Dr. Sam Jejurikar: Welcome to the latest edition of 3 Plastic Surgeons and a Microphone. As always, I’m Sam Jejurikar from Dallas. Joined by my two co-hosts, in my immediate right is Sam Rhee at Bergen Cosmetic located in Paramus, New Jersey, and Dr. Salvatore 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 going to just take care of some house cleaning. Dr. Pacella?
Dr Pacella: This is our disclaimer. 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 on the circumstances, situation, and medical judgment after appropriate discussion. Always seek the advice of your surgeon or other qualified health providers with any questions that you may have regarding medical care, and never disregard professional medical advice or delay seeking advice because of something that you do.
Dr. Sam Jejurikar: So, today, I want to introduce Bradley Hubbard. I’ve had the pleasure of being a partner with Dr. Hubbard at Dallas Plastic Surgery Institute for at least, has it been ten years, Brad; I don’t remember the exact year you joined.
Dr. Hubbard: Something like that.
Dr. Sam Jejurikar: Yeah, it’s been about ten 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, make your appointment. The patients know Dr. Hubbard as an amazing plastic surgeon, but I want to talk about some other aspects of Dr. Hubbard before we actually get into the meat of it.
So, a few years ago, we realized that Dr. Hubbard has quite the personality. And so, his office every year does an amazing Halloween spread where they’ll showcase the office staff and 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 my personal favorite when Tiger King was really the rage. This was when Bradley Hubbard introduced himself to the plastic surgery community of the world and Dallas, Texas. And this is still my all-time favorite.
Dr. Sam Jejurikar: I think this is this year’s Dr. Hubbard, as Austin Power is showing up as a playful and goofy side. But there’s another aspect of Dr. Hubbard that I think people need to know about. Dr. Hubbard as a plastic surgeon, 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. It just drives me nuts when they call me Dr. Sam. I’d always held onto this notion that Dr. first name was a name for a guitarist or a pediatrician, but not really a plastic surgeon.
So, a few months ago, I walked into my office on a clinic day, and there was this giant banner hanging up, which I subsequently learned Dr. Hubbard pays $100 to make every time he does, that said, “Dr. Sam Plastic Surgery.” I saw it and quickly got irritated by it; it was down within about a minute, but it was filmed during that time. Aha, he got me. It was great.
A month went by, and I walked into the OR, and 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 the sterile surgical instruments prevented me from actually doing anything with it. I had to operate the whole day with this sign-up. Ironically though, the prank, although it was epic, backfired just a little bit because as the day went on, other plastic surgeons came by and 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 and became a thing in that OR where people would sign it. And then one day mysteriously disappeared; I don’t know who did it.
But then we moved to the greatest prank of all time, which was August 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 defecated in my parking spot. Immediately my suspicion went to Dr. Hubbard or his first assistant. Hey, to anyone who is a patient of Dr. Hubbard’s, know that the two of them are quite dynamic. And sure enough, we found some footage. We had actually found some video footage of a gentleman who, to me, looks suspiciously like Dr. Hubbard in the parking lot actually doing his business.
Now, what I’ll say in it, and again, we’ll get to the beginning of it right here, I’m convinced this was Dr. Hubbard though I will issue a few disclaimers. One, this is not actual footage of my parking spot, it’s probably not Dr. Hubbard, and he just probably denies his involvement in this, but I do know that he finds it incredibly irritating that I keep saying that he did this which is typically our ways to elaborate. And with that, I turn it over to one of the best surgeons I know, Bradley Hubbard.
Dr. Hubbard: Thanks very much. Best intro ever.
Dr. Pacella: I got excited about the video. We probably finally figured out who the perpetrator was.
Why Belly Buttons are amongst the overlooked areas of plastic surgery?
Dr. Sam Jejurikar: Yeah. Brad, why belly buttons? Why do you want to talk about belly buttons when you could talk about the full spectrum of plastic surgery?
Dr. Hubbard: Well, a couple of reasons, one, I think probably the most overlooked part of a tummy tuck, and that it usually comes at the very end of the procedure. And I think after a long hard day’s work, it’s an afterthought of just trying to get done with the case, like the heavy lifting and the danger, and the things that we worry about are all done already is just a minor last part. But really, I find for patients; it’s probably the most important part. They were trying to get into the world of certain two-piece shapes and show off their abdomen, which was the whole point of surgery. And if you ruin this one aesthetic piece, it can be problematic.
