More Info on Tummy Tuck (Abdominoplasty)
The abdominoplasty or “tummy tuck” is a procedure that flattens the lower anterior trunk by removing skin and fat. This procedure is also called an abdominal dermolipectomy (skin-fat excision). The hip to waist ratio is an important aesthetic relationship in the adult female. This aesthetic relationship can usually be improved by abdominoplasty (tummy tuck) procedures. It is different from the liposuction procedure because in the liposuction procedure, only fat is removed. As a result, with the liposuction procedure there may be large amounts of excess skin after the swelling resolves. The abdominoplasty (tummy tuck) procedure not only removes fat, but also removes excess skin at the same time. In addition to skin removal, during the abdominoplasty (tummy tuck) the remaining skin on the abdomen is advanced (stretched) and secured in a new position with sutures. The stretching of the abdominal “flap” (tissue that is loosened during the procedure) will flatten the abdominal area because as the “flap” is stretched, it will become thinner. This is because a smaller area of tissue will cover a larger area as the flap is advanced. The final result is tighter skin and a thinner external (outside the muscle layer) abdominal wall. The appearance of the abdominal wall is improved because the skin and fat are removed, and the remaining tissue is thinned as it is advanced (stretched).
The abdominoplasty (tummy tuck) procedure has evolved significantly in the past 30 years. Many different techniques and designs have improved the results and predictability of the abdominoplasty (tummy tuck). Most importantly, changes in surgical and anesthesia techniques have improved the safety of the procedure. Historically, the abdominoplasty (tummy tuck) has had a higher incidence of post-operative complications than other elective cosmetic procedures. Changes in techniques and procedures and other factors have lowered the incidence of these complications (see subsequent section on complications). The classic abdominoplasty (tummy tuck) was first described over a century ago to treat excess tissue of the abdomen, and to a lesser degree, the flanks. Many incision locations have been described over the years and the lower abdominal incision has gained the most popularity. The most simple abdominoplasty (tummy tuck), generally referred to as a panniculectomy, consists of a direct wedge excision without any significant flap development (tissue undermining) and advancement of tissue. This procedure is still used today in selected patients, and more commonly used in patients that have lost massive amounts of weight. The classic abdominoplasty (tummy tuck) treats the entire abdomen from the bikini line all the way up to the subcostal margin (the bottom of the ribs just underneath the breasts). This is the most commonly performed abdominoplasty (tummy tuck) procedure. The mini-abdominoplasty modification treats a very small area of the lower abdomen (below the belly button). This procedure is appropriate for patients with a small amount of redundant tissue below the belly button (umbilicus) and no redundant tissue above the belly button. The abdominoplasty (tummy tuck) has since been modified in many ways to include ancillary procedures and expanded to treat the entire trunk, which is termed the belt lipectomy (not performed by all Plastic surgeons). In some patients the abdominoplasty (tummy tuck) is combined with other procedures including brachioplasty, liposuction, breast augmentation, and facial procedures. The combination of multiple procedures has been termed the “Mommy makover”.
Changes in bathing suit styles have influenced the incision design for abdominoplasty (tummy tuck). The two piece bathing suit, which evolved into the “bikini”, exposes the abdomen unlike one piece bathing suits. This resulted in surgeons lowering the abdominoplasty (tummy tuck) incision site to some degree, and also using a mostly horizontal incision as opposed to a vertical incision. Additional changes in bathing suit design caused further modification in the incision design. The sides of bathing suits, both one and two piece, have been shortened, which resulted in the abdominoplasty (tummy tuck) incision being more curvilinear so that it will remain inside the bathing suit. The so called “french design” abdominoplasty (tummy tuck) incision is shaped like a smile. Some patients prefer a flatter incision because they like to wear “hip hugger” style pants, and a flatter scar is preferable in that circumstance. The goal, which is not always attainable, is to completely conceal all scars in bathing suits or more revealing clothing (open midriff).
The abdominoplasty (tummy tuck) procedure and its variants can be divided into medically necessary procedures and aesthetic (cosmetic) procedures. For patients that have significant physical symptoms (rashes, infections in the abdominal fold) the abdominoplasty (tummy tuck) procedure may be reasonably considered as medically necessary. In this situation, there may be insurance coverage for the abdominoplasty (tummy tuck) procedure. Most patients fall into the aesthetic (cosmetic) abdominoplasty (tummy tuck) category which is not covered by third party payers. Some patients that fall into the aesthetic (cosmetic) abdominoplasty (tummy tuck) category may also have a true hernia. In this case, the third party payer may cover that part of the procedure (hernia repair), but not the abdominoplasty (tummy tuck) procedure. All insurance plans are different so each one should be queried as to coverage for abdominoplasty (tummy tuck).
Patients seek abdominoplasty (tummy tuck) for a multitude of reasons. A common concern expressed by patients seeking abdominoplasty (tummy tuck) is poorly fitting clothes and difficulty in finding clothes that fit properly. This is a result of the patient not being in proportion, and their body shape falling outside the typical sizing of stylish clothes. The patients frequently state that they are socially uncomfortable because of the appearance of their abdominal area. Many patients avoid certain types of clothes and bathing suits which can be socially limiting. Patients frequently express a desire to wear two piece bathing suits but are reluctant to do so because of the appearance of the abdominal area. These psycho-social problems frequently become self perpetrating. The excess abdominal tissue can also make activity, including exercise more difficult or impossible, which further compounds the problem. In many patients the fat in this area appears to be exercise and diet resistant, meaning this area is very difficult and sometimes impossible to improve without surgery. Some patients become frustrated because they follow a very healthy diet with normal caloric intake and follow a rigorous exercise schedule yet the abdominal area shows very little improvement. This is especially common after pregnancy, when the skin, fascia, and muscle are stretched. The abdominoplasty (tummy tuck) is not a substitute for proper diet and exercise.
Excessive tissue in the abdominal area can also cause skin irritations, skin rashes, even skin infections. This results from skin to skin contact (folded skin) which causes friction and perspiration. This is termed an intertriginous area, and it can occur in any area of the body. This can occur anywhere there are skin folds, which in this circumstance could be anywhere on the abdomen. Because the abdominoplasty (tummy tuck) eliminates (or minimizes) the intertriginous areas on the abdomen, this problem is improved or eliminated.
Stretch marks (striae) are very common on the abdomen and are a common concern voiced by patients seeking abdominoplasty (tummy tuck). In most patients that get a full abdominoplasty (tummy tuck) the stretch marks in the lower abdomen can be removed. Stretch marks are usually a cosmetic problem, and do not cause physical harm to the patient. There may be a genetic predisposition to stretch marks (some families are more apt to develop them). Both men and women can get stretch marks, but they are much more common and more severe in women. Women that go through pregnancy at a younger age may be more susceptible to developing stretch marks. A higher than normal body index (overweight or obese) may increase the risk of getting stretch marks. The appearance of stretch marks on the abdomen in women is very common, especially during growth and pregnancy. Stretch marks that develop during pregnancy are termed striae gravidarum. In women stretch marks commonly appear during the adolescent growth spurt on the hips, breasts, thighs, and abdomen. Stretch marks (striae) result from tension placed on the skin combined with a specific metabolic profile. Stretch marks are not usually caused by isolated stretching of the tissue. Plastic surgeons place devices called tissue expanders under the skin to gain dimension in skin and other tissues for various purposes. The tissue expanders can be serially expanded to enormous proportions over a short span of time, and at completion, stretch marks are rarely observed. That the skin can undergo tremendous expansion during this process without creating stretch marks means that there are factors other than stretching involved in their generation. In other words, stretching alone is not the cause of stretch marks. One theory regarding stretch marks is that a particular hormone profile is present at the same time the skin stretching occurs, and the simultaneous combination of these two factors causes stretch marks. There may be more than one hormone associated with the development of stretch marks. It has been believed that the hormone profile that makes a person susceptible to stretch marks is present during the adolescent growth spurt and pregnancy. The skin (dermis and epidermis) tears leaving a linear area that is commonly a different color than the surrounding tissue. They usually appear as purple, blue, red, and hypopigmented (light) or hyperpigmented streaks. Stretch marks are also commonly depressed (sink below the surrounding tissue). When the stretch mark is examined, as the finger is drawn across the skin, the skin feels like it falls into the area of the stretch mark. This is a result of the loss of the normal architecture of the skin, which results in loss of support. The difference in color from surrounding skin and the contour difference from the surrounding skin makes the stretch mark “eye catching”. While stretch marks can appear anywhere on the abdomen during pregnancy, they are more common in the lower aspect of the abdomen. Many treatments have been marked for improvement of stretch marks with limited results. Stretch marks, once present, generally do not disappear on their own and seem to be very resistant to improvement by any methods, the one exception (possibly) being laser treatment. Below is an image of stretch marks (striae) that are commonly observed on the abdomen.
Stretch marks (striae)
Excess tissue on the anterior abdomen can cause skin wrinkling. This is another common complaint voiced by patients seeking abdominoplasty (tummy tuck). There are two causes of abdominal skin wrinkling. First, and most obvious is excess skin. Excess skin can result from stretching and weight gain as previously described. Excess skin can also result from loss of skin elasticity. Second, loss of skin elasticity can result from many reasons including aging, stretching, weight gain, poor nutrition, pregnancy, and lack of physical activity. The appearance of excess skin appears to be worse when a patient is in the sitting position. Excess skin can cause skin irritation and rashes, especially at the inferior aspect of the abdomen. This is due to excess moisture and friction in the intertriginous area as previously described.
Skin dimpling (cellulite) is another common complaint patients express when seeking abdominoplasty (tummy tuck). Skin dimpling (cellulite) occurs when a patient gains weight, which expands the skin, while at the same time fibrous septa (connective tissue) retract the skin causing indentation. Skin dimpling (cellulite) can occur in the area of the abdomen, but is more common in the lower extremities. Skin dimpling (cellulite) is also more common in women than men. This problem, if it occurs on the lower abdomen, can usually be improved by the abdominoplasty (tummy tuck) procedure.
The fascia and muscle layers require special consideration in conjunction with the abdominoplasty (tummy tuck). If this area is damaged (stretched), for whatever reason, then it may be repaired during the abdominoplasty (tummy tuck). This is termed fascia repair, or fascia plication, or fascia reconstruction. The causes for fascia stretching in women is pregnancy, weight gain, lack of physical activity, and aging. In men common causes include weight gain, aging, and lack of physical activity. The anatomy of the abdominal wall, including the vascular supply is complex, and repair of this area can be complex. Four situations can exist regarding the abdominal wall anatomy in the pre-operative state. The most desirable situation is normal or near normal anatomy in the pre-operative state. In this circumstance, repair or adjustment of the fascia is not needed. This situation is seen in some patients seeking abdominoplasty (tummy tuck), including some patients that have experienced pregnancy. The second situation that can occur is distention or stretching of the abdominal fascia. This commonly occurs in the midline of the abdomen between the rectus abdominis muscles (sit up muscles). The spreading of these muscles is termed diastasis recti. This area between the muscles, unlike the lateral aspects of the abdomen, does not have a muscular component. If the rectus abdominis muscles spread apart due to intra-abdominal pressure, the fascia also stretches. If the abdomminal fascia is stretched significantly, it may not return to its original state. This stretched abdominal fascia may result in a bulge above or below the belly button. This is not considered a true hernia. The third situation that may exist is a true hernia. A hernia is defined as the exit of an organ or tissue from the cavity or space it should reside. This can occur anywhere on the abdominal wall but is most commonly observed around the belly button in this situation. When a hernia occurs, it may be repaired at the same time as the abdominoplasty (tummy tuck), or may be repaired at a separate time. There are many factors that determine the best timing for hernia repair. If the hernia is very large and requires a complex repair, including the placement of (synthetic) mesh, then a staged repair may be chosen. In some circumstances, such as, a patient with a very large hernia that also has severe respiratory compromise, it may be deemed too risky to repair. This situation, fortunately, is not common. In most circumstances, if a hernia is present, it can be discovered before the abdominoplasty (tummy tuck) by patient history and physical exam. The fourth situation that can occur is a combination of fascia stretching and a true hernia. As with the isolated true hernia, these anatomical problems can be very challenging to repair, and in some circumstances, the procedures to repair these combined problems may be staged (performed at different times).
