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Procedure: Abdominoplasty

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Abdominoplasty

Abdominoplasty (Tummy Tuck)

Abdominoplasty is one of the most commonly performed cosmetic procedures according to the ASPS. In 2009 it was one of the top five cosmetic surgeries performed. Abdominal contouring was first reported by Kelly in 1899. He removed a large overhanging layer of abdominal fat and skin which is called a “panniculus”.  This procedure was performed for functional fat excess. The umbilicus ( belly button), was removed in this early procedure. In the early 1920’s, Thorek described the first procedure that spared the umbilicus.  Adjustments have been made over that time period, primarily exploring varying positions of the incision. Interestingly, such incisional changes have paralleled women’s fashion, as 96% of abdominoplasties are performed in the female population.  When the bikini was fashionable, the abdominoplasty incision was nearly horizontal, and this changed when a French-cut bathing suit became popular.  With the French-cut style, the lateral incision of the abdominoplasty followed the high arch of the French-line bikini cut. Recently with low-cut jeans, the fashion has again reverted to a more straight line, lower incision.  In the late 1970’s reconstruction of the abdominal wall was added to the procedure. Repositioning the abdominal muscles was carried out, which tightened the abdominal wall musculature in a diamond fashion, enhancing the waistline significantly.   These combinations have progressed to the modern abdominoplasty, again, a very popular cosmetic surgery in 2011.

Indications

The most common indication for classic abdominoplasty is a woman, post pregnancy,  who has laxity and bulging of the abdominal wall and/or skin excess in the abdominal area. Pregnancy can stretch the strong tissue between the two rectus muscles of the abdomen. This connecting fascia is called the linea alba. When this fascial connection between the two vertical muscles in the middle of the abdomen is stretched, it is difficult, if not impossible, to correct with exercise alone. The reason it is difficult to correct is because the stretching caused separation of these large vertical rectus muscles. One can strengthen these muscles extensively but if they are laterally displaced and non anatomical, then there will remain a bulge in the midline of the abdomen. The greater the stretching of the deformity, which is often seen with multiple pregnancies, twins or triplets, the greater the bulge and the more common the indication for correction of these deformities with the abdominoplasty procedure.  Such abdominal wall stretching can also be seen with massive weight gain and weight loss, which stretches the skin, usually in greater proportion than stretching the abdominal wall musculature. This procedure is much more common in these days of gastric banding or stapling, or gastric bypass procedures, with enhanced massive weight loss. Men do come in for abdominoplasty procedures but are always related to some form of significant weight loss.

Goals

The goal is to remove the excess skin and tighten the abdominal musculature if needed. The desired result is to create as flat of an abdomen as possible with tight skin. Recreating the umbilicus into a more cosmetically acceptable appearance is an important aid in achieving the overall goal of a youthful, flat, tight abdomen.

 

Who is a Candidate for Abdominoplasty?

Patients with excess abdominal skin and laxity of the abdominal wall are typically good candidates for abdominoplasty.  While a mini-abdominoplasty is useful for those with abdominal wall laxity and only a minimal amount of excess skin, a full anterior abdominoplasty is more suited for those with abdominal wall laxity and a moderate to significant amount of excess skin of the anterior abdominal wall (belly).  Lastly, a circumferential abdominoplasty is most appropriate for patients with excess skin and fat in the flanks (love-handles) and lower back, more typical in patients who have undergone significant weight loss.  Abdominoplasty is often performed in combination with suction assisted lipectomy, or liposuction.

 

How is the Procedure Performed?

 

Planning the Incisions

Your surgeon will plan (“mark”) your incisions while you are in the standing position so that the greatest effects of gravity can be seen.  One incision will be around your umbilicus (belly-button), and the other will be a long-curved line across your lower abdomen, largely hidden below your underwear/bikini line.  For a “mini” tummy tuck, the lower incision is much smaller, and the belly button is not incised at all.  If you are having a circumferential abdominoplasty (see below), this lower incision will be continuous with a curved incision across your lower back.  Therefore, if you have a tattoo or previous scar (i.e., from a Caesarian section) in these areas, you should discuss with your surgeon whether or not these will be removed during the procedure.

 

Anesthesia

Abdominoplasty is performed in the operating room under general anesthesia: you will be totally asleep with a breathing tube in place.  The breathing tube will be removed before you wake up from anesthesia.  A foley catheter (a tube that drains the bladder) will also be placed to collect and measure your urine output. This will generally be removed prior to waking you up, especially if you are going home the day of surgery.

 

Anterior Abdominoplasty

After making the skin incisions, your surgeon will create a wide tunnel between the skin and fat and the underlying muscle starting from the lower incision all the way up to the margin of the rib cage, leaving the umbilicus attached from below.  Next, the surgeon plicates (tightens) the rectus abdominis (“six-pack”) muscles.  This “internal girdle” helps to eliminate the appearance of a “pot-belly” and also tapers the waist.  The elevated skin and fat will then be pulled tightly downwards and the excess tissue removed.  Finally, the umbilicus will be sewn into its new position, your incisions will be closed, and you will wake up from anesthesia. 

