S05E87 Better Tummy Tucks: Expert Tips to Avoid Dog Ears and Achieve Excellence

Fear the dreaded 'dog ears' no more, as hosts Dr. Salvatore Pacella @sandiegoplasticsurgeon, Dr. Lawrence Tong @yorkvilleplasticsurgery, and Dr. Sam Rhee @bergencosmetic unveil the secrets behind crafting a better abdominoplasty. We unravel the expert surgical maneuvers that prevent these unwanted skin bunches and discuss the delicate dance between trimming enough skin to avoid dog ears and keeping scarring to a minimum. The hosts also share their strategies for incision placement that honor a patient's preferred wardrobe choices post-surgery, ensuring that results are not only medically sound but also aesthetically pleasing.

Our conversation also pulls back the curtain on how liposuction can be a game-changer in smoothing out the body's contour and how they commit to the ethical responsibility of post-operative revisions. This episode is a trove of insights into how the art of plastic surgery is continually evolving alongside fashion and personal style. Whether you're a patient considering a tummy tuck or simply fascinated by the transformative power of cosmetic procedures, this discussion is sure to sculpt your understanding of what goes into creating those enviable postoperative silhouettes.

00:00 Welcome and Introductions

00:27 Understanding Dog Ears in Tummy Tucks

02:36 Strategies for Preventing Dog Ears

04:45 Adjusting Techniques Over Time

08:01 Interoperative Strategies and Post-Operative Adjustments

11:56 Addressing Dog Ears After Surgery

17:50 Concluding Thoughts and Podcast Wrap-Up

Dr. Sam Jejurikar @samjejurikar @3plasticsurgerypodcast #podcast #plasticsurgery #cosmeticsurgery #plasticsurgeon #beauty #boardcertified #aesthetic 3plasticsurgeonsandamicrophone ⁠#bergencosmetic ⁠#bestplasticsurgeon #beforeafter #aesthetics #realpatientrealresult #boardcertifiedplasticsurgeon #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery

S05E87 Better Tummy Tucks: Expert Tips to Avoid Dog Ears and Achieve Excellence

TRANSCRIPT

[00:00:06] Dr. Lawrence Tong: All right, welcome again to another podcast. My name is Dr. Lawrence Tong from Toronto, Canada. I'm joined with my esteemed colleagues, Dr. Sam Rhee, who is at Bergen Cosmetic, and also Dr. Sal Pacella, who is at San Diego Plastic Surgeon. Thanks for being here and thanks for our listeners, uh, for listening in today.

The first topic we're going to talk about today is, uh, dog ears. So dog ears. Um, in reference to tummy tucks specifically. So this is a, um, an issue that can crop up with, uh, any kind of tummy tuck that's performed. So we're just going to have a little bit of a discussion about it. Um, what it is, what we can do, uh, during surgery to prevent it.

And if it does happen, what things can we do, uh, to correct it? So, um, we'll start off with, uh, Dr. Rhee. Um, can you tell us a little bit about what a dog ear actually is?

[00:01:02] Dr. Sam Rhee: Yes, let me, uh, let me go through the disclaimer real fast and then, uh, we'll start talking about it. So, uh, this show is not a substitute for professional medical advice, diagnosis, or treatment. It's for informational purposes only. Treatments and results may vary based on circumstance, situation, and medical judgment after appropriate discussion.

Always seek the advice of your surgeon or other qualified health provider with any questions you may have regarding medical care and never disregard professional medical advice or delay seeking advice because of something in the show. So, uh, dog ears are something that a lot of patients have, uh, issues with after tummy tucks.

I'm sure none of ours because we've addressed them, but, uh, they, it is one of the most. Uh, commonly Google searched complications after tummy tucks, actually, um, I found out. And what it is is, uh, when you, when a patient undergoes a abdominoplasty or tummy tuck surgery, you can get this bunching of excess skin or soft tissue at the ends of the surgical scar.

And that kind of looks like a little peak or mound. And that's why the, uh, colloquial term is dog ear for that. And, um, it's something that I think, uh, I've worked on very hard over the years to make sure to avoid, but definitely I, I do see a fair number of patients for revision that I may not necessarily see myself, but that I haven't done myself, but have come to me for, for touch ups or, or corrections after tummy tuck.

