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Category: Body

The Skinny on Liposuction: There’s only so much I can do

While visiting my parents in Los Angeles last week, we toured the famous J Paul Getty Museum, which houses a number of famous paintings and sculptures. My wife photographed one of these for me with her iPhone:

As a wood and marble sculptor myself, I certainly appreciate the artist’s skill. As a plastic surgeon, the bronze sculpture got me thinking about—yes, you guessed it—liposuction. Since the sculptor, Rene Magritte, has very purposefully and dramatically divided the sculpture into thirds, let’s categorize these:

Lower third: The preoperative liposuction appearance

Middle third: The actual postoperative result.

Upper third: The desired postoperative result.

Unfortunately, it is very difficult to take the lower third and turn it into the upper third (i.e. if you are significantly overweight, liposuction will make you smaller, but it won’t make you skinny). On the other hand, if you are starting with only a modest amount of excess fat (middle third), then achieving the upper third may be more realistic.

Also bear in mind that the two of us (plastic surgeon and patient) working together are much more effective than either of us working alone. Liposuction with postoperative dieting and aggressive exercise can take a middle third result and push it closer to an upper third result. Liposuction with postoperative binge eating can take a middle third result and push it closer to a lower third result.

Liposuction (liposculpture) in a realistic, motivated patient is generally quite effective. In the unrealistic, unmotivated patient, it is a waste of time and energy.

I am unsure whether the artist was referring to the unrealistic liposuction patient—or perhaps the overzealous plastic surgeon—when she aptly titled her sculpture, “Delusions of Grandeur.”

Before After 5.4 Liters (Post-Op 1 Month)
DSC07080 DSC09419
DSC07088 DSC09433
DSC07090 DSC09431

** This 27 year old woman from McKinney presented to Dr. Friedman requesting liposuction of her abdomen, flanks, upper back, inner thighs, mammary folds, and arms. She underwent 5.4 liters of liposuction and at her 1 month follow up she demonstrates improved contour of all regions including a flatter stomach and smoother waist line.


Ronald M. Friedman, M.D.

Director, West Plano Plastic Surgery Center

Former Chief of Plastic Surgery, Parkland Memorial Hospital, Dallas

Belly Button After Tummy Tuck

“It’s all about the belly button”

A full tummy tuck involves tightening of the abdominal wall with removal of excess skin and fat.  Contrary to popular belief, we do not need to make you a “new belly button.”  Instead, you will keep your existing belly button (umbilicus), but all the skin around it will be removed and replaced with skin from the upper abdomen (see tummy tuck video).

Plastic surgeons vary widely in their techniques for reshaping the belly button.  This variation in technique creates a similar variation in results.  As you compare plastic surgeons for your tummy tuck, spend time looking at their patients’ belly buttons.

Belly button after tummy tuck performed by Dr. Friedman.

Belly button after tummy tuck performed by Dr. Friedman.

Belly button after tummy tuck performed by other surgeons.

Belly button after tummy tuck performed by other surgeons.


If you have any questions or wish to schedule a consultation call our office at 469-467-0100.

Dr. Friedman is the Founder and Director of the West Plano Plastic Surgery Center on the campus of Presbyterian Hospital of Plano.

Are My Breast Implants Too High? (Part 1)

“Dr. Friedman, aren’t my breast implants too high?”

I am asked this question at least a couple times a week.  And the answer is “Yes, they are too high.  But don’t worry; it’s normal.”

All breast implants placed under the pectoralis major muscle will start out too high and tight.  It takes time for the muscle to expand in response to the stretch of the underlying implants.   Not only is this normal, it is also exactly what we want.  All implants will fall after a first-time breast enlargement surgery.

If your implants start out too high, they will probably end up in good position within six months to a year.

If your implants start out in good position, they will probably end up too low within six months to a year.

The before-and-after breast augmentation photos below illustrate the normal descent of submuscular saline and silicone gel breast implants following breast augmentation.

Saline Breast Implant Sequence:


Before / 1 week / 1 month / 7 months

Silicone Gel Breast Implant Sequence:


Before / 1 week / 1 month / 7 months

Breast Augmentation with Lift Sequence:


Before / 1 week / 7 months / 2 years


Before / 1 week / 7 months / 2 years

If you’re wondering whether the implants keep falling after a year, the usual answer is “no.”  Why not?  The muscle has been maximally stretched by the implants, and your body has formed a capsule of scar tissue around the implants that prevents further descent.