 

Mini-Abdominoplasty

The mini-abdominoplasty is similar to the anterior abdominoplasty with the following exceptions: 1) You will not have an umbilical incision.  This means that at the end of the procedure, your belly-button will be slightly lower than it was prior to the procedure; 2) The surgeon creates a tunnel from the lower abdominal incision to the level of the umbilicus (and not the margin of the rib cage); 3) The rectus muscles are plicated only to the level of the umbilicus; 4) A smaller amount of excess skin is removed than in the traditional anterior abdominoplasty.  Your incisions will be closed and you will wake up from anesthesia as above.

 

Circumferential Abdominoplasty

A circumferential abdominoplasty is performed in a manner similar to an anterior abdominoplasty. Following creation of the tunnel between the lower abdominal incision and the ribcage, you will be turned onto one side and the incision will be extended across your lower back.  Next, the skin and fat will be elevated from the underlying tissue both above and below the incision.   The skin will be then pulled together and the extra will be removed.  After the surgeon closes the flank/back incision, you will be turned onto your other side and the procedure repeated.  Finally, you will be turned onto your back and the surgeon will continue with the rectus abdominis plication as above.  Following removal of the excess abdominal skin, your incisions will be closed and you will wake up from anesthesia.

Results

The results are extremely long lasting.  Usually the results are maintained in an excellent fashion for the remainder of the patient’s life. Except for the usual signs of aging, the only thing that can dramatically reduce the efficacy of the abdominoplasty long term is a repeat pregnancy or a massive weight gain and loss.

NOTE:The patient must also be well aware that a perfectly flat abdomen is significantly dependent on the inherent strength of the abdominal tissues. For example, one can tighten tissue paper only so tight before it rips and tears, whereas stronger tissue can be tightened more enhancing the cosmetic result. Patients are often unaware that the strength of each individual’s abdominal wall muscle and fascia(tissue) vary widely. Therefore an improved contour to the abdomen is predictable, but a perfect, board like abdomen, can not be promised nor expected in all cases. 

What can I expect During my Recovery?

Recovery for abdominoplasty is one of the most difficult of all the plastic surgery procedures.  It is a physical recovery as opposed to many of the plastic surgery procedures, which are not painful but may be a social recovery, such as a face lift.  Abdominoplasty is moderately to significantly painful for the first three days as the muscle plication is the most notable cause of pain. For the next seven days, the pain is lessened, but still present, , and slowly but surely the discomfort abates over the next few weeks. Throughout this entire time the pain should be well controlled with pain medication as the patient ambulates on the day of surgery and is encouraged to walk frequently and early so as to try to minimize the complication of blood clots in the leg, which in the worst case scenario can lead to a possible significant complication such as a pulmonary embolus(blood clot in the leg or pelvis breaks off and migrates to the lungs). 

The drains remain anywhere from 5-10 days on average.  Note: There are some authors who do not use drains and use suture plications; however,  I personally do not find this to be adequate. The drains are placed for a reason, and that is to remove the potential fluid build-up between the abdominal skin fat flap and the abdominal wall.  If fluid develops there, pockets can be prolonged and can create potential long term problems.  That is why a pressure garment is placed immediately after surgery over drains so as to  minimize the fluid collection and enhance the result.  Usually complete physical recovery and restoration of energy takes approximately 6 weeks in most cases. 

What are the Risks?

With any surgery, the major risks are infection and bleeding.  Abdominoplasty is a clean procedure done under sterile conditions and therefore the risk of infection is very low.  The most common complication associated with abdominoplasty is seroma formation, which is when fluid collects in the area of surgery.  The lower abdominal scar tends to heal well, but it may widen or hypertrophy. If this occurs, it can be revised in the office under most circumstances.   Necrosis (death) of the elevated skin/fat or belly button is a rare but feared complication of abdominoplasty, and is more likely to occur in patients who have aggressive simultaneous liposuction, who smoke or whose incisions are closed under excess tension.  Other less devastating but problematic complications involve asymmetry, improper position of the umbilicus, and excess skin at the ends of the incision (“dog-ears”). Lastly, there is a small risk of pulmonary thromboembolism (blood clot in the lungs) in patients who undergo abdominoplasty, the risk of which is reduced with early walking and air filled compression boots that squeeze the legs.

Alternatives to Procedure

 For significant deformities there are no good alternatives in my opinion; however, for mild deformities, with only minimal skin laxity and no significant abdominal wall deformity, body tissue tightening procedures that are non-invasive may be reasonable choices. Such procedures would include Thermage, a radiofrequency procedure that heats the tissue to achieve secondary tightening. Although such a treatment is a possibility, expectations must be realistic as these non-invasive procedures cannot achieve the same result as a surgical abdominoplasty and the results are highly variable from patient to patient. There are no reasonable non surgical alternatives to surgical correction of the abdominal wall laxity at this time. 

Summary

Abdominoplasty is a useful body contouring procedure to remove excess abdominal, flank, and lower back skin, and tighten the abdominal musculature.  Although it requires a short hospital stay, it can greatly improve the appearance of the abdomen following pregnancy or weight loss.   While abdominoplasty is commonly performed, it is essential to select a surgeon who is experienced with this procedure and who understands your cosmetic goals.

 

References

  1. Thorne, Charles, et al. Grabb and Smith’s Plastic Surgery, 6th edition.  Philadelphia: Lippincott Williams & Wilkins, 2007.

  2. McCarthy, Joseph, et al. Current Therapy in Plastic Surgery. Philadelphia: Saunders Elsevier, 2006.