For young plastic surgeons out there, being able to do this well is a huge marketing piece. I think all patients are cruising around Instagram, looking at belly buttons, and that’s how they’re choosing their doctor. , and 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 I analyzed it all down to every detail. So also only have 20-30 minutes, and I feel like if we chose another topic, we’d only recover 10% of it. But I think we can really handle all things belly button in 30 minutes.
Dr. Sam Jejurikar: I will say Dr. Hubbard is incredibly detail-oriented, 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, maybe soon.
Dr. Hubbard: Yeah, I’m just going to take us a fair a couple of slides just to keep us going here with… Okay. Also, I wanted to point out that just to annoy Sam a little bit more, my name in this podcast is Brad.
Dr. Sam Jejurikar: But it’s not Dr. Brad. It’s actually not Dr. Brad. That’s not Dr. Brad.
Dr. Pacella: We must listen to you.
Dr. Hubbard: Correct.
Dr. Hubbard: Can you guys see it?
Rhee: Yeah, you might flip to slide mode.
Dr. Sam Jejurikar: That is the original sign. Perfect.
Dr. Hubbard: So that’s the original side, and we could tell it’s still pandemic with the mask, and to my great pleasure, he was already frustrated before he walked in the door and then followed it on his wall. And he got to see about 50 patients in clinic, and so he’s like, “How do I get this down immediately?” Feels great. The two middle fingers are also classic.
Okay, so I thought to start, okay, so do it right; we got to know how to do it wrong. Because it’s very easy to cruise around people’s Instagram and websites and find some examples of things going wrong. And also, I want to point out that most of these vibes have really nice tummy tuck results that are absolutely ruined by the belly button. This is one. Obviously, it’s much too big. It’s 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 cross it off at the bottom. One of the big complaints I have about a lot of people of tummy tuck technique is just no contour. We can see in the before picture there’s nice shadowing and contour and natural curves around the belly button. In this one, the result is no contour whatsoever. It looks like a hole punched out, and I think it’s a little bit too high.
Dr. Sam Jejurikar: I’ve had patients refer to it as a cat’s anus before, which I thought was…
Dr. Hubbard: Oh, don’t worry, that’s coming up. I got something that’s coming.
Dr. Sam Jejurikar: Okay, got it.
Dr. Hubbard: I don’t think that’s the best example of that, mostly because the tunnel’s up. To get a good cat butthole, you have to have it pumped straight out of the face of it.
Dr. Sam Jejurikar: Got it. Okay.
What makes fixing the belly button difficult?
Dr. Hubbard: But that’s a nice, what I call a coin slot, they did a very big-time vertical oval, and probably it was; they drew a circle but not on tension. And then, once they pulled the tummy tuck down in 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 butthole, I think. This is an interesting one. When she’s standing up, it’s not so bad; when she lays down, she gets this kind of, I don’t know what you call that, Chinese finger cuff slinky phenomenon where the skin bulges out like that, and there’s way too much umbilical stalk. This one tunnels way up; she showers that belly button fills up with rain for sure. And here’s my best cat butthole picture. I could find.
Dr. Sam Jejurikar: Cat anus?
Dr. Hubbard: I’m okay with that too. Anyways, those are all the things to go that can be done wrong, right? And if I was going to give my basic principles, you got to fix the hernia for this error; you got to fix the muscles after and create your ideal length, which really has more to do with the ratio to the flap sickness. If you have a thicker flap or a thicker adipose layer, you’re going to want it to be a little bit longer, but if they have none, then you have to shorten it.
Once you figure out the length, you got to figure out the diameter, then that’s where my technique, I think, is pretty sweet. And then we got to make our inside opening. This is probably the most important thing. You have to set it lower than where the actual number is so that it tunnels downward. If it comes straight out, we get the cat butthole, if it tunnels up, it catches rain, and all things look bad.
Okay, so here’s a little drawing of my technique, and I even.
Dr. Sam Jejurikar: Go back to… Okay.
Dr. Hubbard: Yeah, you want me to? I think the video’s better. At the start, I made it the right length, and now I want to control its diameter, so we just take a wedge out of the bottom portion of the belly button and create a defect that we’re going to fill. And depending on the size of your belly button, if it’s really, really huge or a really, really wide one, you can make your wedge really, really wide and narrow it or change the diameter. If it’s really small, I don’t cut out anything at all; I just make a vertical split there, it’s six o’clock, so I open it and make it a little bit wider in 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 drew this arch about the tip of it being at the start, so my end results are a little bit lower. I don’t know how to. We don’t need to watch this, but that’s how it solves it, and you can see the flap tucks down underneath to reach over the bottom of the belly button.
