 Good morning, everyone. Dr. Salkin and Beverly Hills. We have our fabulous patient here today. We're doing some tummy tuck today with a little bit of lipo contouring. She's beautiful. She's early 50s, two kids at C-section, but right now today we're going to do some work on her to even make her fan fabulous. You can see the marks in the red and the block. I mean, that's where we're doing the lipo. We're doing some in the pubic area. One interesting thing is the more I do it, the more I find out. Look at my blue midline and look at where her umbilical is shifted toward the left. It could be anything from her C-section or how the fat is deposited that happens, but we'll keep it in line. We're going to take off as much skin as possible. I can't take out 100% of the stretch marks, but I'll go as high as I can. Minimum is going to be the green. Maximum is going to be God knows how far. I'll try to do the best as usual. She's very petite. This is just excess skin. You can get rid of excess skin with just working out. Excess skin has to be cut out and when we do that people feel better. They'll be ready. She'll be ready for her bikini. Again, we're going to take out the fat here. She has a great waistline. She's going to have a great waistline. We're going to make her small. She has great buttocks naturally. So she's going to get more flat here. It's going to be fantastic. Stay tuned. This is going to be a great case. Hey everyone, Dr. Saul. We're back in the OR. So before we even get started on the tummy tuck, we did two liters of lipo section. Go over there. Look at the lipo right there. Look at all that beautiful fat. Over two liters of fat from the love handles and the pubic. That's just appetizer. Now we're getting to the real meal. So we're going to start by isolating the belly button. So we put in some tumescent fluid. It's always good to let that sit in there. That's how we get bloodless surgery here. So we're going to isolate going around the belly button. My dear great assistant here assisting me. And there we are. Just to show you how much fat she has, my finger is going through to touch her muscle where we're going to be. And look at how deep she is. So she has about one to about three inches of fat deep. So then we're going to use a scar. Look at my scar is always in the hair bearing area. So when it's in the hair bearing, I know no one wears their bikini below their hair bearing area. So you could see how low the scar is going to be. So we're going to start. So she has a C-section scar you could see right here. So I know inside when I get to that area, she's going to have some inflammatory tissue and scar tissue already there. So that's going to all this you see are the tumescent fluid. You could see there's hardly any bleeding. It's all clear fluid. That's just tumescent fluid. When I did the lipo of the pubic area. So you see this right here. This is the what's remnant after the lipo suction. You could see it's just the fibrous tissue. That's we call it honeycomb because it looks like a honeycomb because the fat's been taken out. So there is a scarfless fascia. It's this layer right here which I'm opening up to get to the muscle fascia. You could see the muscle right in there. Do you see how those diagonals coming in underneath the white? That's the muscle and that's the fascia over the muscle. That's your six pack muscle right there. So this is the scar tissue I told you about from the C-section. Look at it right there. You see how it's stuck down. Everything else opens up except where she has the scar tissue where we have to be more careful. See how smooth this shear layer is right here. But where the C-section scar is there's scar tissue right here. You see that? I'm trying to lift it. Otherwise look at how beautifully it peels. We have to be careful here right there. It's tattered down. So laterally where there is no C-section scar look at how beautifully it separates as I go with my electrical laser pen. It separates it beautifully. But the scar you could see it goes right here. So now when we know we go from the known to the unknown. So now we're just lifting up the scar. I think we're coming through where her belly button was. This is an incision we made. So right now I've lifted everything up and you can see how much of it I could pull off. So we're going to get good amount of skin to pull down. Now we're going to open this up to the belly button. So I know I can take out as much skin as the belly button. You see that? I know I could take it. So I'm going to just open it up here. Boom. So we're down all the way. There's her belly button right there. So you could see when you're in the right plane here there's not even any bleeding. You look at how easily it's like butter. Look like butter it goes very look I can almost do it with my fingers. You see these little blood vessels we have bigger ones underneath but you could see these ones that I could take off and look at how with my just my finger I can move things around because we're in the right plane. A couple of things I want to show you guys at home. Look at this beautiful blood vessel. This blood vessel comes from underneath through the muscle and goes to the fat and to the skin. So when people come and say I want either lipo or tummy tuck there are two different things. This lady here she needs both. This is this thickness needs to be thinned out which is done through lipo but this excess skin needs to be taken out by tummy so they're not interchangeable procedures. They're not interchangeable procedures so everyone someone might need both lipo and tummy tuck but we can't do it together it's not safe. You could see there her six-pack muscle it's a little loose we're going to tighten it up. I went all the way up to the xyfoid bone. The xyfoid bone is on the chest bone and we dissect all the way to the xyfoid which is the continuation of the sternum so now what we're going to do is we're going to put in sutures and tighten her stomach muscle. You could see under it she's not that big of a girl she's very small but it's the fat outside that adds to her circumference. So when she pulls up you could see that there is some looseness of the muscle. Our amazing anesthesiologist has relaxed the patient