Improvement is usually obtained with all abdominoplasty (tummy tuck) techniques. There are three basic types of abdominoplasty (tummy tuck) procedures, and a multitude of variants of these procedures. Because there is wide variation in abdominal anatomy, there are also wide variations in abdominoplasty (tummy tuck) procedures to improve this area. The panniculectomy removes a wedge of redundant tissue, usually at the bottom of the abdomen, which prevents overlap of skin. The area of treatment is generally limited to that area in the lower abdomen. This procedure is generally considered an elective medically necessary procedure to prevent rashes and infections in that area of the body. The full abdominoplasty (tummy tuck) is indicated when the entire abdominal wall requires treatment and the patient is deemed fit enough to undergo the procedure. The full abdominoplasty (tummy tuck) is indicated in patients with redundant tissue below and above the belly button. Although a patient undergoing panniculectomy may have redundant tissue above and below the belly button, he/she may not be a good candidate for a full abdominoplasty, and is a better candidate for panniculectomy. In order to complete this procedure, the belly button is repositioned in the abdominoplasty (tummy tuck) flap. The full abdominoplasty (tummy tuck) usually improves the entire abdomen, that is, the area above and below the belly button. Although the incision for abdominoplasty (tummy tuck) is typically in the lower abdomen, the fullness and extra skin in the upper abdomen is usually also improved. The full abdominoplasty (tummy tuck) tightens the abdominal skin and thins the flap that is developed as it is stretched. The mini-abdominoplasty, similar to the panniculectomy, treats only tissue below the belly button, and in this procedure there is undermining of the lower abdominal tissue to facilitate removal of excess tissue and flap advancement. In general, the belly button is not repositioned in the flap during the mini-abdominoplasty. None of these procedures improve skin tone or fascia tone, but rather, remove excess tissue and in some cases tightens stretched fascia. All abdominoplasty (tummy tuck) procedures (in almost all circumstances) have the incision, which is generally horizontal, placed at the bottom of the abdomen. If a C-section scar is present, the incision is commonly made in that location for the abdominoplasty (tummy tuck). The recovery for abdominoplasty (tummy tuck) may be slightly longer than for other elective cosmetic procedures, such as liposuction (see subsequent section on recovery after abdominoplasty).
Abdominoplasty (tummy tuck) is not a solution for excess weight. Abdominoplasty (tummy tuck) is not a substitute for physical activity. The final result of any procedure, including the abdominoplasty (tummy tuck) procedures, will be compromised by excessive weight and can add significant risk to some of the abdominoplasty (tummy tuck) procedures. If a patient gains weight after surgery, the result will be compromised. A pregnancy after abdominoplasty may also compromise the result. Some patients choose to have surgery before losing weight to “jump start” a new lifestyle. If an abdominoplasty (tummy tuck) procedure is performed in an overweight or obese individual, and the patient loses a significant amount of weight, then revision may be needed or desired. The decision to lose weight before surgery, lose weight after surgery, or not lose weight is considered when planning abdominoplasty (tummy tuck) procedures. For example, if a patient plans to lose weight after an abdominoplasty (tummy tuck) procedure, and elects to proceed with abdominoplasty (tummy tuck) before weight loss, then the surgical plan may change. A key element in planning the abdominoplasty (tummy tuck) procedure is the concept of proportion, and weight loss can affect the treatment plan. For example, if a patient needs a breast reduction, and plans to lose weight after the procedure, the patient may plan the reduction anticipating weight loss. If an obese patient undergoes a significant breast reduction, and then undergoes a gastric bypass and has massive weight loss, she may then need a breast augmentation to achieve proportion. It is important for the patient to help plan the abdominoplasty (tummy tuck) procedure and abide by the plan that is discussed with the Plastic surgeon.
Etiology of abdominal changes
The etiology of excess and unsightly abdominal tissue is multifactorial (many causes). Multiple tissue types are affected and repairs can be very complex. The abdominal fascia can be adversely affected (stretched) and sometimes it requires repair (if possible). The normal function of fascia is to cover, connect, and protect other tissues, so its normal function in the body does not include initiating dynamic function. Fascia does not move or retract by its own action like muscle. One very common cause of excess tissue and stretch of the abdominal muscle and fascia is pregnancy. During pregnancy the muscle wall and the surrounding fascia is stretched. Muscle and fascia, like all living tissues, are distensible. The difference between muscle and fascia in this stretching process is that muscle, unless severely damaged, has the natural tendency to shrink or contract back to its normal length once the stress is removed. Conversely, when fascia is stretched, it does not have the same inherent tendency to return to its normal length as does muscle. The normal function of fascia is to cover, connect, and protect other tissues, so its normal function in the body does not include being the initiator of dynamic function. The variation of anatomy following pregnancy varies widely from patient to patient following pregnancy. In some patients the abdominal wall returns to pre-pregnancy state postpartum (after childbirth). In other patients, and probably more commonly, the fascia (and muscle) remain stretched in the postpartum state. Many factors may be responsible for the disparity in the changes caused by pregnancy from patient to patient. The general size of the patient may be important. A patient with a larger frame may be able to sustain a pregnancy with less “damage” than a patient with a very small (petite) frame. The size of the baby may also be a factor. A very large baby would have the potential to cause more stress to the abdominal wall (muscle and fascia) than a very small baby. In extreme circumstances, a very small frame patient with a very large baby may be at higher risk for adverse changes to the abdominal wall than a large frame person carrying a smaller baby. Repeated pregnancies may cause more risk for changes than a single pregnancy. A protracted difficult labor may also cause damage to the abdominal wall. A patient that is in very good physical condition may be able to go through a pregnancy with less adverse changes than a patient in poor physical condition. The method of delivery may also affect the final condition of the abdominal wall. When a patient undergoes a C-section (caesarean section) incision it will cause scarring in the lower abdominal area. The C-section may also cause muscle separation (rectus abdominis muscles, “sit up” muscles) which can result in a deformity in the lower abdomen. Many patients that have had a C-section experience scar retraction which can cause the tissue in the lower abdomen to “biscuit”. The so called “biscuit deformity” can occur anywhere in the body, and it results from the shortening (contraction) of a scar, which results in the protrusion of the adjacent tissue. The “biscuit” deformity in this circumstance is typically above the C-section scar. This deformity which occurs in some patients getting a c-section can usually be improved or eliminated with the abdominoplasty (tummy tuck) procedure. Below is an image of a “biscuit” deformity secondary to a C-section.
“Biscuit” deformity after C-section
As one gets older, there is a natural tendency to gain weight. Patients frequently complain about their abdomen “sticking out too far” during abdominoplasty (tummy tuck) consultation, and excess intra-abdominal fat is frequently the cause. As a person gains weight over time, a significant portion of that weight is deposited inside the abdomen. The intra-abdominal fat is also referred to as “visceral fat”. The location of “visceral fat” is an important distinction for two reasons. First, as fat is deposited inside the abdomen, the abdominal wall (fascia and muscle) is stretched. If the fat accumulation is severe enough, and is present long enough, the same changes can occur that are observed during pregnancy. The result can be distention of the fascia and muscle, which will become very obvious if the patient loses a significant amount of weight, comparable to what occurs after childbirth. The second reason this is important is in reference to understanding what can be treated during abdominoplasty (tummy tuck). The abdominoplasty (tummy tuck) only treats the tissue (fat and skin) outside the body wall (fascia and muscle). The only means of reducing the mass inside the abdomen (visceral fat) is weight loss. The importance of this is related to which patients are the best candidates for abdominoplasty (tummy tuck). If there is a small component of intra-abdominal fat, then the patient is a better candidate than if there is a large component of intra-abdominal fat. This does not mean that abdominoplasty (tummy tuck) should not be performed on patients that have a significant intra-abdominal fat component. It does mean that this patients result may not be as close to an ideal result as the patient that has very little intra-abdominal fat. The amount of intra-abdominal fat will also determine to some degree what techniques are recommended for abdominoplasty (tummy tuck) and what ancillary procedures are recommended as well. The amount of intra-abdominal fat determines how much correction can be obtained during the abdominoplasty (tummy tuck) procedure. If the primary contributor of the abdominal protrusion is extra-abdominal fat, then a significant correction can be expected. If the primary contributor of the abdominal protrusion is intra-abdominal fat, then some correction can be obtained, but not as complete a correction as the patient with minimal intra-abdominal fat. Patients are referred for dietary consultation prior to surgery if they express an interest in losing weight. Weight gain can also cause displacement of the belly button inferiorly (towards the bikini line). In most patients the belly button can be returned to its normal location during full abdominoplasty.
Patients seeking abdominoplasty (tummy tuck) should undergo a medical history screening, a general physical exam, and a focused physical exam of the abdomen. In addition, the patient may also have ancillary studies to help ensure fitness for the abdominoplasty (tummy tuck) procedure. The focused exam of the abdomen helps determine the general elasticity of the abdomen. The amount of redundant tissue is also determined, both in the standing and sitting positions. The abdomen is also examined for fascia stretching and hernias. If a hernia is suspected, then other studies may be obtained (ultrasound, MRI). The flanks are also examined for excess tissue (fat). Any scars on the abdomen are examined. Abdominal scar assessment is very important because scars can adversely affect the circulation of the abdominal wall. If large scars are present, in particular horizontal or oblique scars, the procedure may need to be altered in order to maintain perfusion (blood supply) to the abdominal tissues. Morbidly obese patients should undergo weight loss before any body contouring procedures are performed. Referral to weight loss specialists is completed if the patient so desires.
Gastric bypass patients and other weight loss surgery patients seeking abdominoplasty (tummy tuck) procedures need special consideration. Weight loss surgery (that results in massive weight loss) can have great health benefits for patients and “cure” many serious health problems including high blood pressure, cardiac disease, type II diabetes, sleep apnea, pulmonary disease, gastroesophageal reflux (GERD), and orthopedic problems. Weight loss surgery also lowers the risk of deep vein thrombosis. Any history of deep vein thrombosis is explored (discussed in more detail in subsequent section). There are also some adverse affects in some gastric bypass patients, in particular, nutritional deficiencies. Weight loss surgery can be categorized into “restrictive” types of surgery and “malabsorptive” types of surgery. Restrictive types of weight loss surgery are less likely to cause malnutrition than malabsorptive types of procedures. The importance of good nutrition as related to any surgical procedure cannot be overestimated. There are several nutritional parameters that can adversely affect the gastric bypass patient undergoing any significant surgical procedure. Patients that have lost massive amounts of weight may have a severe deficiency in some critical nutrients that results in anemia. Gastric bypass patients commonly present with iron deficiency as a result of poor absorption or deficiencies in iron intake. Gastric bypass patients frequently have anemia (low red blood cell mass) which may cause a delay in surgery until this problem is corrected. If abdominoplasty (tummy tuck) is undertaken while the gastric bypass patient is anemic, it may result in a blood transfusion. While blood transfusions are generally safe, if a transfusion can be avoided by correcting nutritional deficiencies before surgery, this may be the most prudent choice. Another problem with gastric bypass patients is the red blood cell reserve. When a gastric bypass patient loses blood during surgery, it may take a longer period of time for the patient to return to a normal red blood cell level. While moderate anemia is not thought to have a large effect on the wound healing process, it is very important in relation to the abdominoplasty (tummy tuck) procedure. Protein deficiency may occur in gastric bypass patients and other weight loss surgery patients. Protein deficiency can result in wound healing problems, such as dehiscence (wound separation) and delayed healing (a longer time to heal than normal). Electrolyte imbalance can also be observed in many gastric bypass patients. Electrolyte imbalance can create an increased risk for cardiac dysrhythmias and can cause other problems as well. The patient’s immune system can be adversely affected by nutritional deficiencies. Compromised immunity can cause problems during recovery after an abdominoplasty (tummy tuck) procedure. In summary, the nutritional status of the gastric bypass patient is carefully evaluated before abdominoplasty (tummy tuck) and in some circumstances the patient will undergo treatments to improve the nutritional status before surgery. The timing of abdominoplasty (tummy tuck) is important to consider in the gastric bypass patients (and any patient that has undergone massive weight loss). The patient’s weight should be stable before abdominoplasty (tummy tuck) is performed. Some Plastic surgeons prefer the patient have a stable weight for several months before performing abdominoplasty (tummy tuck), while others prefer a longer period of time. Stable weight in this setting means variation of less than 15 pounds over a defined period of time. The target goal for this group of patients is a a BMI (body mass index) of 25 to 30 (overweight category), but a higher BMI is sometimes acceptable. In some patients the abdominoplasty (tummy tuck) will result in more weight loss (in addition to weight lost from the surgery itself) from increased activity, which may justify the procedure at a higher than ideal weight.