Dr. Sam Jejurikar: When you’re putting in that stitch, is that like a three-point stitch where you’re anchoring that flap down to the fascia? How are you putting in that key anchoring stitch?
Dr. 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 going to go away underneath the skin in about a month. So, if I’m going to anchor the belly button with something, I’m going to do a
Dr. Sam Jejurikar: Okay.
Dr. Hubbard: So, this is a standard reminder that I may go over the everyday patient, and that’s the result I’m hoping to achieve regularly. I think it does a bunch of cool things that hide the scar on the bottom because there is no scar on the bottom edge. I think it gives a little bit of contour or shape, especially at the lower half, as it curves up to that flat placement. For people with thick scars or keloid scars, and flat pile type of scars, in its complex little plastic, it’ll break up in there for us, and that can control the size. So those are all the things I like about it.
How Dr. Hubbard makes scars less visible
Dr. Sam Jejurikar: So just for our viewers out there, because our viewers aren’t plastic surgeons, one of the great things about Dr. Hubbard’s technique is, a basic principle of plastic surgery is although, we can’t make scars visible, 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. Hubbard’s technique, and he glossed over this, the key thing is that there is no scar along the bottom of the belly button. Because of the way that skin flap is set, there’s this nice, really youthful coating 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 look at 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. I think that’s a small point, but it’s important for the viewers.
Dr. Pacella: Brad, just a question here. So, traditionally when people do tummy tucks in the donor flap, the abdominoplasty flap, they cut out a circle, a defect. So are you just cutting a small C-shaped lit and using that tissue that somebody would normally take out and discard and hooking that into the apex of where your umbilicus is?
Dr. Hubbard: Yeah, exactly. I call it an arch-shaped incision.
Dr. Pacella: Got it.
Dr. Hubbard: Let me go back to our thing. As you can see, my skin there is folded down, and to cover the bottom 30%, 40% of the belly button, replace that skin that I just cut out.
Dr. Pacella: Got it.
Dr. Hubbard: So it’s a one-for-one exchange. And besides my scar, it does tow 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 an old pun.
Dr. Hubbard tummy tuck/belly button surgery strategies
Dr. Pacella: What do you do when the abdominoplasty flap is thick? So, somebody who’s heavier or has a lot of subcutaneous fat there?
Dr. Hubbard: Yeah, well, in this demonstration, it’s not like that. And what I would do in that situation is when I cut out my wedge of belly button where I want the flap to 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 or wedge 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 basement, so just buried enough.
Dr. Pacella: Got it. Sorry, we sent you backward, and I knew you were ready to move on to another slide. Maybe move on there.
Dr. Hubbard: Yeah, that’s the whole point of starting a conversation. So, I think it’s pretty easy to get a result on a standard patient, and there are some patients where it starts to get tricky. This is one who has a belly button hernia, basically right at the base of it. These are tricky ones because the blood supply to that skin is a little bit compromised, and I find it hard to get a good any with these. Do you guys agree?
Dr. Sam Jejurikar: I completely agree. And one of the big things…
Dr. Pacella: There’s no fat.
Dr. Hubbard: There is no fat thickness to give you any depth. There’s rectification which will help, but sometimes that fascia in between the rectus is so floppy that the belly button still can get pulled out.
Dr. Sam Jejurikar: So one of the big trends in plastic surgery you and I talked about a lot is neo-umbilicoplasty. In this sort of patient, how could you imagine using your technique as a neo-umbilicoplasty? Or would you not think about doing that?
Dr. Hubbard: I never, I’ve yet to see a neo-umbilicoplasty that’s better than a good belly button solve, if that makes sense. I think there are some neo-umbilicoplasty techniques that are better than others for sure, that get nice results even, but still don’t recreate exactly the aesthetics that we’re looking for, especially in thicker patients. So in, in all cases, I try to avoid that if I can.
Dr. Sam Jejurikar: What do you guys think about that?
Rhee: I agree with Brad. I don’t think I’m a big fan of neo-umbilicoplasty, even in, I don’t know, secondary reconstructions. I will always try to salvage the original if I can. And I’ve seen surgeons who advocate going direct to neo-umbilicoplasty in some cases, but yeah, I don’t see why.
Dr. Pacella: Even in the thickest or most destroyed belly buttons in the setting of an umbilical hernia, I think there’s still some tissue to salvage, and I agree, the natural tissue’s always the best to use, even in part.
