared. I don't know who who did it, but then we moved to the greatest prank of all time, and.

This is August of last year when I'm leaving work one day. And a few minutes before I leave, my office manager, whose parking spot's right next to me, sends me this picture. Someone has actually defecated in my parking spot. Immediately my suspicion went to Dr. Hubbard and his first, or his first assist, Kate, who, anyone who's who is a patient of Dr.

Hubbard's know that the two of them have quite a dynamic. And sure enough, we found some footage and we actually found some video footage of a gentleman who, to me, looks suspiciously, Doc like Dr. Hubbard. In the parking lot actually doing his business now. What I'll say in it, and again, we'll get, we'll get to the beginning of it right here.

I'm convinced this is Dr. Hubbard, so I will issue a few disclaimers. One, this is not actually footage of my parking spot. This is probably not Dr. Hubbard. And he strongly denies his involvement in this, but I do know that he finds it incredibly irritating that I keep saying that he did this. Pranks typically are way too elaborate to be quite this.

And with that, I turn it on, turn it over to one of the best plastic surgeons. I know Bradley.

Best intro

[00:05:23] Dr. Bradley Hubbard: ever. I got excited about the video. I thought we finally, figure out who the perpetrator was.

[00:05:31] Dr. Sam Jejurikar: So, so Brad, why belly buttons? Why do you wanna talk about belly buttons when you could talk about the full spectrum of plastic surgery?

[00:05:39] Dr. Bradley Hubbard: Well, a couple reasons. One, I think it's probably the most overlooked part of a tummy tuck that usually comes at the very end of the procedure and I.

After a long, hard day's work, it's sort of an afterthought. We're just trying to get done with the case. Really like the heavy lifting and the danger and the, the things that we worry about are all kind of done already. And this is just kinda a minor last part, but really for, I find for patients, it's probably the most important part.

They are trying to get into the world of two piece swimsuits and showing off their abdomen. That was the whole point of surgery. Ruin this one aesthetic piece. It can be problematic, I think for young plastic surgeons out there. Being able to do this well is a huge marketing piece. I think all patients are cruising around to Instagrams and looking at belly buttons, and that's how they're choosing

that. And. As I also have a problem with obsessing about things and at one point in time this became one of my obsessions and I spent way too much time thinking about it. And so kind of analyzed that all down to every detail. So also, we only have 20, 30 minutes. I feel like if we chose some other topic, we'd only cover 10% of it, but I think we can really handle all things belly button in 30 minutes.

[00:06:52] Dr. Sam Jejurikar: I, I will say Dr. Harber is incredibly detail-oriented as, as we all are, but he takes obsession to a whole new level. But I will say he typically comes up with very creative solutions. So I know you've got some slides to show us, Brad,

[00:07:06] Dr. Bradley Hubbard: I'll share a couple of just to going here. Let's see. Okay. Also, I wanted to point out that just to annoy Sam a little bit, My name on this podcast is Brad ,

[00:07:24] Dr. Sam Jejurikar: but it's not Dr.

It's actually not Dr. It's actually not Dr. Brad.

[00:07:31] Dr. Bradley Hubbard: Correct. So this is the, Can you guys see it?

[00:07:34] Dr. Sam Rhee: Yeah. You might flip to slide mode

[00:07:38] Dr. Bradley Hubbard: call.

[00:07:40] Dr. Sam Jejurikar: Okay. That is, That is the original sign. Perfect. So

[00:07:43] Dr. Bradley Hubbard: that's the original side and we can tell this is still pandemic with the mask. My great pleasure. He's already frustrated before he walked in the door and then saw this on his wall and he was about see about patients in, and so how do I get this immediately?

Okay. So I thought I'd start like, okay, to do it right, we gotta know how to do it wrong. It's very easy to cruise around people's Instagram and websites and find some examples of things going wrong and also, I wanted to point out most of these slides have really nice tummy tuck results that are absolutely ruined by the belly button.