Classification systems have been proposed to help define the severity of the problems in candidates for abdominoplasty (tummy tuck). The severity of the problems in part determines which procedures are reasonable and which procedures are recommended. An explanation (with expansion of descriptions) of one classification system (Matarasso, Clin Plas Surg 1989;18:797) is below. This classification system is somewhat subjective and serves as general guideline for patients seeking abdominoplasty (tummy tuck). All patients do not neatly fit into these categories.
Below are examples of patients that could be placed in the different classes of abdominal anatomy. The following patients represent a wide range of anatomy. As noted previously, patients do not always fit exactly into one of the categories described in the above table.
Type I abdomen
Type II abdomen
Type III abdomen
Type IV abdomen
The specific abdominal contouring procedure to be performed is chosen by the patient after the informed consent process is completed. There are three different basic procedures and many variants of those procedures to choose from, and in some patients more than one option may be reasonable. For example the Type I abdomen may be treated with liposuction alone, or may be treated with a very conservative mini-abdominoplasty. Either procedure is reasonable in selected patients, and this choice of procedure is based on the patients goals. For example, the Type I abdominoplasty (tummy tuck) patient may be averse to scarring. If this is the case, then liposuction may be chosen because of the limited scarring, and this is a reasonable choice. There may be some limitations to liposuction in some patients. If this patient chooses liposuction to avoid the scarring associated with abdominoplasty (tummy tuck), then the limitations of this procedure should be understood and accepted. In this type of patient, if liposuction is performed then it is possible that there will be loose skin and and skin irregularities. In addition, if a fascia-muscle repair is indicated this would be more technically challenging during a “closed” procedure (liposuction) than during an “open” procedure. A Type I patient may choose a mini-abdominoplasty or a full abdominoplasty (tummy tuck) instead of liposuction. If mini-abdominoplasty is chosen then the loose skin could be reduced, and the fascia-muscle repair could be performed during the procedure under direct vision. The “trade off” in this circumstance would be the additional scar burden that comes with any abdominoplasty (tummy tuck) procedure as compared to liposuction. There are some circumstances where the Plastic surgeon may decline to perform the specific procedure chosen by the patient. An example might be the Type IV abdominoplasty (tummy tuck) patient that requests liposuction. In some circumstances, the Plastic surgeon may feel that liposuction would not be beneficial to the patient, and may be harmful, in which case he/she may decline to perform the procedure.
The Abdominoplasty procedures
The content below describes the three main types of abdominoplasty procedures. There are many variations of these three procedures. The evaluation of patients that are considering abdominoplasty (tummy tuck) may not result in a recommendation for a single procedure. As with all surgery of this type, there is wide variation in anatomy, and therefore, wide variation in recommendations. Patients seeking improvement of the anterior trunk (abdomen and flanks) can be placed into one of three subjectively determined categories. The first category is the patient whose anatomy, in the judgement of the Plastic surgeon, is ideally suited for liposuction. There are some patients where a particular procedure is strongly recommended, for example, liposuction may be recommended over abdominoplasty (tummy tuck). The second category is the patient whose anatomy, in the judgement of the Plastic surgeon, is ideally suited for abdominoplasty (tummy tuck) or some similar procedure. In these patients abdominoplasty (tummy tuck) may be recommended over liposuction. The third category falls into a gray area, intermediate between the first and second category, and this patient is not an ideal candidate for liposuction, and is also not an ideal candidate for abdominoplasty (tummy tuck) or some similar procedure. In this category of patients, more than one recommended procedure may be reasonable and recommended by the Plastic surgeon. Because there is no ideal procedure to recommend for this group of patients, there will be some (different) disadvantages to any procedure recommended by the Plastic surgeon. Because the recommendations in this category are more subjective, the opinions of Plastic surgeons may vary regarding the preferred procedure for a particular patient.
The images below give a general idea how body shape or anatomical Type might affect a recommendation for a particular procedure. Some patients may have an anatomic situation that is more appropriate for liposuction, while other patients may have an anatomic situation that is more appropriate for abdominoplasty (tummy tuck). Still other patients may fall into a category where liposuction or abdominoplasty (tummy tuck) could be reasonably recommended. The images below illustrate three different anatomical situations. The first patient is a good candidate for liposuction. The second patient could be treated with either liposuction or an abdominoplasty (tummy tuck). The third patient is a candidate for abdominoplasty (tummy tuck). This is not to imply that the third patient could not undergo liposuction. The third patient could undergo liposuction as a primary procedure, but the result would not be ideal because liposuction alone in this patient would leave large amounts of extra skin. There are no rules for
Bias towards Liposuction
Abdominoplasty or Liposuction
Bias towards abdominoplasty (tummy tuck)
The mini-abdominplasty is best suited for patients that have a limited amount of excess skin and fat that is localized to the lower abdomen. The best candidates also have very little adverse changes in the abdominal muscles (in particular the rectus abdominis muscles) and the abdominal fascia. The incision for the mini-abdominoplasty can vary from very short to very long. The area that is treated with the mini-abdominoplasty is (mostly) below the belly button. Because the belly button is not part of the operation the upper central part of the abdomen is not improved to a large degree. The mini-abdominoplasty will not correct excessive loose skin or excessive fat above the belly button. The incision for the mini-abdominplasty is typically in the lower abdomen in the “bikini line”. As noted previously, the surgeon makes a recommendation as to the exact location and shape of the incision, but the patient makes the final determination as to the exact location of the incision. It is important to understand that the location that the incision is drawn is not the final location of the scar. When the superiorly based flap is elevated and advanced inferiorly, the elastic nature of the tissue causes a natural tendency to pull upwards. The amount of upwards pull is determined by two main factors. First is the natural elasticity of the tissue. The more elasticity the tissue has, the more retraction force it will exert. The second is the amount of tissue the surgeon elects to excise (remove). The more tissue the surgeon excises, the farther the flap will be advanced to achieve closure, and the farther the flap is advanced, the more retraction force it will exert. In summary, the natural elasticity and the amount of tissue that is excised will in part determine the amount of retraction force the flap exerts on the lower part (lower skin edge) of the abdomen. This is important because the retraction force of the superiorly based flap will pull the incision superiorly so the final location of the incision site (the final location of the scar) will be higher than the location it was drawn before the surgery. The level (height) of the scar can be demonstrated by retracting the inferior abdomen superiorly after the proposed incision is drawn on the patient. Again, the shape and height of the incision is recommended by the Plastic surgeon but the final determination of the location and shape is left to the patient. While the mini-abdominoplasty primarily corrects tissue problems below the belly button, a very limited amount of correction can be obtained above the belly button. This is achieved by flap development (which loosens the tissue) on either side of the belly button while leaving the belly button unaltered. This allows a minimal amount of stretch of that tissue which may give limited improvement in the area above the belly button. The limited improvement observed above the belly button is a result of tissue stretch, and not flap advancement as in the full abdominoplasty. A drain (or drains) is typically placed in the lower portion of the abdomen during abdominoplasty, the tube of which exits a different area. The drain that is preferred is a “closed system”, meaning the tube drains into a closed container that is emptied periodically. This prevents the drainage from coming in contact with clothing and bedding, and theoretically lessens outside elements (bacteria) from entering the area. The closed system also facilitates accurate measurement of the volume of drainage that is removed from the wound, which in part determines when the drain is removed. The incision for the mini-abdominoplasty is typically repaired with absorbable internal sutures (stitches). This means most of the sutures will not have to be removed after healing because they are “absorbed” by the body. Because the sutures are internal (inside), they cannot be seen and will usually not cause irritation as external permanent sutures may sometimes cause. If the mini-abdominoplasty is performed on a patient with significant excess tissue above the belly button, then there may be excess tissue remaining after the procedure, which would not be the ideal result. In patients that have lower abdominal redundancy and a very small amount of redundant fat in the upper abdomen, a combination procedure may be performed. In this patient, a mini-abdominoplasty could be performed to correct the lower abdomen, and a very conservative liposuction procedure could be performed in the upper abdomen. This area above the belly button becomes a part of the new primary blood supply and liposuction performed in this area should be performed with caution. Liposuction is performed only in the area that has not been undermined. The undermined area (flap) created during abdominoplasty is not treated with liposuction because this could further diminish the blood supply which could result in wound healing problems. The primary differences between the mini-abdominoplasty and the full abdominoplasty is the belly button is not disconnected from the abdominoplasty flap during the mini-abdominoplasty procedure, and there is limited dissection above the belly button with the mini-abdominoplasty. The belly button is disconnected from the abdominoplasty flap to facilitate the treatment (reduction) of redundant tissue in the upper abdomen (between the lower edge of the ribs and the belly button) in the full abdominoplasty (tummy tuck). Because of the limited area that the mini-abdominoplasty treats, the recovery for this procedure may be somewhat easier than for the full abdominoplasty (tummy tuck). Below are images showing the typical incision site for the mini-abdominiplasty and the typical area of tissue undermining. The area of undermining is shown in the image on the right and is shaded blue. The image that follows shows the area of tissue that is typically removed during mini-abdominoplasty. Note: the image below is used only for purposes of illustration and not implication of choice of procedure for this particular patient.
Incision site, mini-abdominoplasty
Tissue removed during mini-abdominoplasty
Tissue removed during mini-abdominoplasty
The full abdominplasty (tummy tuck) is the most commonly performed type of abdominoplasty. The entire anterior abdominal wall is treated with the full abdominoplasty (tummy tuck), meaning below and above the belly button. Most of the tissue below the belly button is removed in this procedure which will remove stretch marks (striae) if they exist in this area. The incision with the full abdominoplasty (tummy tuck) is in the same general location and is the same shape as the incision used in the mini-abdominoplasty. The incision used in the full abdominoplasty (tummy tuck) is typically longer than the incision used for the mini-abdominoplasty. A longer incision is required for the full abdominoplasty (tummy tuck) because the abdominal tissue (flap) is advanced further than in the mini-abdominplasty which can cause the tissue at the ends of the wound to protrude. The tissue protrusion is known as a “dog ear” and is sometimes seen in the lateral aspects of the full abdominoplasty (tummy tuck) scar. The farther the flap is advanced, the more tissue can be removed. The more the flap is advanced the longer the incision must be in order to avoid redundancy (dog ears) in the lateral aspect of the scar. In some circumstances the surgeon may intentionally leave small “dog ears” in the lateral aspect of the incision in an effort to minimize the total length of the incision. In many circumstances, the small “dog ears” at the lateral aspect of the wound will resolve on their own with time, leaving a desirable final result and a shorter final scar. Another technique used to minimize “dog ears” and shorten the final scar is to perform liposuction in the limited area of tissue redundancy. In general, the more abdominal tissue that is removed, the longer the incision. In patients that have extreme amounts of excess tissue, the incision may extend all the way to the posterior axillary line, which is the area where the side transitions to the back. In most patients (except those that have lost an extreme amount of weight) the incision extends to the anterior axillary line (front part of the side) or the mid-axillary line (middle part of the side). The incision for the full-abdominoplasty is usually repaired with absorbable internal sutures (stitches). This means most of the sutures will not need removal after healing because they are “absorbed” during the healing process. Because the sutures are internal (inside), they cannot be seen, and will not cause skin irritation.