Dr. Sam Jejurikar: Interesting because I probably do about 25 to 30% neo-umbilicoplasty, and I reserve it for two groups of patients. One morbidly obese patient with a BMI of over 35, and I’m doing a different abdominoplasty on something called the Tulua Abdominoplasty, which I know Dr. Hubbard knows what it is, and you guys know what it is. But for our viewers, it’s basically a very modified non-traditional tummy tuck where you’re suctioning the upper flat; you’re not tightening in the same way. But because of the way you’re dragging down the belly button stock with all transverse locations, you can’t really salvage the belly button. And then I 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 because 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-umbilicoplasty. 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 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… In many of them now, I forget that they were not native belly buttons, and I…
Rhee: You do that primarily, Sam?
Dr. Sam Jejurikar: Yeah, I do. I do, even though it’s risky. Let me actually, most of the time, I do; a couple of times, I have
Dr. Hubbard: That would make me a little edgy.
Dr. Sam Jejurikar: Well, the mesh is buried when the way that that’s the case. The mesh is buried below the rectus abdominis muscle, so the mesh isn’t exposed. But yeah, there’s. Definitely, I’ve been blown once by it, but 99% of the time, it’s been okay.
Dr. Hubbard: Okay. Wow. I think I got one or two more things; we can stimulate another conversation here. So umbilical hernia, just proving you can do it with a real umbilical hernia, the key with this really is, I think, and then the other technique that belly button skin has been so stretched out and so dilated, you need to have that wedge technique to narrow its diameter. Otherwise, you’re going to end up with something really vague or with a low skin.
And then this is the last one I was going to show you. I believe so firmly and avoid the neo-umbilicoplasty. 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 270 degrees and let the skin, plastic surgery rules, the delay principle, and was able to get it to live, which I thought was pretty cool.
Dr. Sam Jejurikar: That’s awesome. That was really good.
Rhee: How many of these would you say you’ve done any secondary work on, in general?
Dr. Hubbard: Of my own that we’re talking about?
Patient Tummy tuck/belly button revisions
Rhee: Yeah, just like, how many of your tummy tucks would you say you go back and do any kind of revision of the umbilicus at all if any?
Dr. Hubbard: Pretty rare, maybe 1 or 2% since doing on Instagram and people are trialing 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 on my own, pretty rare. Pretty rare we do anything.
Rhee: It’s interesting because I’ve seen the chevron design, but that’s where it’s reversed. It’s actually you’re going inferiorly with that wedge as opposed to superiorly, which I’ve seen before. And I think your technique is better. I think it makes more sense to me.
Dr. Hubbard: I think the chevron was designed because everyone talks about footing over the belly button as 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 for 20-year-old women in 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 then look at both aesthetics. But anyway, the chevron is just, they’re trying to put a big pile of skin on the top of the belly bottom, and they would make it look like it’s hurting, but most of the time, it just looks like a big pile of skin, I think.
Dr. Sam Jejurikar: I can say looking at the OR schedule at our surgery center, I see Dr. Hubbard’s name frequently doing revision belly buttons on other people’s patients. So I know that that’s indeed a true thing. And I’ll say that I largely adopted his technique a year and a half, two years ago, because I was so sick of hearing him talk about it all the time. It profoundly improved my patient satisfaction with their belly buttons.
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 going to cut a circle around your belly button and seal a circle back in. They might use interrupted buried sutures that don’t leave track marks. And in some cases, people still use horrific sutures that leave these ugly little track marks around them. 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 think this is a really nice summary 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 really know how much you’ve thought about this, and everything you’ve said I’ve largely adopted. Do you guys have any other questions for Dr. Hubbard at all?
Dr. Pacella: Have you published this? Because I think you should call this the Dr. Brad Bellybutton, actually, and refer to it.
Dr. Hubbard: I appreciate it. It’s actually been a running joke. We train fellows in our group every year. And since our very first fellow eight years ago, I reassigned this, it’s something to write up and publish, and I think it was finally accepted by PRS just a couple of 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 it in there.
Dr. Sam Jejurikar: I think social media is going to be so much more powerful for naming it. So, Dr. Brad Bellybutton, here we come.
Rhee: There we go.
Dr. Hubbard: That’s fantastic.
Dr. Sam Jejurikar: And by the way, if you don’t know about each other, Dr. Pacella and Dr. Brad are both ardent Buffalo Bills fans, and I know Dr. Hubbard is eager to get off his podcast so he can start one. Well, thanks for your time, Brad. We really appreciate it, and we know that our viewers are much more educated about it. So thank you again.
Dr. Hubbard: Oh, thanks for having me, guys. It’s a lot of fun.
Dr. Pacella: Take care.
Rhee: Thank you.
Dr. Hubbard: All right.