so we could see where the defect is so the edge of the muscle is here to here so we're going to put it back together. Nothing gets cut it gets folded on top of each other it's called plication. So here we go we do a figure of eight sutures if you guys follow us on instagram or whatever social media I'm sure you've seen us do this. This is a very critical moment in the surgery because this is what gives you the internal corset I talked to you about. It's like you're always wearing a corset from the inside so it really tightens you very nicely as you could see it's only through the white not through the muscle and it gets folded like that and closed up. The muscle doesn't have any strain which is kind of ironic because you think muscle is stronger but if you put suture through a muscle it rips but this white layer that covers all muscle in the body the fascia is the strong layer and holds it together. So I want you guys to see something with just one stitch here tightening it it pushed everything down low so we're going to put another suture down here to kind of make it even you see how it looks like she has a little bit more down here it's because we put that stitch and everything pushed down as you could see as I put in this suture it kind of pushes everything back in. So let's go over what we've done you could see we've tightened the midline with interrupted sutures that's one layer I'm going to put in a second layer of suture right now but one thing I want you to see from the inside is look at how much thicker the white stuff is on this side and thinned out it is on this side and it looks like a little hill the tissue we call it attenuated attenuation means thinned out on the right side her fascia is attenuated and thinner on the left side it's thicker so you could see the little ball formation there. I want you to also appreciate with all the dissection and everything we've done there is really no bleeding there's nothing that's bleeding here these are the holes from the lipo the honeycomb I told you about you could see we did lipo here so those are the honeycombs that's her pelvic bone this is her pelvic bone but look at this all this no bleeding so this is the incision line which we put the interrupted suture in so I go over it and again do another fold on top of it as you could see I pick it up it hides the suture so it's not palpable and boom you see how I pull it together even a little bit more so when you every surgeon does it a little differently some people do two layers some people do one some people don't do any layers it just depends on your surgeon and what they elect to do but I like to have the safety of having two layers of suturing and you can see it's just over time it's better just in case something happens you have a backup so we did our placation of the muscle look at how nice and tight that is she's very small under she has a lot of fat underneath the skin she has some visceral fat underneath the muscle she has to lose that herself with exercise but you could she's her sub q fat is significant let's measure that for the people at home so you could see it's about two inches maybe two and a half almost six centimeters so we dissected everything in a nice plane we went all the way up to the ribs this is her ribs right up here and right up there we could see we we lifted up the skin nicely this is the area of lipo we go lateral this is the area of lipo we did there's the honeycomb on this side there it is the all the honeycomb right there so now we could see how much pull we have look at that look how much pull we have these are her fat I can't take it out next time when she comes we could do lipo and thin her out but we can't do it right now because this is how this thickness is how she's getting blood flow I saved this big vessel for her sometimes you see them you should save them sometimes you don't this side I saw it this side I don't see any so we saved it that gives extra blood flow to the flap so we're going to get ready to cut the extra pieces off we could see that we have even extra skin so we're going to go all the way so I went way above our mark you can see we're going above so this is a little old c-section scar if you look at it you could see the white line the c-section scar right there so this was the line which I thought I would be at least be able to take all this skin but you could see with my dissection up higher I'm taking much more this is we'll measure this where's our handy ruler we're going about two inches more than I thought which is pretty good so in total we're going 15 plus about seven so 22 centimeters so we marked it so we we do we measure twice cut once this is another so when I get to the other side I know how long the flap is that we cut out so we mark it from here to here so I'll mark it right there for us always we measure twice and cut once so this is our line we're going to go right along our line get to a nice sharp point let's see we're going to measure twice and cut once so 15 from here to here seven from there to there so exactly 22 then we're going to measure with our little lap which we marked off let's see from the tip to here exactly to the point I mean we're trying to be precise here scientific here we go a lot of people is asked the number one question is is it my belly button or do I get another belly button it's it's most of the time it's always yours I just make another incision you can see I've marked the midline I marked where her belly button should be so I make a small incision through this I'm going to pull out her her her umbilicus which is on a stop which is attached to her abdominal fashion hey everyone we're done with the case now for the big reveal I just want you guys to imagine at home how much we have taken out this was the c-section scar you could see the white scar down here continuation here I want you to see the length of these two skins and watch the reveal look at that beautiful abdomen we've basically taken the same length that she has we've taken out from her this was her old belly button right there in that circular area look at how nicely her belly button is invaginated she has a very thin line and she can see the lateral marks coming in she's going to look spectacular