One distinct advantage of the full abdominoplasty (tummy tuck) over liposuction and the mini-abdominoplasty is full access and direct vision of the anterior abdominal fascia (and musculature). The advantages of full access to this anatomical area is two fold. First, it allows a direct visual and digital (touch) exam of the fascia-muscle layer, for which there is no diagnostic substitute. Second, it allows full access to the fascia and muscle which facilitates adjustment and repair if it is deemed necessary and possible. There has been a trend in Plastic surgery over the last three decades to perform operations under direct vision for the same reasons. The rhinoplasty is an example, where the “open rhinoplasty” has now become very common. Not only does the open rhinoplasty allow direct visualization and direct manipulation of the internal nasal structures, it has facilitated many surgical maneuvers during rhinoplasty that were difficult or impossible using the more traditional “closed rhinoplasty” technique. The same holds true for the full abdominoplasty (tummy tuck) procedure, meaning that direct access to the anterior abdominal wall and muscle improves diagnostic accuracy and facilitates technical maneuvers during the procedure. In many patients, the same changes (stretching, for whatever reason) that resulted in a need for a full abdominplasty (tummy tuck) also result in the need for fascia adjustment. In other words, the external abdomen (fat and skin) cannot be stretched significantly unless the fascia and muscle is stretched at the same time. The muscle, as previously noted, does at least have the potential to recover (shrink) when stretched, but the skin and fat has less potential to shrink back to its original dimensions. Some patients that have significant stretching of the skin, fascia, and muscle have those structures return to normal dimensions or near normal dimensions when the stress is resolved, and therefore do not need repair or adjustment. In most circumstances the need for a fascia-muscle repair is known before surgery and is diagnosed by physical exam. In some cases radiologic studies are obtained to diagnose the structural problems. As with the mini-abdominoplasty, the final location (height) of the scar in the full abdominoplasty (tummy tuck) is higher than the location drawn before surgery. After the tissue is loosened which is facilitated by undermining, the excess tissue is removed as in the mini-abdominoplasty. Pre-operative markings drawn before surgery are used as a guide for excision of excess tissue. In some circumstances guidance incisions (tailor tack technique) are utilized to help determine the level of tissue removal.
Following tissue removal, the abdominal wall is inspected for fascia integrity. Any visible blood vessels on the fascia or back wall of the flap are secured. The anterior abdominal wall consisting of fat, superficial fascia, and skin receives its blood supply in large part form the rectus abdominis muscle. The superficial fascia is in two distinct layers (termed the fascia of Camper and the fascia of Scarpa) , and are superficial to the fascia sheath of the abdominis rectus. The abdominal wall fat is above, in between, and below these fascia layers. It is particularly important to secure the vessels that overlie the rectus abdominis muscle. The rectus abdominis muscles, also called the “sit up muscles” are a pair of long muscles that rest inside (upper on half) or under (lower one half) the fascia layer. When the trunk is flexed or extended, the muscle slides inside or under this sheath, and the muscle moves independently of the sheath. The muscle moves more than the sheath when the trunk is flexed or extended, and this becomes very important when considering the vascular anatomy. The vessels from the rectus abdominis muscle exit the muscle, perforate the fascia layer, and then supply blood to the fat, superficial fascia, and skin. These vessels are referred to as “perforating vessels” and are large enough to be visible with the naked eye. Because the rectus abdominis muscle moves more than its fascia covering during flexion and extension of the trunk, the blood vessels are tortuous and redundant, similar to a loose spring. This allows the blood vessels to lengthen and shorten, not by stretching, but by uncoiling, as the rectus abdominis muscle moves inside or underneath the fascia sheath. The end result is that the vessels that supply the abdominal wall are able to move (uncoil) without being torn off the fascia sheath, which would occur if they were not tortuous and redundant. The importance of this vascular anatomy related to abdominoplasty (tummy tuck) concerns the division of these vessels (to facilitate flap advancement) at the time of surgery. If there is significant advancement of the abdominoplasty (tummy tuck) flap, some of these vessels could “tether” the flap if they were not divided. In this circumstance, the vessels are divided from the abdominal tissues, but are still attached at their origin, which is the rectus abdominis muscle. As a result, the divided vessels will continue to move with the rectus abdominis muscle, and once divided, could potentially cause bleeding if disrupted by muscle movement. These vessels can cause bleeding in the potential space under the flap and above the fascia, and can also cause bleeding under the fascia. Bleeding under (inside) the fascia can be a challenging diagnostic dilemma, because this area is isolated from the drain which is used to monitor the wound. Because of this anatomic situation, the perforating vessels of the abdominal fascia should be inspected and controlled at the time of the abdominoplasty (tummy tuck). This also has implications for post-operative instructions, which are discussed in a subsequent section. Below are images showing the typical incision site for the full abdominoplasty (tummy tuck) and the typical area of tissue undermining. The area of undermining is shown in the image on the right and is shaded blue. The area typically excised during full abdominoplasty (tummy tuck) in the image that follows is shaded in red. Note: the image below is used only for purposes of illustration and not implication of choice of procedure for this particular patient.
Incision site, full abdominoplasty
Undermined area, full abdominoplasty (shaded blue)
Tissue removed during full abdominoplasty (shaded red)
The panniculectomy is a variation of abdominoplasty that is used in a selected group of patients. It is not the most commonly performed type of abdominoplasty procedure. The difference between the panniculectomy and the other abdominoplasty procedures is that there is little or no undermining of the abdominal tissues during the procedure. Tissue undermining is avoided in this procedure for several reasons. In some patients, there is concern about circulation in the abdominal tissues and the development of a flap could further compromise the circulation. Less than robust circulation before surgery could be further compromised by extensive tissue undermining which could increase the risk of healing problems. By avoiding extensive undermining of the tissue the existing perforating vessels are preserved which decreases the likelihood of flap failure. Foregoing tissue undermining also decreases operative time, probably decreases time to full ambulation, and probably decreases recovery time.
The goals of the panniculectomy are usually very different from the goals of the full abdominoplasty (tummy tuck) and the mini-abdominoplasty. The goals of the full abdominoplasty (tummy tuck) and the mini-abdominoplasty are typically aesthetic, or aesthetic and functional. The panniculectomy is usually not performed for aesthetic reasons, but rather for medical and/or functional purposes. Patients that are candidates for panniculectomy frequently have rashes, infections, and difficulty wearing clothes due to an excess of overhanging tissue in the lower abdomen. Activity can be limited by a large panniculus. Patients that are candidates for the panniculectomy are frequently overweight which can result in respiratory compromise. Any surgery that potentially could adversely affect respiratory function should be approached with extreme caution. In this group of patients, any surgical procedure on the abdomen could adversely affect respiratory function, and this would certainly include the panniculectomy and the other abdominoplasty (tummy tuck) procedures. This is especially true when a large visceral fat component is present in combination with primary pulmonary disease. An excellent aesthetic result is usually not expected or obtained in patients undergoing panniculectomy, but some improvement in the functional parameters is expected.
Because the tissue of the abdomen is not (significantly) undermined during the panniculectomy, direct access to the fascia and muscle layer is not obtained. Because direct access to the fascia is not obtained, repair (tightening) or adjustment of that structure is more challenging. However, in many patients that undergo panniculectomy, fascia repair is relatively or absolutely contraindicated. The reason that a patient is a better candidate for a panniculectiomy than for a full abdominoplasty (tummy tuck) may be the same reason a fascia repair is contraindicated. In this circumstance, lack of direct access to the fascia is inconsequential. In many patients that undergo a panniculectomy the decision not to perform fascia repair (tightening) or adjustment is made prior to the procedure. This situation is discussed with patients before surgery. There are may reasons fascia repair may be avoided. The fascia must have some degree of inherent integrity in order to repair it. If the fascia does not have reasonable integrity the repair will be difficult or impossible and even if the repair is completed, there is significant likelihood it will fail. Patients that are candidates for panniculectomy are typically not in the best physical condition. As a result, there may be additional risks for surgery that are not present in the otherwise healthy abdominoplasty candidate. For example, extremely overweight or obese patients have a higher risk for some complications, and many patients that are candidates for abdominoplasty fit into this category. Because the abdomen is not undermined significantly, there is very little improvement of the overall shape. Many patients that undergo panniculectomy have a significant intra-abdominal fat component which causes the abdomen to protrude. The intra-abdominal fat, also called visceral fat, is inside the fascia-muscle layer. Visceral fat is never treated during any abdominoplasty procedure, and can only be improved by weight loss.
There are distinct advantages to the paniculectomy over the full abdminoplasty (tummy tuck) and the mini-abdominoplasty in selected patients. By definition, tissue undermining must be performed to create a flap, and formal flap creation is not a goal of the panniculectomy. Because the ability of a surgical wound to heal is directly dependent on the blood supply, by retaining the native circulation the wounds theoretically have a better ability to heal. The very limited undermining of the abdomen retains the native circulation of the tissues which lessen the risk of a compromised blood supply. Another very important consideration for all patients, and especially this group of patients is early ambulation after surgery. Because there is limited undermining of the abdomen during the procedure the total operative time is limited. This can be very important in patients that are medically compromised because long procedures can result in a more difficult recovery for the patient. The limited undermining performed during the panniculectomy is to facilitate apposition of the tissue, and not to advance tissue as a flap. Because the panniculectomy is less invasive than mini-abdominoplasty or full abdominoplasty, the recovery is theoretically easier and quicker. This means that full ambulation may be earlier as well. The importance of early ambulation has been realized over the past three decades and has been studied extensively. Early ambulation is especially important in patients that are medically compromised. Failure to regain activity after surgery can delay recovery and also cause life threatening health problems, including deep vein thrombosis (covered in a subsequent section).
The incision for the panniculectomy is similar to the full abdominoplasty and the mini-abdominoplasty and is placed in the lower abdomen. The incision for the panniculectomy is typically placed in or near the natural fold in the lower abdomen as with the full abdominoplasty (tummy tuck) and the mini-abdominoplasty. The horizontal incision that is placed in the natural skin fold is the only incision used in this procedure (except the incision for drains) similar to the mini-abdominoplasty. Like the mini-abdominoplasty, there is usually no incision around the belly button during the panniculectomy. The incision for the panniculectomy is usually very long because the redundant tissue extends into the flank area. Because the incisions for the panniculectomy tend to be longer, some surgeons will elect to place multiple drains during surgery. Patients that undergo a pannicultomy have more (volume) drainage and drain for a longer period of time than more ideal patients. As a result, in addition to having more drains than the ideal abdominoplasty patient, the drains are sometimes left in for a longer period of time.
The recovery for patients getting a panniculectomy may require a longer facility stay and more ancillary care than the full abdominoplasty (tummy tuck) or mini-abdominoplasty patient. As previously noted, this is not a result of the surgery being more extensive but more a result of the pre-operative condition of the patient. This group of patients may require precautionary measures after surgery to help ensure early ambulation. In some patients, assistance with physical therapy specialists may be helpful.
Below are images showing the typical incision site for the full abdominoplasty and the typical area of tissue undermining. The area of undermining is shown in the image on the right and is shaded blue. The area typically excised during full abdominoplasty in the image that follows is shaded in red. Note: the image below is used only for purposes of illustration and not implication of choice of procedure for this particular patient.