This being one obviously it's much too big. It's kind of a big oval orientation. The hardest part about finding slides that I could use for this is people put watermarks all over their slides because they want to take credit for their horrible belly buttons, . So luckily I found a couple of these where I can just like cross it off at the bottom.

This is one of the big complaints I have in a lot of people's tummy tuck technique is just no contour. We can see in our before picture there's nice shadowing and contour and natural curves are on the belly button, and this. The result is no contour whatsoever. It looks like a hole punched out, and I think it's a little bit too

[00:08:56] Dr. Sam Jejurikar: high.

I've had, I've had patients refer to it as a cat's anus before, which I thought was the best. Oh, don't worry. That's coming up.

[00:09:02] Dr. Bradley Hubbard: I coming it. I don't think that's the best example of that. Mostly cuz the tunnel's up to get a good cat butthole, you have to have a tunnel straight up, like

[00:09:10] Dr. Sam Jejurikar: looking at all of it.

Got it.

[00:09:12] Dr. Bradley Hubbard: Ok. So this is a nice, like what I call a coin slot. They did a. Big time, vertical, oval and probably was. They drew a circle but not on tension, and then once they pulled the tummy, tucked down on tension, they created this oval shape. That'd be my guess. Here's just way too big of a diameter. Here's a good cat pothole.

I think this is an interesting one. When she's standing up, it's not so bad when she lays down, she gets this kinda, I dunno what you call that, like Chinese finger cuff, like slinky kind of phenomenon where the skin bulges out like that just left way too much Umbilical stalk. This one tunnels way up.

She showers that belly button fills up with for sure. And here's my best capa picture I could find. Cat anus. I'm okay with that too. So anyway, those are all the things to go that can kinda be done wrong, right? And if I was gonna give like my basic principles, you gotta fix a hernia that's there. You gotta fix the muscles after, create your ideal length, which really has more to do with ratio to like the flap thickness.

If you have a really thicker flap, a thicker ad post layer, you're gonna want it to be a little bit longer. But if they have none, then you. Shorten it up. Once you've figured out the length, you gotta figure out the diameter. And that's where my technique, I think is pretty sweet. And then we gotta make our inside opening.

This is probably the most important thing. You have to inset it lower than where the actual is so that it tunnels downward. It comes straight out. You get the cat butthole. If it tunnels up, it catches rain, all sinks like that. Ok, So here's a little drawing of my technique. And I even, I don't know if

these

[00:10:57] Dr. Sam Jejurikar: will play.

Go back. Go back to, Okay.

[00:11:00] Dr. Bradley Hubbard: Yeah, you want, I think the video's kinda better, so, Okay. Yeah. So this is the start is I made it the right length and now I want to control its diameter. And so we just take a wedge out of the bottom portion of the belly button, create a defect that we're gonna fill.

And depending on the size of your belly button, if it's really, really huge or really, really wide, one, you can make your wedge really, really wide and narrow it, or change the diameter. If it's really, really small, I don't cut out anything at all. I just make a vertical slit there at six o'clock, and so I can open it and make it a little bit wider diameter.

So next is the inset, if that's where I think the belly button is. I want my result to be lower. So I draw this arch about the tip of it being at the stock. So my end result's a little bit lower. I dunno to, Okay, we don't need to. So, but that's how it also in, you can see this tucks down underneath. To resurface the bottom of the belly button.

[00:12:12] Dr. Sam Jejurikar: So are you doing a three, when you're putting in that, that stitch, is that like a three point stitch where you're anchoring that flap down to the, to the fascia? How are you putting in that key anchoring stitch?

[00:12:23] Dr. Bradley Hubbard: Usually not. Usually I've anchored the sock of the belly button already, and I don't use the stitch to do that.

These are dissolvable stitches that are gonna go away underneath the skin in about a. So if I'm going to anchor the belly button with something I'm gonna do with a permanent suture. Okay. And so this is just kind of a standard, my makeover every day patient, and that's the result that I'm hoping to achieve on a regular basis.