[00:02:36] Dr. Salvatore Pacella: Yeah, I think, um, you know, the biggest issue in avoiding dog ears is understanding. I think the, I think our viewers and listeners need, uh, have to understand that there's, there's an arbitrary place where you have to stop the tummy tuck, right? And so it's a, it, stop the incision for the tummy tuck. And so it's a, it's a little bit of a, of guesswork as to how far it goes, right?

So like, if you're trying to stay between a, uh, inside a bikini line and you're going from hip to hip, well, if you got any excess tissue on the sides, how far do you want to taper that, right? And so, uh, The longer you go, the more the scar is behind the, behind the side of the hip, right? And so if you can taper that at a, at a thinner, in a thinner way, in a more acute angle, that's really the best opportunity for preventing dog tears, I think.

You know, and it's, it's a, it's a fight between, um, removing the skin and not making the incision too long.

[00:03:36] Dr. Lawrence Tong: Right. I, I agree. Totally. Uh, for our viewers, uh, when we do a tummy tuck, you know, we are removing a piece that's sort of like this shape. And so the dog ear occurs right at the end, because that's a pivot point. That's where the, um, the skin has to sort of, uh, Um, fold and if that angle is very large, like if it's a 90 degree angle, then when the skin folds, there's going to be a little bit of bunching where, where it, uh, where it actually folds.

So what, uh, Dr. Pacella was speaking about was to make that incision a little bit longer so that angle at the end sort of tapers more gently. And if you can get it to taper more gently, then you have a less likelihood of getting a dog ear. Um, but. As Dr. Pacella also said, if that happens, then your incision is longer.

So we're, we're trying to get a, the best compromise possible in, in trying to get the least amount of scar length, but also, uh, to try to prevent dog ears.

[00:04:34] Dr. Salvatore Pacella: I wish there was a dog around here we could kind of describe. Oh, Hawk, come here, buddy.

[00:04:43] Dr. Sam Rhee: are you, were you going to show his dog here? No. So I think, um, the way I have designed, my incisions have changed over time. And there are a couple of things that I think, um, I've learned from experience over the years. The first is, uh, and I think we've talked about it before, when we talk about tummy tucks is keeping that incision low, uh, and that is a challenge sometimes depending on how much skin excess you have to work with.

Uh, but the lower you can manage that incision, the more. clothing, the more, uh, the more comfortable a patient feels post operatively in terms of cosmetic appearance. So that's the first thing. The second thing is, is, as Larry described, the, the skin that you're cutting out of the belly is like an ellipse.

It's an oval. And when you cut out that oval, that oval does depend on in part, on that particular patient. How much skin excess there is, where is it located, how far does it extend to the sides, as Sal has said. So, when I measure out my ovals, I'm actually very geometric at this point about it. I, um, I will actually measure the top I'll usually freehand it when I'm with the patient, and then I will also make some fine tune adjustments before I actually start.

And I will measure the bottom part of the oval. I'll measure the top part of the oval. And most of the time, that top part of the oval is a little longer than the bottom. And that's why you will get, uh, and if you don't adjust for that, you're going to get the dog ears on the side. So, what I will do is, um, as Sal said, um, Angle that incision at the ends, make sure that I, uh, address that skin excess, but for me to do that, I have to know how much longer the top is from the bottom, adjust for that, and then Some of it is also angling that incision in the right direction.

So, um, and I think we've talked about it before. Fashions change with clothing. So what used to be an acceptable incision maybe 10 or 15 or 20 years ago is no longer the case now. And I have had patients bring me different swimsuits or Or underwear and say, this is really where I want that incision to lie.

And a lot of times it's low to begin with, but it actually kind of tapers up as you go more to the side or to the flanks around the hips. And so I usually actually do about 90 percent of my. Uh, measurement and cut, but that last 10 percent where it's on the sides, I freehand that right before I close to make sure one, I'm not leaving, um, a dog ear and two, to make sure that that incision is kind of angling the right way up by the hips and that takes practice.

I mean, it, it, it, I feel very comfortable with it now, but it wasn't something that like I learned in residency or was like, you know. Uh, it, it, it took some, um, figuring out and, and also like, you know, over time, because like I said, uh, styles and fashions change.