Incision site, panniculectomy
Undermined area, panniculectomy (shaded blue)
Tissue removed during panniculectomy
The umbilicoplasty refers to surgery that improves the belly button and can also improve hygiene in some circumstances. It is usually performed in conjunction with the full abdominoplasty (tummy tuck) but usually not performed during the mini-abdominoplasty or the panniculectomy. The umbilicoplasty is also performed as an isolated procedure in some patients. Because of the limited operative field, the umbilicoplasty can be performed under local anesthsia in many patients. Patients that present for umbilicoplasty have minimal redundancy of tissue elsewhere in the abdominal area but have extra tissue in the umbilical area. Many different designs for umbilicoplasty have been described. The umbilicoplasty can be completed by direct excision or flap repair, and the degree of deformity in part determines which procedure is recommended. The recovery for isolated umbilicoplasty is usually very easy due to the small operative area. Drain(s) are not usually required for umbilicolplasty. Below is an image of a patient presenting for umbilicoplasty and the incision design for this type of problem. This patient has no excess skin or excess fat and wanted improvement of her belly button which changed as a result of pregnancy. There are many different designs for umbilicoplasty one of which is illustrated below.
Incision design for umbilicoplasty
Ancillary and combined procedures
Body contouring procedures are frequently combined along with other types of procedures, and the combination of these procedures has been termed the “Mommy makeover”. Many different combinations of surgery have been safely performed by Plastic surgeons. Many combinations of aesthetic surgery can be performed as long as it does not cause excessive operative time, excessive blood loss, or cause increased risk for healing problems. For example, one commonly performed combination surgery is abdominoplasty and liposuction. These are considered two “body contouring” procedures. Another commonly performed combination surgery is abdominoplasty and breast augmentation. While these are the most commonly performed combinations, many other combinations have also been performed, such as abdominoplasty and rhinoplasty (nose reshaping). While procedures outside the scope of “body contouring” are not as commonly performed, they can be performed safely in some circumstances. There are many factors to consider when determining if plastic surgery procedures should be performed at the same time, or staged, meaning performed at different times. Long operative time has been associated with increased risks for complications. If a combination surgery (Mommy makeover) will take excessive time, then the procedures may be staged. There are no hard and fast rules regarding the maximum safe operative times for combination surgery (Mommy makeover). A very important factor when determining a maximum desired operative time is related to the patients general health. If a patient is healthy and is normal or close to normal weight, one might consider combining procedures in one operative session. If a patient is not thought to be healthy, then the surgeon may be biased towards staging procedures. Longer operative times have been thought to be associated with increased infections, and more risk for hypothermia (low temperature). Hypothermia during surgery is thought to be associated with higher blood loss and more frequent infections, and longer operative times convey more risk for hypothermia during surgery. Deep vein thrombosis has been associated with long operative times, and because this problem has had a higher incidence with abdominoplasty (tummy tuck), a separate section covers this topic. It follows that minimizing operative times can be important in reducing complications. Some surgeons feel that if surgical procedures will last longer than 6 hours, then staging should be considered. Some surgeons feel that the maximum time should be more in the 3 to 4 hour range. The maximum time of the procedure could also be biased by the individual patient situation. For a healthy patient, the target goal for operative time may be above 6 hours, and in a medically compromised patient, the goal may be less than 2 hours. Again, there is no exact time limit for the safe length of surgery. These operative times are used only as very general guidelines. Potential blood loss is considered when planning combined surgical procedures. With modern operative techniques, blood loss is generally not excessive enough to warrant staging procedures unless there is unexpected bleeding during or after surgery. Many factors are considered when planning elective aesthetic surgery and there is no formula to assist in making the decision to combine procedures, or to stage them. The most important factor in making these decisions is patient selection. Patients that have co-morbid disease, such as a history of deep vein thrombosis, cardiac disease, pulmonary disease, thrombophilia, high blood pressure, diabetes, obesity, and/or collagen vascular disease require consideration of those factors when planning surgery. Smokers commonly have co-morbid disease that is considered when planning surgery. These co-morbid factors may meet the threshold to avoid elective cosmetic surgery altogether. Combination surgery (Mommy makeover) is generally thought to be safe in selected patients.
The image below illustrates one commonly performed combination surgery, which is abdominoplasty (tummy tuck) and liposuction. The area treated by abdominoplasty (tummy tuck) is shaded in red, and the area treated by liposuction is shaded in blue. Note: the image below is used only for purposes of illustration and not implication of choice of procedure for this particular patient.
Abdominoplasty liposuction combination surgery
The fascia and muscle layer is sometimes repaired or tightened during the abdominoplasty (tummy tuck). The fascia can become permanently stretched due to pregnancy, weight gain, lack of physical activity, the aging process, or a combination of those factors. Fascia stretching usually does occur from a combination of reasons, and in women, the most common cause is pregnancy. The entire abdominal fascia is affected by pregnancy but the area that is most affected on a permanent basis is the midline above and below the belly button. There is no muscle in the center of the abdomen (between the two rectus abdominus muscles), which consists of fascia only (in this layer). This area is termed the linea alba (white line), which is a fibrous structure that runs from the lower sternum (bottom of ribs in the middle) to the pubic area. The linea alba is an internal structure that cannot be directly observed except during surgery. The linea alba is under the linea nigra, which is a dark vertical (hyperpigmented) area in the skin that can occur during pregnancy. When the abdominal fascia is stretched, it does not always return to its original state. In some patients this can result in a bulge in the mid-abdomen. This mid-abdomen bulge is a common complaint voiced by patients interested in some type of abdominoplasty procedure. As the fascia stretches, the anterior muscle layer, termed the rectus abdominis muscles, spreads out and takes on an oval dimension in the medial and lateral direction. In other words, instead of taking a direct and straight course from the bottom of the ribs to the pelvis, the muscle curves outward towards the flanks creating a more oval shape. The rectus abdominis muscles are the anatomic structures that result in the so called “six pack”. These muscles are sometimes referred to as the “sit up” muscles. If the rectus abdominis is observed from the side (viewing in an anterior posterior direction) the muscles will also take on a more oval shape. It is the combination of the rectus abdominis muscles and the fascia changing shape that causes the protuberant abdomen in men and women.
When there is severe stretching and thinning of the abdominal fascia, this situation may result in a true hernia. The repair of hernia can range from very simple to very complicated. For large hernias, further studies may be indicated before any repair is undertaken. In some circumstances, an MRI may be ordered to help define the anatomy and the severity of the hernia. In some circumstances, pulmonary function tests may be needed to assess possible pulmonary compromise before abdominoplasty or fascia plication. If a large hernia does exist, it may be repaired at the same time as the hernia, or repaired before the abdominoplasty procedure as a staged process. If a patient is medically compromised, or there are other complicating circumstances, the hernia may not be repaired.
When performing a full abdominoplasty or a mini-abdominplasy a decision is made whether or not to attempt a repair of the fascia and muscle if indicated during the procedure. Recently authors of Plastic surgery literature have written a significant change in the absolute indication for repair or tightening of these structures. Based on modern Plastic surgery principles, which have evolved dramatically over the last three decades, surgical procedures are now customized for each patients individual situation. In other words, the same operation, for example, one type of abdominoplasty is not performed on every single abdominoplasty patient, irrespective of their individual anatomy. This is precisely why there is more than one type of abdominoplasty and many variations of those types. Thirty years ago some surgeons would repair or tighten the abdominal fascia and muscle as a matter of routine on every patient undergoing an abdominoplasty. No single operation fits every patient, and fascia repair is not appropriate for all patients. Based on modern Plastic surgery principles and common sense, procedures are customized for each patient. Performing the same operation on every patient defies common sense because not one single procedure is appropriate for every single patient because of the wide variation in anatomy.
The abdominoplasty (tummy tuck) is not a substitute for proper diet, weight control to approach a normal BMI (body mass index), or adequate physical activity. BMI (body mass index) is a measure of body fat based on height and weight. BMI is used to estimate the patient’s weight as compared to a normal weight. The abdominoplasty (tummy tuck) procedure and its variants are not a treatment for excess visceral fat. Visceral fat is inside the abdomen and around organs. The only remedy for excess visceral fat is weight loss. This is directly related to the decision to repair or tighten the abdominal fascia and muscle, or not to repair those structures. The key to understanding the success or failure of the fascia and muscle repair in abdominoplasty (tummy tuck) is determining the etiology of the fascia stretching, and whether or not that etiology is still present. If the etiology of the fascia muscle stretching is still present (visceral fat), then a repair of the fascia and muscle during abdominoplasty (tummy tuck) may not be the best choice. When excess visceral fat is present, the fascia and muscle are stretched by forces and reach a state of “equilibrium”. In other words, the abdominal fascia and muscle have been stretched because of excessive pressure or stress. If the etiology of the fascia and muscle stretching is still present and in “equilibrium”, a repair or tightening of those structures will result in a recreation of the stresses that resulted in the fascia and muscle stretching in the first place. If the repair recreates excessive stress, then several changes can and will occur. The first thing that may occur is a failure of the fascia repair. If this does occur, then the repair will have been done without long term success, and should obviously have not been done in the first place. If a fascia repair fails, the sutures that have been placed may be under so much tension that the fascia and muscle tear. The tearing or failure of fascia can occur in the area of the sutures line, or can occur in an area remote to the sutures line. Failure of a fascia repair can result in abdominal bulges and/or hernias. If there is bulging in the abdominal fascia, it may be symmetrical or asymmetrical. Because living tissues are dynamic, excessive stress will cause changes in the tissue, and in this circumstance, change back to the pre-operative state. If a fascia repair does fail, this may create additional problems other than the stretching of the abdominal fascia and muscle. This risk is obviously higher in a patient that is not an appropriate candidate, meaning the patient that has poor fascia integrity and poor muscle integrity before surgery. This type of patient is at much higher risk for failure of fascia and muscle repair than the patient that has excellent fascia and muscle integrity. If the fascia and muscle sutures are placed under excessive tension and they tear the fascia, a true hernia may result which is a more complicated problem that may require a much more complicated solution. A true hernia can occur in any patient undergoing fascia and muscle repair, but is more likely in the patient that is not a good candidate for this repair. Fascia and muscle repair during abdominoplasty (tummy tuck) is not a treatment for excess visceral fat. When a repair is performed on a patient with excess visceral fat, it results in excessive intra-abdominal pressure which in turn caused the problem (stretching) in the first place. In order for a fascia and muscle repair to be successful long term, whatever caused the problem (stretching) must be resolved at the time of the repair. For example, if a patient is pregnant, one would never consider tightening the fascia during the pregnancy. After the pregnancy is completed, the stress that caused the fascia stretching is resolved (the baby has been born) so it is reasonable to consider fascia and muscle repair if the fascia is loose. After pregnancy, if the patient returns to normal weight, the fascia may be loose when examined at the time of surgery. If the fascia can be easily advanced (pulled to the middle) from both sides, then a repair is indicated. If the fascia cannot be easily advanced to the midline during the procedure, then a fascia muscle repair may result in failure. The same principle holds true in men and women as related to visceral fat. If there is excessive visceral fat to the degree that the fascia cannot be easily advanced to the midline (moved to the middle) then a fascia muscle repair may not be the best option. When a patient, man or woman, undergoes significant weight loss, the fascia is commonly loose enough to advance to the midline. In this group of patients, a fascia and muscle repair can be performed with reasonable expectation for good long term results provided the patient does not gain weight. The decision made by the Plastic surgeon to repair or not repair the fascia is based on the previously described principles. When making the decision to repair or not repair the fascia and muscle during this procedure the surgeon considers the risks of any procedure before surgery. In the case of the abdominoplasty (tummy tuck) procedures, there is one risk that historically has been higher than for other Plastic surgery procedures. That complication is deep vein thrombosis (blood clot) and embolus (blood clot migrating in the venous system). This is a very serious complication that can cause severe health problems, and can result in death. The reasons that this complication is more common in the abdominoplasty (tummy tuck) patient is multi-factorial, meaning there are many potential causes, and the causes may be different in different patients. Contributing factors to deep vein thrombosis includes choice of anesthesia techniques, flexed trunk after surgery, lack of mobility, obesity, and fascial plication. When these factors are combined, the risk would obviously be increased. The best approach to problems of this type is always prevention. In order to prevent a thrombotic event and a subsequent (pulmonary) embolus, the etiology of the problem must be delineated. Only then can preventive measures be employed. The American Society of Plastic Surgeons formed a task force to study this problem, and the resulting findings and conclusions have helped decrease the morbidity and mortality in this group (and other groups) of patients. The thrombo-embolic event is mentioned here because some Plastic surgeons believe that repair or tightening of the fascia and muscle during abdominoplasty (tummy tuck) is inappropriate in some patients, and this repair may cause an increased incidence of deep vein thrombosis. Because the incidence of this problem has historically been higher in the abdominoplasty (tummy tuck) patient, a separate section on this topic follows.
