Staging procedures is when more than one operation is recommended to achieve a result more safely, predictably, or both.
The most commonly staged procedures for cosmetic plastic surgery are body contouring procedures. This can be in patients who have lost large amounts of weight, or in patients considering a large breast implant but who also have very droopy breasts that need lifted, or in patients who are wanting to be much thinner using large volume liposuction but also have extra skin the area that needs to be removed. Another common time for staging is when a patient wants lots of things done, and they are recommended to be broken up into stages as it would be too much surgery done all at once. The image shown is a patient of mine who is an example of having several stages to achieve her result.
Staging procedures are often recommended for safety concerns. Any time skin is being removed and tightened, there is a chance there may not be enough blood flow to allow for normal healing. One of the most common situations we recommend a staged approach is in the patient wanting a tummy tuck, who also has a significant amount of fat to be removed. The way the body heals a tummy tuck incision is that the blood needs to flow from the upper abdomen down to the lower abdomen. This blood flow brings the cells necessary to allow the tummy tuck incision to heal with a thin, flat scar. If there is not enough blood flow, some of the skin near the incision can die and cause the incision to split apart and heal poorly. Another chief cause of poor blood flow to an incision is tightness, be that a compression garment that is too tight, or a patient standing up straight after a tummy tuck and making their own skin too tight for the blood to flow.
For now, we will focus on surgical causes of poor blood flow, and in the tummy tuck patient, that surgical cause can be liposuction. Liposuction comes with a fair amount of swelling immediately after surgery. If there is too much swelling, this can limit the amount of blood flow that gets to the incision to heal it. Therefore, if a patient has a fair amount of extra fat in the upper and mid abdomen, we may recommend the patient have the liposuction procedure performed FIRST, aka Stage 1.
By performing liposuction first, the fat is removed, the patient is placed into a compression garment, and they complete the swelling and healing process. Because there is no large incision to heal, the body will be able to heal all of the skin without issue. This lets us be a little more aggressive with the liposuction, and get the patient even thinner, because we aren’t worried about having enough blood flow to heal an incision.
The swelling process takes 3-4 months and is assisted by postop compression garments and massage. Once all of the swelling is gone, there is sometimes even more skin that before the liposuction. This is because fat tends to hold skin pushed out and smooth. Removing the fat beneath the skin can leave the skin loose. Which brings us to Stage 2.
Once the patient has healed from liposuction, we perform a tummy tuck. In that setting, there is less concern for low blood flow as a result of swelling because all of the liposuction has been performed. Now we can focus on just tightening skin and muscles and achieving a flat and tight result. Essentially, first the patients gets skinny with liposuction, and then they get flat and tight with a tummy tuck. This is a safer and more predictable approach.
That’s not to say that every patients needs a staged approach. If the fat cells are not abundant in the upper and mid abdomen, then liposuction can be performed in the love handle area, for example, and normal healing of a tummy tuck scar can be expected. This is because the blood flow necessary to heal a tummy tuck mostly comes from the upper and mid abdomen. So if little or no liposuction is performed in these areas, then there will be adequate blood flow for healing. During a consultation, we can assess where a patient primarily keeps the fat cells, and determine a plan for whether the tummy tuck can be performed in a single or in a staged fashion.
-Christopher D. Knotts, MD FACS