The “Tummy Tuck”
Abdominal surgery is generally performed after weight changes, pregnancy or as a correction after other surgical procedures that have left poorly healed scars and results in a smoother and flatter stomach area. Pregnancy, weightloss, caesarean section or hysterectomy scars can all contribute to a fatty bulge developing in the lower abdominal area. The amount of excess tissue present, its composition and its distribution, determines the procedure of choice. Often, this operation is done in combination with repairing separated abdominal muscles (diastasic recti) or with liposuction to assist in recreating contours.
Whilst abdominoplasty and liposuction are not a replacement for good nutrition or exercise, there are some cases where surgery provides an appropriate remedy for excess skin and liposuction enables the removal of excess fat.
Different types of Abdominoplasty
The "Classic" Abdominoplasty
If there is a significant quantity of fat and skin to be removed, an abdominoplasty is performed. This is the classic tummy-tuck operation in which a curvilinear incision is made just above the pubic hair line and fat and skin elevated from the abdominal wall to recontour it and make it flatter. The skin is undermined all the way to the costal (ribcage) margin, then it is redraped, the lower excess is removed and the rectus abdominis (six pack) muscles, the ‘abs’, are brought together if they have separated as a consequence of pregnancy. The lower layer of abdominal fat is then trimmed away to sculpt the remaining flap prior to stitching it back together over two plastic drainage tubes. High superior tension sutures are used to redistribute the tension of wound closure away from the skin edge and these, combined with long term post-operative wound taping, can significantly improve ultimate scar quality. The umbilicus (belly button) which is left attached to the abdominal wall throughout the procedure is then brought through a new, higher hole and neatly sutured in place.
It is usually necessary to combine abdominoplasty with liposuction if the fat deposits extend far around into the flank area in order to optimise the post-operative contour. Additionally liposuction enables a thin layer of lymphatic tissue to be left behind in the deep plane of the lower abdominal wall, creating a ‘soak-away’, and dramatically minimising the incidence of post-operative fluid collection or seroma. Patients stay in hospital for 48-72 hours and then the drains are removed and they are discharged with a long dressing along the lower part of the abdomen.
Mini "Tummy Tuck"
Best thought of as pinching the lowest part of the lower abdomen downwards towards the pubic area.
This procedure is usually carried out in conjunction with liposuction if there is a smaller quantity of tissue to remove from the lower abdominal area but not such a small amount that liposuction would be enough by itself. The scar is once again placed horizontally along the upper margin of the pubic mound but is more limited in length. Liposuction is usually performed on the upper part of the abdomen and the belly button is not disturbed by the surgery. The wound is then sutured over a small plastic suction drain and dressings applied. Patients stay in for one night and the drain is removed on the first post-op day.
The "Mummy Tummy"
In addition to concerns about loose skin around the stomach area that result from pregnancy weight gain and weight loss, pregnancy can also stretch and weaken the abdominal muscles. In pregnancy, the abdominal muscles part to make space for the baby: diastasis recti. If this separation remains postpartum, this can result in reduced core stability. In some cases this can also cause lower back pain, as other muscle groups are used to compensate for this lack of core strength.
Whilst undergoing an abdominoplasty, diastasis recti can be repaired by surgically rejoining the muscle sheaths. This helps achieve a flatter stomach and reduced strain on the lower back.
The Fleur-De-Lys Technique
The Fleur-De-Lys abdominoplasty is very similar to a conventional abdominoplasty except that it permits circumferential tightening by removing a vertically orientated wedge of skin and thus creating a scar in the midline extending from the pubis to the end of the sternum. This is highly effective in patients who have had significant weightloss and its effect on redefining the waistline cannot be over emphasised. Whilst patients may be concerned about the prospect of a midline scar, it is usually inconspicuous and heals extremely well.
Surgery After Significant Weightloss
With the massive recent increase in bariatric (weightloss) surgery such as gastric banding, gastric sleeve, gastric bypass or intragastric balloon insertion, many more patients are needing this surgery following massive weight loss.