As previously described, the anatomy of the fascia and muscle layers of the abdominal wall are complex. Further, the normal anatomy of the abdominal wall fascia above the belly button is different than the anatomy below the belly button. Because the anatomy of the abdominal wall is complex, sometimes repair of this area is complex. If there is stretching of the abdominal wall from pregnancy, weight gain, lack of physical activity, or the aging process, in some patients the abdominal wall must be “disassembled” and then “reassembled” during abdominoplasty in order to achieve repair or tightening. While this is a very simplistic description of a sometimes very complex type of repair, the techniques for repairing the abdominal wall can be thought of in those terms. This newly described technique for repairing the abdominal wall is termed the “component separation technique” and it allows repair of some large defects that were previously very difficult or impossible to repair. The component separation technique can also be used to repair large hernias. In some patients, a synthetic or biologic mesh is used in addition to the component separation technique to repair more complex defects. When the component separation technique is indicated in a patient, the procedure falls into the reconstructive surgery category rather than the aesthetic category. If the component separation technique is indicated at the same time an abdominoplasty (tummy tuck) procedure is performed, then some surgeons may opt to perform a very conservative abdominoplasty (if performed concurrently). Some surgeons may also decide not to perform an abdominoplasty (tummy tuck) at the same time, and either delay the abdominoplasty (tummy tuck) procedure until later time, or simply not perform an abdominoplasty (tummy tuck) procedure on this type of patient. There are no objective rules for making the decision to perform a component separation repair of the abdominal wall and an abdominoplasty (tummy tuck) at the same time, but there are several considerations. First is the size of the extent of the area of fascia repair or hernia. A very large abdominal wall defect may bias the surgeon to stage the two procedures. When the component separation repair of the abdominal wall and an abdominoplasty (tummy tuck) are performed at the same time, the operative area could include the intra-abdominal area (area where the organs are present) and a space outside the abdominal wall. These two areas could potentially then be connected, and together they create a very large space. If there is an infection after surgery in either of these areas, the infection could potentially penetrate the adjacent space. If an infection does occur in both spaces, this could result in a very serious and life threatening problem. It would likely result in a protracted hospital stay and could potentially require multiple operations. This problem might be further complicated if mesh were placed during the procedure, especially if that mesh was synthetic. Synthetic mesh does not have an ability to resist or fight infection like living tissue, so this could complicate the recovery after surgery if an infection did occur. Synthetic mesh is prone to infection when used during abdominoplasty (tummy tuck), and infections have occurred in these types of repair many months or years after the procedure was performed. Another consideration is that of viscera support. If the fascia and muscle layer are repaired at the same time as an abdominoplasty (tummy tuck), then there is potential for the fascia and muscle layer repair to fail at the same time. If this occurs the viscera (organs) could potentially be exposed. While this circumstance would be extremely rare, it has occurred and therefore should be considered as a possibility when these repairs are undertaken concurrently. Fascia plication is not a treatment for abdominal protrusion resulting from excessive visceral fat.
The image below shows the abdominal fascia being approximated during full abdominoplasty (tummy tuck). If the fascia can be approximated (advanced) easily then fascia repair is reasonable to undertake. If the fascia cannot be easily advanced, then advancement and suturing may cause too much tension, as previously described.
Fascia approximation during full abdominoplasty (tummy tuck)
Fascia repaired during full abdominoplasty (tummy tuck)
Abdominoplasty and cigarette use
The abdominoplasty (tummy tuck) procedures can be greatly affected by lifestyle choices. One of those choices is cigarette smoking. It is common knowledge that cigarette smoking is detrimental to good health. Smoking cigarettes has many harmful effects to patients undergoing surgery, and there are some procedures that are affected more than others. Abdominoplasty (tummy tuck) procedures are included in the group of procedures that can have serious consequences as a result of smoking cigarettes and for this reason it is included in a separate section here.
Smoking cigarettes has many detrimental effects on the human body. The harmful effects of cigarettes to the wound healing process and to flap surgery can be divided into short term effects, and long term effects. The long term effects of cigarettes include (but are not limited to) heart, lung, and vascular disease. These long term harmful effects to the heart, lungs, and blood vessels can harm the wound healing process, and also harm flaps created during abdominoplasty (tummy tuck). The long term effects of cigarette smoking are insidious and not recognized for many years. As with many harmful substances, the severe long term consequences of cigarette smoke do not appear for many years in most patients. Cigarette smoke can cause severe short term effects, especially in patients with co-morbid disease. An example of this is asthma, and cigarette smoke can cause severe problems at the time of exposure. The use of cigarettes has long been known to have a detrimental effect on wound healing. This is especially true when a patient undergoes flap surgery. A flap is a section of tissue that is removed from one place called the donor area, and then moved to another place called the recipient area. It is critical that the blood supply to a flap remain intact. It this context, blood supply means arterial or venous patency. If the blood supply to the flap is not intact the flap will not survive. The blood supply to the flap must have both functioning components, arterial and venous, or the flap will not survive. Without the arterial component, blood cannot get into the flap. Without the venous component, blood cannot get out of the flap. If either the arterial or venous components are absent, the flap will not survive.
The abdominoplasty (tummy tuck) procedures (mini-abdominoplasty and full abdominoplasty) create very large flaps. When the flaps are created, the normal blood supply to the flaps is changed. In order to advance the abdominoplasty (tummy tuck) flap, which allows excision of excess tissue, the blood vessels that provide the primary blood supply to this area are sometimes divided. This results in what was the secondary blood supply becoming the primary blood supply. The new primary blood supply typically increases over a period of several weeks, but immediately after surgery it is likely that the new blood supply is less than the pre-operative blood supply. Because additional harm to the already compromised blood supply can cause severe wound healing problems, it is important to maintain the new blood supply. There are many factors that can affect the blood supply to flaps. One factor is pressure. Pressure can be exogenous (from the outside) or endogenous (on the inside), and either can have a detrimental affect on the flap. An example of exogenous pressure is described in the complications sections and is related to the placement of binders. Abdominal binders are sometimes used after abdominoplasty (tummy tuck) to support the operative area. Binders can cause very serious wound complications because the pressure from the binder can cut off the blood supply to the flap, in which case the flap will not survive. Binders can also cut off the blood supply to flaps resulting in partial flap loss. Endogenous pressure can cause tissue swelling. Severe tissue swelling related to a surgical procedure could cut off the blood supply to the flap, in particular, venous egress, in which case the flap will not survive. Another cause of compromised blood supply is wound tension. Wound tension, different from the aforementioned etiology of pressure from binders, can cause a decrease in the blood supply to the abdominoplasty (tummy tuck) flap resulting in similar complications. The abdominoplasty (tummy tuck) flap is intentionally placed under tension at time of closure. If the tension is too great, the blood supply can be compromised. The detrimental effect of excess tension can be seen in many other types of plastic surgery including breast reduction, breast lift, and facelift. Tension on the flap during closure and the use of binders after surgery are two factors that are controlled by the surgeon.
There are many toxic compounds in cigarette smoke that cause wound healing problems. Cigarette smoke can decrease the blood supply to flaps as an immediate effect. The wound healing problems caused by cigarette smoke are multifactorial, meaning there are many physiologic processes that are harmed in addition to decreasing the blood supply to the wound. Nicotine is a mood altering stimulant drug found in cigarettes and it is known to be very addictive. Nicotine has many detrimental side effects on the body, including harmful effects to wound healing. Immediately after smoking a cigarette, the blood vessels exposed to nicotine constrict (get smaller) as a direct effect of nicotine exposure. Vasocontriction decreases the blood supply to the flap. This vasoconstrictive effect is immediate (within seconds or minutes). Nicotine also causes the body to release its own (natural) vasoactive compounds such as norepinephrine, epinephrine, and vasopressin, all of which can cause vasoconstriction. These naturally occuring compounds can also decrease the blood supply to a flap. In summary, cigarette smoke can have a direct and indirect effect on the blood supply to a flap, which is detrimental and immediate. Secondary cigarette smoke can also potentially cause these problems. Nicotine also has a direct adverse effect on platelet (cells that contribute to blood clotting) adhesiveness which can cause microvascular occlusion (blockage of very small vessels). Increased platelet adhesiveness can also cause wound healing problems. One cell type that is very important to wound healing is the fibroblast, and proliferation (growth and production) of these cells is harmed by nicotine. Harm to fibroblasts is detrimental to the healing process. Carbon monoxide, which is also found in cigarette smoke limits the ability of red blood cells to transport oxygen, which is critical to the wound healing process. Poor oxygen supply to healing tissues inhibits cellular respiration, which prevents normal wound healing. Hydrogen cyanide, which is another compound found in cigarette smoke is harmful to enzyme systems that are active during wound repair. Properly healing enzyme systems are also necessary for cellular respiration which is critical to normal would healing. E- cigarettes also contain nicotine, and the effects they have on wound healing may also be detrimental. Further, there are likely more undefined problems yet to be discovered related to the harmful effects of cigarette smoke as related to wound healing.
The use of cigarettes also increases the likelihood of a wound infection after surgery, including abdominoplasty (tummy tuck). While infections are not common in healthy non-smokers after abdominoplasty (tummy tuck), they can occur, but infections are more likely in smokers. Cigarette smoking alters wound healing physiology, and cessation of smoking improves the wound healing process. Cessation of smoking ameliorates some of the detrimental effects caused by the compounds in cigarettes. If a patient stops smoking 4 weeks before surgery the wound healing environment is improved. The oxygenation of the tissues will improve after cessation of smoking which improves tissue (flap) metabolism. Cessation of smoking improves the patient’s immune system which makes infection less likely. When a patient stops smoking inflammatory cells become more responsive and are able to migrate to and kill infection causing bacteria more efficiently. The time to restore the inflammatory function after cessation of smoking is thought to be about 4 weeks. Based on this information, it is reasonable to set 4 weeks before surgery as the minimum time to cease smoking before surgery. It is thought that the proliferative (reparative) function of wound healing does not return in 4 weeks. The proliferative function of wound healing is that which rebuilds the tissues and includes many types of cells, including the fibroblast. Because the tissue building proliferative (reparative) function does not return in 4 weeks, it is possible that this may also contribute to increased infections in cigarette smokers. The reparative phase is the second phase of wound healing and lasts for several weeks after surgery. This may follow because the longer a wound takes to heal, the longer the wound is exposed to microbes that could cause an infection. In summary, cigarette smoking adversely affects the inflammatory and reparative cell functions that are involved in wound healing. It is important to note that the aforementioned addresses only the cellular aspect of wound healing. Another important component of wound healing is the humoral (non-cellualar) contribution to the process. Cigarette smoking also has a detrimental effect on the humoral component of wound healing. The direct effect of the humoral component on wound healing, wound infection and wound separation is less well defined, but it can be reasonably assumed that the humoral component of wound healing, like the cellular component, is made less efficient by cigarette smoking.