I think it does a bunch of cool things that hides the scar on the bottom because there is no scar on the bottom edge. I think it gives a little bit of contour or. , especially at the lower half, as it kind of curves up that flat placement for people who make thick scars, orkel scars or contractile type of scars, which kind of puts little like zplasty or breakup in there for us.

Yeah, and that can control the size. So those are all the things that I

[00:13:22] Dr. Sam Jejurikar: like about it. So just for our viewers out there, cuz our, our viewers aren't plastic surgeons. Sure. One of, one of the great things about Dr. Harvard's technique is a basic principle of plastic surgery is an order. You, we can't, we can't not make scars visible, but to make them less visible.

We can try to break them up so that they are not straight lines or they're not in continuity. So with Dr. Harper's technique, And he kind of glossed over this. But the key thing is there is no scar along the bottom portion of the belly button because of the way that skin flap is, is in set. There's this nice, really youthful hood over the top of it, and no scar across the bottom that's visible.

And so the scar is hidden in a place where it's not seen and the remainder of the scar is very much broken up. And so that's why when you. This result, and then the results that I assume will follow. You don't really see the scar in the same way that you see it in all the ones that you showed preoperatively, even though there is a scar there, which is great, and I think it's a, it's a small point, but it's a, But it's important for the viewers.

So Brad, just

[00:14:22] Dr. Salvatore Pacella: a, just a question here. So, traditionally when people do tummy tucks, they in the donor flap, the, the, the abdominalplasty flap, they cut out a circle a, a defect. So are you just cutting a, a small C shaped slit and using that tissue that somebody would normally take out and discard?

And tucking that into the, the apex of where your, your onus

[00:14:49] Dr. Bradley Hubbard: is. Yeah, exactly. I call it like an arch shaped incision. Got it. I went back to that thing. So you can see my skin there is, is folded down to cover the bottom 30%, 40% of the belly bun replace that skin that I just cut out. Got it. So it's kinda a one for one exchange.

And it hides my scar and it kind of, It does tug down on that little flap of skin or that arch of skin, which I think creates little indentation or contour in the abdomen so you don't get as much of a hole punch.

[00:15:23] Dr. Salvatore Pacella: So what do you do in situations where the the abdominalplasty flap is, is rather thick?

So in a, in a heavy, somebody who's heavier or has a lot of subcutaneous

[00:15:32] Dr. Sam Jejurikar: fat there?

[00:15:34] Dr. Bradley Hubbard: Yeah. Well, right in this demonstration, it's not like that. And what I would do in that situation is when I, when I cut out my wedge of belly button, where I want the flap to kind of fold into, I wouldn't take that wedge the whole length of the belly button or the whole depth of the belly button.

I would only go down a wedge. It's like two centimeters deep, just the right size for my flap to fit in place so the scar wouldn't go buried all the way down to the base of the sock, just buried enough.

[00:16:04] Dr. Sam Jejurikar: Got it. Got it.

So, sorry, we, we sent you backwards and I knew you were ready to move on. Another slide. Maybe move on there.

[00:16:11] Dr. Bradley Hubbard: That's the starting conversation here. So, so I think it's pretty easy to get a result on our standard patient, and I think there are some patients where it starts to get really tricky. This is one where, Has a belly button hernia, basically right at the base of it.

She has like severe rectal dias. And these are tricky ones because the blood supply to that skin is a little bit compromised. And it's hard to get a really good any I find with these.

[00:16:42] Dr. Sam Jejurikar: Do you guys agree? Completely agree. So, So, and one of the big things,

[00:16:47] Dr. Bradley Hubbard: there's no fat, there is no flat thickness to give you any depth.

There's a rec lation, which will help, but sometimes that passion in between theus is so floppy, the belly button still can get pulled out.

[00:16:59] Dr. Sam Jejurikar: So one of the big trends and plastic surgery that you and I have talked about a lot is neo umbilicals. So in this sort of patient, how could you imagine using your technique as a neo umbilical possy?

Or would you not think about doing.