[00:08:01] Dr. Salvatore Pacella: One little, uh, trick I oftentimes do, which I learned early on in practice is if, if I have somebody that's maybe a little bit on the larger side that I'm worried about tapering the incision off a little bit too far or too laterally, um, most of the time I'm doing liposuction of the flanks and lower back at the same time.

So I'll hang on to the liposuction equipment. And before I'm about to close, I'll really kind of go a little, quite a bit more aggressively, even subdermal underneath the skin to sort of distribute that fat a little bit more right at the very point of the incision. And I found that that helps quite a bit to reduce the prominence.

[00:08:43] Dr. Lawrence Tong: Yeah. Um, another interoperative thing, uh, that I do, and you guys might also do it, is, uh, when I'm actually starting the closure, um, I don't know if you guys use staples temporarily to sort of align the skin. But when I'm doing that and I'm stapling, I'll, I'll start by stapling from the most external portions of the incision.

And then I'll, um, advance the, the top flap immediately, meaning towards the center and just take out the dog ear right away. At that point, you're going to get maybe a little bit of extra skin as you move towards the center, but then You know, you just redistribute that and that's a, that's the way primarily that I use to try to get rid of, uh, the dog ear.

And then, as, uh, Sal just mentioned, maybe a little bit of liposuction, um, to sort of thin out that area. Because if the, if the skin is very thick, uh, with adipose or fat tissue, then, then they have a greater chance of, uh, the dog ear forming.

[00:09:43] Dr. Sam Rhee: Yeah, I

[00:09:43] Dr. Salvatore Pacella: And your, your strategy, uh, sorry, uh, your strategy, uh, Larry about, um, about advancing the upper flap. That, that, uh, helps with, uh, Sam's discussion about, you know, how the upper flap is oftentimes a longer dimension, you know, so I, I do the same thing. And the nice thing about that is when you, when you advance the flap laterally to medially, you, you sort of create a little bit of bunching centrally, which looks very similar to how the rectus abdominis is, you know, you want, you don't want the front of the tummy to be completely flat.

That looks abnormal. You want a little bit of a very, very, very gentle, uh, convexity there.

[00:10:23] Dr. Sam Rhee: Yes, I do both of what you guys say. I, I have to be careful not to over to cheat so much where I get a lot of pleading or bunching like I can get away with like maybe a couple centimeters where you can distribute that like you said evenly so it doesn't, it doesn't look bad. Um, and then absolutely Sal, I think.

You have to kind of aggressively liposuction the lateral flank areas to really get that tissue to, to smooth out a little bit better. And I'm not afraid. I used to be really afraid of extending that excision. Um, I used to try to keep it really aggressively short and that's where you get into trouble, especially with patients with a lot of skin.

Like I will show them where it's going to be. And most patients will take an extra inch or two of incision if it's smooth, then to get the dog ear and, and, and keep it. shorter for sure.

[00:11:13] Dr. Salvatore Pacella: Right. And, you know, I would also say that, you know, despite our best efforts, sometimes you just get a little pooch, you know, a centimeter or so of redundancy. And, you know, for the listeners out there, this is really not a huge deal. Um, you know, doing a tiny little touch up in the office under local anesthesia is super easy.

It won't set back your recovery really. It's, you know, so most of us as surgeons will easily perform a little small revision in the office at no charge just to make you happy. So I think, um, you know, it's a balance between making the incision long and getting it flat.

[00:11:56] Dr. Lawrence Tong: Yeah, so, um, Sam, maybe you can elaborate on. Uh, that, for what the, what the viewers are hearing, what is, you know, how do you actually treat a dog ear that has already formed after the fact, um, what are sort of the, uh, options for patients and, and the steps and how you would sort of go about managing something like that.

[00:12:17] Dr. Sam Rhee: I think Sal's right. Um, as a surgeon, if there's anything that's poochy there at the sides, it's my responsibility to address that. And, um, I have had other patients who've reported that their surgeons either refuse to take care of the dog ears or we're charging some sort of crazy amount to, to revise it.

On their own patients. And I, I feel like it's our responsibility to, you know, at minimal cost to, to address that. Um, there are really two components as, um, we've discussed one is, is it, is there fat tissue, like, is it thick and will liposuction alone help smooth that down or is there some skin excess as well?