In addition to wound infection, cigarette smokers also have a higher incidence of wound separation. This means that the wound healing process does not create enough strength after surgery to keep the edges of the tissue together. After abdominoplasty (tummy tuck) small wound separations can occur and are usually inconsequential. Small wound separations are usually treated conservatively with dressing changes. Because the wound area in abdominoplasty is very large, it is very important to minimize the chances of large wound separation. It is the large wound separation that is of concern to the Plastic surgeon. A large wound separation may need additional treatment, including surgery and wound therapy. In some circumstances, a wound VAC (vacuum assited closure) is untilized. The possibility of wound separation is a very important consideration with abdominoplasty because in some patients, including mini-abdominoplasty and full abdominoplasty patients, when the flaps are advanced and closed (sutures together) they are placed under considerable tension. Some wound tension is created during closure with in anticipation of tissue “relaxation” after surgery, and also to counter the poor elasticity of tissue commonly observed in this population of patients. Wound separation can sometimes contribute to wound infections because the internal aspect of the area becomes exposed. Wound separation after abdominoplasty can cause further problems with recovery, especially in patients that have had a complex fascial repair at the same time. Wound separation can also contribute to wound infection. If prosthetic mesh is used for the fascia repair, the risk of a secondary infection in this area is even higher with wound separation, because prosthetic (man-made) mesh has a tendency to become infected. This is because prosthetic mesh does not have the ability to fend off infection like living tissues. If there is wound separation and there is a failure of a fascia repair at the same time, there wound then be a direct route from outside the body to the abdominal cavity that contains the organs. This could result in a very large infected area both in the subcutaneous space and the intra-abdominal space. Because cigarette smoking increases the risk of wound separation, this factor should always be considered when planning a complex surgery such as abdominoplasty combined with fascia repair.
Another potential problem that can result from cigarette smoking after abdominplasty (tummy tuck) is tissue loss. A robust blood supply to the abdominoplasty (tummy tuck) flap is critical to the healing process. Anything that compromises the blood supply to the flap can result in tissue loss. The problems of wound healing, wound infection, wound separation, and tissue loss frequently occur in combination. The occurrence of any one of these problems can lead to the occurrence of the other problems. For example, a patient may experience tissue loss, which may lead to wound separation. The wound separation may lead to a wound infection. The possible occurrence of these problems in combination emphasizes the importance of close follow-up (post-operative care) after abdominoplasty (tummy tuck).
Any adverse effects on wound healing and the abdominoplasty flap can be additive, or multiplicative. For example, excessive tension and smoking could cause more risk than either factor alone. Cigarette smoke dramatically increases the chances of tissue loss after abdominoplasty. The loss of tissue is directly related to compromised blood supply as previously described. Small areas of tissue loss after abdominoplasty are not uncommon and typically require no treatment. Larger areas of tissue loss may require treatment, and because of the large size of the abdominoplasty flap, a large amount of tissue can potentially be lost. Large areas of tissue loss after abdominoplasty are not common, but can occur. Large areas of tissue loss can contribute to secondary infections.
The area at highest risk for wound healing problems (tissue loss) in the mini-abdominoplasty and the full abdominoplasty is the central area below the belly button illustrated below in red. This is the area of the flap that has the most tenuous blood supply after flap development.
Risk area for tissue loss
Cigarette smoking can contribute to pathologic blood clotting (deep vein thrombosis). There are multiple effects cigarette smoking has on blood clotting. Long term cigarette smoking causes damage to vessels which can increase the likelihood of blood clotting. Cigarette smoking also causes platelets in the blood to become more adhesive (sticky) . Increased platelet adhesiveness causes an increased likelihood of blood clotting. Cigarette smoking can cause a condition termed secondary polycythemia which is an overproduction of red blood cells. Polycythemia results in increased blood viscosity (thickness) which increases the risk of blood clots. The risks of blood clotting and deep vein thrombosis in the abdominoplasty patient is reviewed in a subsequent section.
Cigarette smoking in combination with other co-morbid disease can make complications after an abdominoplasty (tummy tuck) a virtual certainty. For example, if a patient is obese, has poorly controlled diabetes, and is a chronic cigarette smoker, the chances of wound complications after surgery is a virtual certainty.
The aforementioned adverse effects of smoking and the added risk for surgery can be reversed to some degree by cessation of smoking before abdominoplasty (tummy tuck). Smoking cessation does not mean cutting down. Smoking cessation does not mean just a couple of cigarettes a day. Smoking cessation means no cigarettes, and it also means no exposure to secondary cigarette smoke. This means complete cessation of cigarette smoking and avoidance of secondary smoke at least 4 weeks before and 4 weeks after abdominoplasty (tummy tuck). Cessation of cigarette smoking before abdominoplasty (tummy tuck) is the sole responsibility of the patient. If supportive measures are requested to cease cigarette smoking before abdominoplasty (tummy tuck), which falls outside the scope of Plastic surgery, referrals to those sources can be completed.
Deep vein thrombosis and pulmonary embolus
Deep vein thrombosis, which is the pathologic clotting of blood in the blood vessels is a known complication of major surgery, including abdominoplasty procedures. When a part of that clot breaks free and is carried to another part of the body it is then termed an embolus. If a blood clot inside a vein breaks free and travels to the lung, it is then termed a pulmonary embolus. This entity is also termed thromboembolism. The incidence of this problem has historically been higher with abdominoplasty procedures than with other elective Plastic surgery procedures and is covered in some detail as a result of that fact. Blood clots can occur in the lower or the upper extremities, and clots in both locations can result in an embolus. The blood clot can block blood flow to anatomic structures, such as the lung. In addition to the physical blockage of blood flow, chemical mediators that result from the clot are also involved in the embolic process. This is a very serious complication and focus has been placed on prevention over the last three decades. There are many factors that are thought to increase the incidence of deep vein thrombosis and embolus. It is commonly thought that the etiology of deep vein thrombosis is multi-factorial. In order to decrease the incidence of thromboembolism the risk factors should be defined so that prevention can be planned. There are three primary factors that can cause the blood to clot inside a deep vein, including the blood in the lower extremities. Damage to blood vessels can result in blood coagulation. If a vein (or artery) is damaged, then blood clotting is more likely. Damage to veins can result from trauma, and can also result from a non-traumatic disease process. Slow blood flow can cause blood to clot. Slow blood flow can be a result of damaged veins, lack of activity, dehydration, and many other causes. Blood that is more viscous (thicker) is more likely to clot. The viscosity of blood is also affected by the patients state of hydration, and being dehydrated increases the risks of deep vein thrombosis. There are many other factors that cause blood to clot, but the aforementioned are common factors.
Many known risk factors for deep vein thrombosis and embolus have been described, some that can be controlled, and some that cannot be controlled. These risk factors have been defined in risk assessment models, and the Caprini Risk Assessment Model is one that is commonly utilized. The Caprini Risk Assessment Model has been specifically validated in plastic surgery patients (Pannucci CJ, et al). One very important risk factor is a previous history of deep vein thrombosis. Other risk factors include family history of deep vein thrombosis, obesity, advanced age (stratified), major surgery, long operative times (progressive risk), oral contraceptives or hormone replacement therapy, smoking, varicose veins, history of malignancy, recent pregnancy, and congenitally acquired clotting disorders. When more than one of these risk factors is present at the same time, the total risk may not be additive, but rather multiplicative. There are many other contributing risk factors that are less common than those previously noted.
After the existing general risks for deep vein thrombosis and embolus have been subjectively quantified, the stratification of patients with this system is useful for two purposes. When considering elective surgery, that is, surgery that may be deferred or not done at all, there is reasonably some level of risk that would result in a decision to defer surgery. In some circumstances, the risk for deep vein thrombosis and embolus may be deemed great enough that surgery is never performed on the patient. The decision to perform surgery or not perform surgery based on these risk factors is somewhat subjective. If the Plastic surgeon deems the risk acceptable, and the patient deems the risk acceptable, then surgery may be performed. If the Plastic surgeon or the patient deems the risk unacceptable, then the procedure is not performed. The risk factors for deep vein thrombosis and embolus are of great help in making the decision to operate or not operate. The second reason for evaluating the risk factors for deep vein thrombosis and embolus is for planning surgery, especially for procedures (abdominoplasty) that have historically had a higher incidence of this problem. By stratifying patients according to risk factors, additional preventive measures can be taken before, during, and after surgery. There are many precautionary measures that are taken for every patient, even those that have very low risk for developing deep vein thrombosis and embolus after surgery. For example, patients are always well hydrated before surgery to help ensure the intravascular volume is adequate. Many Plastic surgeons routinely utilize lower extremity compression garment or A-V impulse boots in every patient to assist lower extremity circulation during and immediately after surgery, and until the patient is ambulating without difficulty. This is true even in patients that are deemed very low risk for thromboembolism. It is important to understand that while many contributing factors are explored for all patients, there are potentially other unknown factors that may contribute to the development of thromboembolism. For example, the blood tests routinely ordered before surgery, in particular the blood tests that concern blood clotting, do not test all factors related to blood homeostasis (clotting enough to stop bleeding but not too much to cause excessive clotting). As a result there may be a tendency to form pathologic blood clots in a patient that is not picked up by the blood tests. Further, the ability to form clots in any patient varies with time, so there may be a low likelihood that a patient will form a pathologic blood clot at one point in time, and then at another point in time have a higher likelihood of forming pathologic blood clots. As a result, the Plastic surgeon must always assume that there may be other unknown risk factors, even in healthy patients, and take precautionary measures accordingly. The previously noted routine hydration and lower extremity compression devices are examples of precautionary measures that are used even in healthy low risk patients. The concept is to think prevention when considering the possibility of deep vein thrombosis.
In higher risk patients, sometimes a medicine (enoxaparin) is added to the post-operative period to help prevent deep vein thrombosis. This medicine is a type of heparin that is sometimes used to prevent blood clotting by inhibiting the clotting cascade (by accelerating the activity of anti-thrombin III ). While this medicine may help decrease the incidence of deep vein thrombosis, it also increases the chance of excessive bleeding. Because there is some risk to using enoxaparin, it is not routinely used on all patients. Enoxaparin is used only in selected patients that meet criteria for its use. Enoxaparin is used when the risk benefit ratio is acceptable, meaning more benefits are expected from its use than risks. Another precaution that is sometimes taken in high risk patients is the placement of a “filter” in the superior vena cava to stop blood clots from reaching the lungs. The filter does not prevent the formation of blood clots or the migration of blood clots but it can help prevent the migration of blood clots to the lungs, resulting in a pulmonary embolus.
Anesthesia for abdominoplasty (tummy tuck)
In recent years, anesthesia techniques have been examined by Plastic surgeons as a risk factor of developing deep vein thrombosis. The choice of anesthesia techniques are thought to have an effect on the incidence of deep vein thrombosis and embolus, and these techniques can be modified to lessen (but not completely prevent) the incidence of this problem. The lower extremities (and upper extremities) depend on muscular action to assist in venous circulation. In the lower extremity, the soleus muscle which overlies and contains the deep veins acts as a physiologic pump in the lower extremity. Anything that inhibits or prevents the muscular action of this physiologic pump can result in stagnation of blood, which is a risk factor for deep vein thrombosis. If a patient is “paralyzed” (given muscle relaxers) during abdominoplasty, the soleus muscle will be flaccid and not function as a physiologic pump. A benchmark publication in 2004 (Ersek RA) showed that the type of anesthesia can greatly affect the incidence of thromboembolism. In this study of over 30,000 patients treated over a 36 year period with dissociative anesthesia, there was not a single case of deep vein thrombosis or embolus. The conclusion of the author was deep vein thrombosis and embolus did not occur in this patient cohort because the soleus muscle was not paralyzed (flaccid), and this prevented blood stagnation and thrombus formation. While many other factors are involved, the state of the soleus muscle during abdominoplasty (tummy tuck) is a very important consideration. Other studies have shown that most occurrences of deep vein thrombosis and embolus were in patients that had undergone general anesthesia (with muscle relaxation) during the procedure. In addition, one of the medicines (ketamine) sometimes used for this type anesthesia decreases platelet aggregation, and this may have some protective affect against deep vein thrombosis and embolus. Considering this information, general anesthesia that paralyzes muscles should be avoided when other anesthesia techniques are possible. In some circumstances, general anesthesia would be required for abdominoplasty (tummy tuck). An example would be a patient undergoing abdominoplasty (tummy tuck) and an extensive ventral hernia repair. Because of the technical requirements of this surgery, general anesthesia would probably be required.