[00:17:13] Dr. Bradley Hubbard: I, I never, I've yet to see a neo umbilical plasticy that's better than a good belly button salvage, if that makes sense. I think there's some neo umbilical plastic techniques that are better than others for sure. They give nice results even, but still don't recreate exactly the aesthetics that we're looking for especially in thicker patients.

Sure. So in, in all cases, I try to avoid that if I

[00:17:37] Dr. Sam Jejurikar: can. What do you guys think about that?

[00:17:42] Dr. Sam Rhee: I agree with Brad. I don't think I'm a big fan of neo umbilical plasty. Even in, I don't know, secondary reconstructions. I, I will always try to salvage with the original if I can. And, and I've seen surgeons who advocate going direct to neo umbilical plasty in some cases.

But yeah, I don't, I don't see why.

[00:18:04] Dr. Sam Jejurikar: Even in the,

[00:18:05] Dr. Salvatore Pacella: even in the the thickest or most destroyed belly buttons in the setting of an umbilical hernia, I think there's still some tissue to salvage and, know, I agree. It's like the, the natural tissue's always the best to use, even in part

[00:18:17] Dr. Sam Jejurikar: art. Interesting. Cause I probably do about 25. To 30% neo umbilical plasty, and I kind of reserve it for two groups of patients.

One morbidly obese patients who have a BMI over the age of 30 who, who have a BMI over over 35 who I'm doing a different style adominoplasty on something called the Chua Abdominalplasty, which I know Dr. Harbor knows what it is, and you guys know what it is. But for our viewers, it's basically. A very modified nontraditional tummy tuck where your lip is suctioning the upper flap.

You're not tightening in the same way, but because of the way you're dragging down the belly button, stock, stock with all transverse location, you can't really salvage the belly button. And then I do do a fair number of. Tummy tucks in combination with general surgeons who do massive abdominal wall reconstruction.

And many times when I walk into the operating room, the belly button is gone cuz they got rid of it. It's part of the hernia repair because they said they couldn't salvage it. So in those situations, I do neo umbilical plasty. I've been really happy with my technique over the last year because I've taken a version of Dr.

Hubbard's reconstruction where I, where I take this crescent flap. I tuck it down in the manner he does, and I do a full thickness skin graft from the skin that was taken off the tummy. And it looks reasonable. I core out a little bit of fat, so there's a little bit of, I mean, in many of them now, I, I kind of forget that they were not native belly buttons and I, you do that

[00:19:43] Dr. Bradley Hubbard: primarily Sam.

[00:19:47] Dr. Sam Jejurikar: Yeah, I do, I do. Even though it's risky. , let me, lemme actually, most of the time I do, a couple times I have

[00:19:55] Dr. Bradley Hubbard: sutures, yeah. Permanent sutures are mass infection that make me a little edgy.

[00:20:00] Dr. Sam Jejurikar: Well, well, the, well the me the mesh is buried when the way that, that's the case, like the meshes buried below the rec and dominus muscles, so the mesh isn't exposed.

But yeah, there's definitely, I've been burned once by it. But, but 99% of the time it's been. Cool. Okay.

[00:20:19] Dr. Bradley Hubbard: Well, I dunno, I think I got one or two more things. If we can stimulate another conversation here. So umbilical hernia, just kinda proving you can do it with a real umbilical hernia. The key with this really is, I think in any other technique that belly button skin's been so stretched out and so dilated.

You need to have that wedge technique to narrow its diameter. Otherwise you're gonna end up with something. And then this is the last one I. I believe so firmly in avoiding the neo umbilicus. This is a lady who had a previous umbilical hernia repair. I got the operative note, the stock was completely released off of the muscles and so that blood supply was gone.

And so I did a delay procedure three weeks ahead of time and cut the circle like 270 degrees and let the skin kind of, classic plastic surgery rules, the delay principle and was able to get it to live.

[00:21:16] Dr. Sam Jejurikar: Which I thought was pretty cool. That's awesome. That was really good.

[00:21:21] Dr. Sam Rhee: How many of these would you say you've done any sort of secondary work on?

