When should you consider an Abdominoplasty (“Tummy Tuck”) and what can you expect?
Abdominoplasty will address two main problems:
- excess loose abdominal skin
- abdominal wall laxity. It is a misconception that this operation is primarily to excise fat. Although some fat will be excised, the ideal candidate for abdominoplasty would be at or near their ideal body weight with loose skin and a lax abdominal wall.
The typical candidate has had children and the stretching and separation of the abdominal wall muscles has caused a “pooch” in the lower abdomen. The ideal candidate would have loose skin above the belly button (umbilicus). It is important to have a little extra skin above the belly button, as this skin is what is used to close the defect created by excising the skin below the umbilicus. (See technical details below.) Pregnancy is the usual culprit for expanding the abdomen, but anything that has expanded the abdomen, such as massive weight gain and loss will set someone up to be a candidate for abdominoplasty or tummy tuck. Many patients question whether they should have abdominoplasty or liposuction (which is an easier recovery than a tummy tuck). The answer lies most often in the skin tone. If skin tone is good and the primary problem is excess abdominal fat, liposuction may be all that is required. However, if the muscle tone is lax and is coupled with poor skin tone, then these structures need to be tightened and excised, respectively. There are two vertical muscles that run parallel to each other in the middle of the abdomen running from the ribs down to the pubic area referred to as the rectus abdominus. There is a right and left muscle. This broad band flat muscle when developed in a thin person causes a “six pack”, but can be separated during pregnancy or massive weight gain. If these muscles do not come back to the midline then any amount of muscle exercise will not be effective in returning the abdomen to a flat pre-pregnancy or pre-weight gain contour. This muscle separation is addressed during the abdominoplasty procedure.
The goal of this surgery is to remove most, if not all, of the skin located below the belly button extending to the top of the pubic hair. The incision extends essentially from side to side and it is absolutely necessary that it be this long so that the scar can lay flat with no bulging on either side. It is helpful to think about cutting a circle out of a piece of fabric. It would be impossible to just close that circle without having excess fabric bunch at both ends; therefore, the ends must be tapered. That is why the incision is tapered to the left and right hip ending near the love handles bilaterally. The more skin that is removed the longer the scars extend laterally. This scar is unavoidable. The abdominal skin and fat are elevated off the abdominal wall after the belly button has been incised circumferentially and left on a stalk of tissue that is left attached to the abdominal wall. Therefore, the flap that is elevated has a hole in it where the belly button used to be, and when looking under the flap to the abdominal wall the surgeon sees the belly button attached to the umbilical stalk. The separation of the muscles in the midline with abdominal wall looseness and laxity is also noted. The muscles are then tightened and repositioned to the midline so that the abdomen is flat. The excess abdominal skin is removed and a new belly button is marked in the midline and the old belly button is pulled through the skin excision and sutured in place to create a more youthful, contoured belly button. NOTE: It is important to realize that the abdominal flap can only be thinned to a certain degree as excess thinning of the flap would cause decrease in blood supply and might jeopardize losing some skin in depth of the flap. If this flap is too thick then liposuction may need to be carried out in a later operation, but this cannot be done at the same time.
The wound is closed over drains, which are brought out through the mons/pubic hair area, and these are left in place from 3-10 days and in rare cases even longer. The drains are very important to keep any drainage fluid from collecting between the skin/fat flap and the abdominal wall, as we want this to reattach as quickly as possible to facilitate healing and to maximize contour. Although the drains are a necessary evil, we utilize drains that are not only the most efficient and functional on the market, but are also the most painless to remove. Discomfort varies from patient to patient.
What should you expect during recovery?
Abdominoplasty is one of the most difficult recoveries in plastic surgery, although it is a procedure among the highest, if not the highest, in patient satisfaction in our practice. When tightening the abdominal muscles one can get muscle spasms, which may cause discomfort that can be significant for approximately 3 days. Some patients choose the option of a pain pump catheter to be placed at time of surgery that lasts for approximately 3 days in which a topical anesthetic agent is dripped onto the abdominal wall and comes out through the drain. Most patients find this to be helpful and choose this option, although it is not mandatory. For approximately 1 week the patient stays flexed at the hips to alleviate any pressure on the wound, and then over the next 3-7 days begins to stand more upright so that at 10 days to 2 weeks post op the patient is totally upright. We recommend not lifting any weights over 10# for approximately 4-6 weeks. That is why patients with small children need to take this into account as they cannot lift their children for approximately 1 month. Appropriate help needs to be arranged. Patients can drive when they feel that they are not a danger to others, i.e., they can look in their blind spots easily and react appropriately unencumbered.
What are the possible complications of this procedure?
Morbid obesity, or even a patient who is significantly overweight, is not a good candidate for abdominoplasty. Smoking makes the operation prohibitive as the chance of skin loss is greatly enhanced. A patient with extensive prior abdominal surgery could be a contraindication, especially with high transverse incisions under the rib cage, as this would decrease blood supply and increase the risk of skin loss.
Skin loss due to decreased blood supply may be seen rarely. It is more common in smokers, and in our office we do not knowingly perform this operation on smokers.
Belly button necrosis (or loss) is a variant of skin loss as the umbilicus can have poor blood supply and be compromised as well in this procedure. This will result in a less than satisfactory scar around the umbilicus and a prolonged healing.
Fluid (seroma) can collect between the abdominal flap and the abdominal wall requiring drainage in the office and possible return to the O.R. to drain the seroma or excise the seroma pocket. This can be an early or late complication, but is most often noticed in the first month after surgery.
Infection ranges anywhere from 1-2% in our series.
Bleeding may also occur requiring a return to the O.R. Fortunately this is a rare complication as well.
Deep vein thrombosis (DVT)/pulmonary embolism (PE) clots can form in the legs and in rare instances may “dislodge” and travel to the lungs (pulmonary embolism). DVT’s would require oral ingestion of blood thinners for a period of time as would, of course, P.E. Pulmonary embolism may be life threatening and is the most serious consideration. It is fortunately extremely rate. Although a fatality has not occurred and PE’s and DVT’s are extremely rare, we still take special precautions in every operation. All patients have compression garments in place during surgery, which have been well proven to drastically reduce the incidence of this complication.
What are the costs?
We do not feel that it would be appropriate or ethical to post prices for procedures on the internet. We do, however, understand that cost is a factor you must consider. We would be happy to speak with you about this so that you may determine whether the procedure you are considering falls within your budget. Our pricing structure is based on the time, complexity, and surgical costs involved. Please feel free to call our office at 214-823-1978 and speak with Leah for more details.