Recovery after abdominoplasty
The recovery after abdominoplasty (tummy tuck) is usually uneventful. Significant complications with abdominoplasty (tummy tuck) procedures are fortunately not common. The complications that are associated with abdominoplasty (tummy tuck) that are shared with all surgical procedures are bleeding and infection. Clinically significant (requiring additional surgery or therapy) bleeding after abdominoplasty (tummy tuck) is not common, but it can occur. There is always bleeding after (most) any surgical procedure, with drainage going both inside and outside the wound. There is usually significant drainage after abdominoplasty (tummy tuck), which consists of serous (clear component of the blood) drainage along with the cellular blood components. Most of the drainage that is observed after abdominoplasty (tummy tuck) (in most all patients) is serous, with a smaller component that is cellular. The clear drainage observed after abdominoplasty (tummy tuck) is a result of the large raw surface area that is created during the procedure. Because of the significant volume of drainage associated with abdominoplasty (tummy tuck), many surgeons place a drain or drains inside the operative area. If this clear fluid collects inside the operative area and is clinically significant (a large volume), it is called a “seroma”. Very small amounts of fluid will usually be absorbed by the body, but if the volume of the fluid is significant, it may require surgical drainage. Some surgeons report minimal problems with abdominoplasty (tummy tuck) without the use of drains, but there is one significant advantage of using drain(s) other than the obvious functional advantage (removal of wound drainage). Drain or drains, especially closed system drains, allows the Plastic surgeons, Physicians assistants, Nurses, and the patient to monitor the wound drainage. Closed system drains have a bulb that collects drainage and allows measurement of the drainage volume. By monitoring the volume, color, and consistency of drainage, the providers and the patient can get a good general idea of the status of the wound. The ability to monitor the area of surgery is very important for all abdominoplasty procedures because there is a significant difference in these procedures and many other Plastic surgery procedures. The abdominplasty procedures create a large potential space that can contain a large amount of fluid (blood). In general, the full abdominoplasty creates a larger potential space than the mini-abdominoplasty, and the mini-abdominoplasty creates a larger potential space than the panniculectomy. The importance of this potential space is that the patient could experience a large amount of blood loss without being aware of it (no symptoms). Plastic surgery procedures do not always create a large potential space that can contain large amounts of blood. For example, if there is excessive bleeding after breast augmentation, the potential space (the space around the implant) is so small that a small amount of fluid (blood) will be immediately recognized by the patient. If excessive fluid (blood or serum) is in the breast pocket there will be significant asymmetry, discomfort, and sometimes skin bruising (ecchymosis). Patients can immediately recognize any size differences in the breast, and will also immediately recognize that there is a significant difference in discomfort on one side more than the other. Patients will also immediately recognize any significant difference in breast shape, especially if it creates asymmetry. In other words, the patient will very likely be aware that there may be excessive bleeding. The situation is very different for the abdominoplasty (tummy tuck) procedures. If excessive bleeding occurs after abdominoplasty (tummy tuck) there is typically no asymmetry of the abdomen because there is only one potential space, unlike breast augmentation. The abdominal tissue is typically thick enough that it can obscure excess bleeding, meaning that the abdomen may not appear swollen. The thickness of the tissue can also obscure excess drainage to the degree that it is difficult to palpate on physical exam. The abdominoplasty (tummy tuck) patient can also experience excess bleeding and not have external (skin) bruising, again, due to the thickness of the flap. The potential space created during abdominoplasty is very large, and the tissues surrounding the space are very distensible. The combination of these two factors allows a significant volume of fluid without causing any additional discomfort to the patient. Post-operative instructions are issued and explained to patients before surgery so that if excessive drainage does occur, the patient will be more likely to recognize it. During abdominoplasty (tummy tuck) patients are typically hydrated with intravenous fluids, and these fluids can change laboratory values. The altered laboratory values can cause the true red blood cell mass (total amount of red blood cells) more difficult to determine because the value after hydration is lower than before hydration. It may be difficult to determine if the lower values are from hydration, or from excess drainage (bleeding), thereby making the diagnosis of excess bleeding more challenging. Patients can develop infections after abdominoplasty surgery. If the infection is an abscess, and is contained deep within the operative area, the typical signs of infection may not be present. Infection (abscess) can occur after abdominoplasty (tummy tuck) and the patient may not have redness or pain in the area of surgery, which can make the diagnosis more difficult. In addition, a patient may have an infection after abdominoplasty (tummy tuck) and have very little change in laboratory values (white blood cell count) that help diagnose infection. Drainage can be observed and cultured from the drain if infection is suspected, but without a drain, the infection may be completely contained within the wound, thereby precluding observation or culture. Further, a patient can have an infection after abdominoplasty (tummy tuck) and have no symptoms (fever). If a drain has been placed during the abdominoplasty (tummy tuck) and an infection occurs, then the exudate will probably be present in the drainage tube and bulb unless it is loculated (in an isolated area of the wound). The aforementioned factors can make diagnosis of excess drainage (bleeding) more challenging, which is the second reason that many surgeons choose to place a drain or drains during abdominoplasty (tummy tuck). The aforementioned factors could also make diagnosis of an infectious process more challenging in patients that undergo an abdominoplasty (tummy tuck), again, justifying the placement of drain(s). Both of these complications are rare, and the placement of a drain or drains may assist in diagnosing and treating these problems. As with any complication of any surgery, the earlier the problem is diagnosed, the earlier treatment can be initiated, and early treatment may improve the outcome. The recovery period after abdominoplasty (tummy tuck) is very different than recovery after other elective cosmetic procedures. This is because the abdominoplasty (tummy tuck) procedure creates a large operative area and can restrict liberal movement. Abdominoplasty (tummy tuck) creates a very large potential space that can collect fluid (blood), and has unique anatomy in the operative area. These factors can result in a prolonged recovery period and problems that require further therapy. These factors also mean that the plastic surgeon must follow abdominoplasty (tummy tuck) patients very closely in the period immediately after surgery.
After the abdominoplasty (tummy tuck) procedure the patient should engage in activity as instructed by the Plastic surgeon. Recognition of the importance of immediate post-operative mobilization has improved recovery and has decreased the incidence of some of the problems that can occur after an abdominoplasty (tummy tuck). There is a balance between too little activity and too much activity, either of which may be detrimental to recovery. If the patient has too little activity, the recovery may be prolonged and there may be increased risk for developing deep vein thrombosis. If the patient engages in too much activity, this may result is problems such as excess bleeding or wound separation. Excess activity after abdominoplasty (tummy tuck) can result in excessive bleeding as a result of physical disruption of vessels in the areas of surgery. As previously described, the unique anatomy makes vessels in the area of abdominoplasty (tummy tuck) more susceptible to disruption, especially with excessive activity immediately after surgery. After any surgery, including abdominoplasty (tummy tuck), excessive activity can result in bleeding not only from physical disruption of the vessels in the area of abdominoplasty (tummy tuck), but also from high blood pressure. A high level of physical activity results in higher blood pressure. High blood pressure increases the risk of excessive bleeding after surgery. The activity goal after abdominoplasty (tummy tuck) is to reach a balance between being active enough to improve the speed and safety of recovery, but not so active as to cause increased risk for the aforementioned problems. In general, the patient should be out of bed for brief periods of time with assistance only the day of surgery after recovering from anesthesia. It is important to get out of bed with assistance only until the affects of anesthesia have completely resolved and normal balance has returned. When getting out of bed it is also advisable to have assistance. The rectus abdominis muscle (sit up muscle) is activated when rising from bed, and as previously described, has many perforating vessels. Excess activity of the rectus abdominis muscle when getting out of bed may increased the risk of disruption of a perforating vessel and excess bleeding. The day after surgery activity can be increased slightly to include daily living activities. Lifting of heavy objects should be avoided for the first several weeks after abdominoplasty (tummy tuck). This is because lifting heavy objects could disrupt vessels in the abdominoplasty (tummy tuck) area which could result in excess bleeding. In addition, lifting heavy objects immediately after abdominoplasty (tummy tuck) can result in excess bleeding due to the so called Valsalva effect. The Valsalva effect occurs when a patient has a forced expiratory attempt with the airway closed, as when trying to clear the ears during a pressure change. The Valsalva effect increases blood pressure and heart rate, both of which could contribute to excess bleeding. Excessive blood pressure, and excessive venous pressure in this case, could cause excess bleeding. This etiology is suspected when there is excess bleeding and no bleeding arteries can be identified when the wound is explored. In other words, excess blood is found in the wound and no bleeding vessels can be identified when the wound is explored. The importance of some activity immediately after abdominoplasty (tummy tuck) cannot be overemphasized. Inactivity, and especially inactivity after surgery, is a risk factor for developing deep vein thrombosis and embolus. The circulation in the lower extremity is assisted by the muscular action of the muscles, in particular the calf muscles, which helps move the venous blood back towards the heart. With inactivity, the blood in the deep venous system becomes stagnant, and therefore more likely to clot. Patients are asked to ambulate on a regular basis while awake to assist in preventing deep vein thrombosis. This can be as little activity as walking across the room. Patients are also asked to stay well hydrated with fluid containing electrolytes in the period immediately follow abdominoplasty (tummy tuck). If a patient stays well hydrated after abdominoplasty (tummy tuck) there is less likelihood of developing deep vein thrombosis. Patients are instructed not to use heat or cold packs in the area of the abdominoplasty (tummy tuck). Hot or cold can causes thermal injuries to the tissues and this is more likely when those tissues are numb. If the tissues are numb, the natural protective mechanism are not active and the patient will not know if thermal injury is occurring. The use of abdominal binders after abdominoplasty (tummy tuck) may or may not help recovery. Some Plastic surgeons believe that the use of abdominal binders in young healthy patients do not provide any benefits but do cause some risk. In other words, the benefit-risk ratio for the use of abdominal binders after abdominoplasty (tummy tuck) may not justify their routine use. This is especially true for patients that have high risk for deep vein thrombosis. Some Plastic surgeons also believe that the use of binders after abdominoplasty (tummy tuck) increases the risk of flap compromise and deep vein thrombosis. The risk may be magnified if binders are placed in conjunction with a large fascia repair or hernia repair. Considering this, some Plastic surgeons do not recommend the routine use of binders after abdominoplasty (tummy tuck).
Pain medicine should be used as directed after abdominoplasty (tummy tuck). Adequate pain control after abdominoplasty (tummy tuck) is important not only for the comfort of the patient, but also for control of blood pressure. If a patient is not comfortable after abdominoplasty (tummy tuck), one well known physiologic response is an increase in blood pressure. Increased blood pressure after surgery from uncontrolled pain increases the likelihood of bleeding. Activity should be increased gradually after abdominoplasty (tummy tuck) until full activity is attained. Full activity after abdominoplasty (tummy tuck) should be attained in 3 to 4 weeks in most patients. If a drain or drains are placed during the abdominoplasty (tummy tuck) they are usually removed in about 1 week. Patients are generally followed for at least 2 years after abdominoplasty (tummy tuck) to observe scar maturation. If adverse scarring is observed during this period it can be treated with various modalities. The recovery instructions after abdominoplasty (tummy tuck) should be followed very closely by the patient. Prior to an abdominoplasty (tummy tuck) procedure, detailed recovery instructions are explained and provided to patients in writing. In addition to written and oral instructions, patients can communicate by cell phone if any additional questions arise regarding the post-operative instructions, or if there are any concerns.