Like in general?

[00:21:29] Dr. Bradley Hubbard: Of, of my own or

[00:21:30] Dr. Sam Rhee: you talking about? Yeah, just like how many of your tummy tucks would you say you go back and do any kind of revision of the unbill um, at all, if any?

[00:21:40] Dr. Bradley Hubbard: Pretty rare. Okay. I would say one or 2%. Since. Doing on Instagram and people are following belly buttons, I would say I do two or three a month of other people trying to convert it or change their technique into something that looks a little bit better which is much more difficult than doing it the right way the first time.

But of my own, pretty rare, pretty rarely

[00:22:00] Dr. Sam Jejurikar: do anything.

[00:22:02] Dr. Sam Rhee: It's interesting cause I've seen the Chevron design, but that's where it's reversed. It's actually you're. Inferiorly with that wedge as opposed to superiorly, which, which I've seen before. And I think your technique is better. I think it, it makes more sense to me.

[00:22:20] Dr. Bradley Hubbard: I think the Chevron was designed because everyone talks about like putting over the belly button was important. People talked about that as the ideal, belly button aesthetics back in the day, which unfortunately weren't ideal. Tummy tuck, belly button aesthetics. So it's ideal like 20 year old.

Women on, sororities on campus where they took all those original patients from, and that's a hard bar to go after. I think it's probably better to compare the tummy tuck results and, and look at those aesthetics. But anyway, the Chevron is just, they're trying to put a big pile of skin on the top of the value bottom that would make it look like it's hooding.

But most of the time it just looks like a big pile of skin. I.

[00:23:02] Dr. Sam Jejurikar: I, I can say looking at the, OR schedule at our surgery center, I see Dr. Hub's name frequently doing revision bellybuttons on other people's patients. So I know that that's indeed a true thing. And I'll say that I, I largely adopted his technique.

A year and a half, two years ago, cuz I was so sick of hearing him talk about it all the , it has profoundly improved my patient satisfaction with their belly buttons. It's a, to the viewers, this seems like a simple little thing that we're talking about. But most plastic surgeons that you go to are just gonna cut a circle around your belly button and sew a circle back in.

They might use interrupted buried sutures that, that, don't leave track murs. In some cases, people still use, horrific sutures that leave these ugly little track marks around it. This is something that takes 10 or 15 minutes more at the end of the case, but it can make a huge difference in the final results.

Guys, Brad, I don't know if you have any other final thoughts about this at all. I mean, I think this is a really nice summary of, of what someone can do if they really think about how to plan every little step of an operation to create the aesthetics that patients want. And so, I mean, I really, I know how much you've thought about this and everything you've said, I've, I've largely adopted.

Do you guys have any other questions for Dr. Hubbard at all? Have you

[00:24:14] Dr. Sam Rhee: published this? Because I think you should call this the Dr. Brad Bellybutton actually, and, and refer to it.

[00:24:20] Dr. Bradley Hubbard: Thank you, Sam. I appreciate it.

It's actually been a running joke. We train fellows in our group every year and. Since our very first fellow, like eight years ago, I reassigned this as something to write up and publish, and I think finally it was accepted by PRS just a couple months ago, so it took eight years worth of fellows to get it done.

I should have thought about the naming ahead of time. I don't know if it's too late, but it's a good idea. We should throw out it in

[00:24:50] Dr. Sam Jejurikar: there. I mean, I think I think social media is gonna be so much more powerful, powerful for naming it. So Dr. Brad Bellybutton, here we come. There we go.

And by the way, you two don't know it about each other, but Dr. Pacella and Dr. Brad are both artists, Buffalo Bills fans, and I know, oh, nice. Dr. Hubbard is eager to get off his podcast so he can start watching . Well, thanks for your Brad. I, I we, we really appreciate it and we know our viewers are much more educated for it.

So thank you again.

[00:25:22] Dr. Bradley Hubbard: Oh, thanks for having me guys. It's a lot of fun. Take care. Thank you.