If it has been over a year since your breast augmentation and your implants are still too high, read my next blog for an explanation of possible reasons and treatments.

Product Placement and Plastic Surgery

When shopping for a plastic surgeon, look for surgical skill rather than products.

Smartlipo, Fraxel, Sculptra, Zerona, Velasmooth: the array of plastic surgery products is increasingly complicated and confusing.  Much of this is related to marketing of products directly to consumers, both by physicians and manufacturers, in order to create product demand.  Instead of calling my office to ask how many liposuction surgeries I have done, people call to find out whether I have CoolLipo available.  Instead of asking how many breast augmentations I have done, they want to know whether I offer “gummy bears.”Torso-Granadillo

This is an unfortunate mistake.  There are gynecologists who do “LASER lipo” and ear/nose/&throat doctors who place the latest implants.  However, the ability to purchase a particular product does not always translate into competency in using it.

When you are researching cosmetic surgery, remember that the surgeon doing the procedure is far more important than the product he or she is using.  Saline breast implants placed by someone who has done 2000 augmentations will generally look far better than the latest silicone gel breast implants placed by someone who has placed 20. This is not to say that product choice is unimportant; some products are clearly better than others for certain patients.

Before you worry about the specific product a surgeon uses, look at his education and experience.  Look at his before & after photos–not just one or two, but twenty or thirty.  Look at his online reviews. Observe his bedside manner.  Evaluate the cleanliness of his office.  Speak to patients of his who have had the procedure that interests you.  Then, after all of that, worry about the “products” he offers. If you select the right surgeon, you’ll probably get the right product anyway.

If you have any questions or wish to schedule a consultation call our office at 469-467-0100.

Dr. Friedman is the Founder and Director of the West Plano Plastic Surgery Center on the campus of Presbyterian Hospital of Plano.

Surgeon Vs The Machine

Question: Ultrasonic liposuction, laser liposuction, tickle liposuction, body jet liposuction, liposculpture, power-assisted liposuction:  the number of liposuction technologies can be overwhelming.  Should you go to the guy with the laser machine, or should you visit the guy who uses sound waves to break up fat?

Answer: You should probably visit the surgeon who has the best credentials, bedside manner, and before/after photos.  The technology is usually secondary.  In fact, a surprisingly high proportion of the physicians performing liposuction have no formal background in plastic surgery; many are gynecologists, general surgeons, internists, and family doctors.  Their motivation is understandable. As health care reimbursement declines, many move outside their specialty training in an effort to improve their bottom line.  Many of these physicians purchase the “newest technology” and take weekend courses to learn how to use it.  Unfortunately, the machine is just a machine.  It requires extensive training, expertise, and experience to achieve quality liposuction results.

Perhaps the best analogy is that of an artist.  Suppose that you provide a drawing novice the best pencils, canvas, easel, and drawing room that money can buy.  Now give an experienced artist the nub of a used-up pencil and an old piece of typing paper.  Who do you think will produce the better drawing?

By way of disclosure, I have been performing liposuction for 18 years using a superwet technique.  In my private surgery center in Plano, I inject a “wetting” solution of local anesthesia, epinephrine, and saline followed by liposuction via a cannula (hollow tube) connected to a suction machine that produces a vacuum.  The technology is relatively modest; you can judge the results for yourself.  You may also be interested in learning that I have been performing wood and marble sculptures for about 30 years.   I am tired of hearing the term, “liposculpture,” from physicians who have no artistic background and have never sculpted anything in their lives.

I am not suggesting that you should ignore technology altogether.  Certain patients may be better served by certain machines.  However, it is my impression that for the vast majority of patients, the liposuction surgeon is far more important than the machine.

Liposuction of abdomen, hips, flanks, inner and outer thighs


Before front / Before side / Before back


After front / After side / After back

Liposuction of abdomen, flanks, and lumbar regions


Before front / Before side / Before back


After front / After side / After back

Liposuction of knees

Before / After

Before / After

Liposuction of submental (under the chin)

Before / After

Before / After

Ronald M. Friedman is a board-certified plastic surgeon providing liposuction, tummy tucks, and breast surgery to the Plano, Frisco, Allen, Fairview, and McKinney communities.  He is the Director of the West Plano Plastic Surgery on the campus of Texas Health Presbyterian Hospital of Plano.

© 2018 Ronald M. Friedman, M.D., P.A.

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