And most of the time, if I'm going to go back on my own patients, it's really. Maybe I can just do a little bit of liposuction there, smooth it down, and that gets us where we need to be. Sometimes I, I have to extend the incision slightly in order to really smooth it down or, you know, a combination of both.

But, um, as Sal said, it's not a huge procedure. It's very minor. I'll generally wait some months, uh, You know, somewhere between, you know, I usually like to wait six months if possible, um, and make sure that we get it all to settle out. Um, sometimes if it's early, I have tried, uh, some Kenalog injections. If it's just mostly like some fat in there and I can get a little bit of a fat reduction just from injecting a little bit of Kenalog.

Uh, it's a, it's a freebie. Like a lot of times it doesn't work, but. You know, if I can get it to get down a little bit, that's great. Um, and most of the time it's, as Sal said, pretty minor. Get that touched up and, uh, make sure I address every little detail with that.

[00:14:04] Dr. Lawrence Tong: Anything to add to that, Dr. Pacella?

[00:14:07] Dr. Salvatore Pacella: No, I, I agree with it a hundred percent. I mean, um, the only other thing I would say is, um, you know, many times what, what I've found that can sometimes contribute to the outside of the scar not looking as good as the center of the scar is, so, you know, we, we oftentimes do these suture, the suturing techniques, uh, what we call subcuticular.

So right underneath the skin and then, you know, at the very tip of the incision, um, you can hide the knot deeper down into the tissue or alternatively bring it out towards the skin. And so I found at times when I want to try to hide the knot in there, um, that's a setup for this, the knot becoming infected or having what we call a suture abscess or a spitting suture.

And when you have sort of separation in that area, Um, it just makes the very tip of the scar look odd and wider and red. And so, you know, I routinely bring out my sutures, um, and tie them to externally at the skin. So there's not a knot kind of deep in the skin,

[00:15:12] Dr. Lawrence Tong: The other thing, um, that. Sam mentioned about liposuction, this is a slightly different issue, but oftentimes you'll see that where the incision occurs, if you have your incision fairly low, especially, is that there's going to be a mismatch between liposuction The upper flap and the lower flap. So the skin that was brought down from above sometimes is thicker because that skin in and around the mons area or even lower down, uh, can be a lot thinner and, uh, as surgeons, we have to be careful.

aware of that. And if we see that, that is something that could happen. Sometimes we'll talk about, um, also doing some liposuction at the time of the surgery, but sometimes you see this little step there and patients will think that there's something wrong with the scar when it's actually a mismatch in the, in the flap thickness.

And sometimes going back in to do some liposuction, uh, we'll just solve that problem very easily.

[00:16:13] Dr. Sam Rhee: Yeah, when I do my initial tummy tuck, I have learned to not be aggressive or oftentimes, if not needed, to, uh, not lipo the mons area or the lower area at all because you're, like you said, you can do that and you can thin that area out. And then that top flat looks so thick. It's, it's quite a step off. So I'm.

I've learned a lot because they used to teach us never be too aggressive with the lipo during the abdominoplasty, yada, yada, yada. And I have gotten more and more aggressive with my lipo in those areas. I felt like it was sort of a misnomer back in, in the day when we trained. And, and that's really the best way to sort of get that nice, even, um, sort of, Uh, approach to that incision.

And the same thing for me, Sal, like I don't knot it at the end anymore. I bring it out. I'll, um, like I said, I'll, I'll maybe put a, you know, secure that to a small nylon or something. Like, I just want that area to just be super smooth. And like you said, when you knot it at the ends, um, that, that can cause problems.

So, um, so definitely it's all these little things that I think experience teaches us, um, and. It's so funny. Every time I talk to you three, uh, we have often come to the same conclusions, even though we never actually talked about it. Like, you're like, you do that too. Yes. I figured that out as well. So, um, it, you know, experience just really sort of leads us to converge on what works.

[00:17:48] Dr. Lawrence Tong: All right. Very good. Um, if there's nothing else to add, uh, gentlemen, uh, That will conclude the podcast for today. Thank you, all our visitors, uh, for, for listening and, uh, be sure to stay tuned, um, for our upcoming episodes. See you guys later.