In these cases a conventional abdominoplasty simply is not enough and the excess skin extends circumferentially around the trunk from front to back. Also there is often excess tissue in the upper abdomen and significant horizontal excess. In cases like this, in order to optimise the outcome, it is essential to remove the entire excess in a safe and predictable way. Bodylift is often the procedure of choice and involves firstly positioning the patient face-down on the operating table. A liposuction and recontouring of the back, flank and buttock areas is performed and the back closed prior to carefully turning the patient over and completing the removal of skin and fat by liposuction and abdominoplasty with the patient lying on their back.
The major challenges with this surgery are that there is more tissue to heal and it is important that patients are not absolutely starving themselves in order to lose more weight just prior to this surgery as they simply may not have enough protein in their body to heal. Also, positioning the patient during recovery is absolutely critical in order to prevent wound healing complications. The patient should be turned every hour or so and avoid lying or sitting directly on the buttocks/lower back for at least two weeks. Several steps are taken to ensure that blood loss is minimised perioperatively, including the use of electrocautery for every part of the procedure, rather than the more conventional scalpel. The patient must be capable of handling a small drop in blood cell count by prior administration of iron supplements as well as the red blood cell stimulating performance enhancing drug EPO (erythropoieitin).
A reversed abdominoplasty is sometimes used in weightloss patients with significant upper abdominal excess tissue which is resistant to conventional abdominoplasty surgery and involves pulling the upper abdomen upwards to the inframammary fold (crease under the breasts).
What are the scars like?
In standard abdominoplasty the scars stretch from one iliac crest (hipbone) to the other with a circumferential scar around the belly button. It is intentionally left in the region that a bikini would cover. Short scar techniques for abdominoplasty are a false economy and often lead to undulating contours and unaesthetic folds in the skin of the abdominal wall. These short scar methods are best avoided and play no part in our practice. In a mini-abdominoplasty the scar is between one third and a half the length of a standard abdominoplasty scar. The main problem of mini-abdominoplasty is its effect on the position of the umbilicus. Mini-abdominoplasty can often exaggerate hooding around the umbilicus and pull it into an unnaturally low and very unaesthetic position. For this reason Mr McDiarmid only performs this surgery on rare occasions and, if there is enough tissue, would always recommend a full abdominoplasty. The scars are initially red but gradually fade to give the appearance of a faint line. Using the high superior tension technique to pay off the tension of wound closure far away from the healing skin edge, as well as taping the scar for three months or so afterwards, can significantly improve the quality of the resultant scar.
How painful is it?
Most of the pain subsides over the first 36 hours and since the abdominal skin is initially numb following this procedure the discomfort experienced by patients is limited. Mini-abdominoplasty requires an incision approximately half the length of standard abdominoplasty and as a consequence of this is far less uncomfortable. Patients are offered a short course of pain killers on discharge from hospital.
What happens after surgery?
All sutures are dissolvable and take three weeks or so to dissolve away. Patients need not stay in bed but should limit their activities to pottering around the house for the first week or so. A long dressing covers the lower part of the abdomen and this is left in place for between one and two weeks until the first review appointment when the dressings are removed. At three months patients have a final check up with post-operative photography.
What could go wrong?
Abdominoplasty is a procedure which does not mix well with cigarette smoking. Smokers should give up completely at least six weeks prior to surgery as the nicotine reduces blood supply in the skin flap and can cause delayed healing and infection. Infection is very rare, as is bleeding and any small quantities of blood are usually dealt with by the drains.
Seroma, or the accumulation of clear fluid, is a more common consequence of this surgery as a large raw area is created between the abdominal wall muscles and the skin. If this happens to a minor degree it is best left alone as it will disperse itself over one or two weeks. If a larger collection occurs then it may require drainage with a needle and syringe. This is pretty painless as the abdominal wall is quite numb after surgery. In the rare event of a seroma reaccumulating after drainage, re-drainage may be necessary until it is a manageable size and can be left to dissipate. Sensation is always lost initially and gradually returns to the abdominal wall over a matter of months after the surgery. As previously stated the use of pre-liposuction of the lower abdominal tissue to remove fat from the valuable sub-scarpa’s fascial lymphatics and preserve their vital function has drastically reduced the seroma rate in Mr McDiarmid’s practice.