Abdominoplasty An abdominoplasty or tummy tuck is a procedure designed to firm up the abdominal muscles and to remove excess skin and fat from the lower abdomen. Oftentimes scars and stretch marks can be incorporated with this skin excision. When the operation is performed alone it is performed at the surgicenter. When performed at the time of other procedures (hysterectomy, bladder surgery, etc.), patients are admitted to the hospital. Insurance carriers rarely cover the cost of the procedure when it is performed alone. But, when performed in conjunction with other operations, insurance will cover the hospitalization fees and usually most, if not all, anesthesia and operating room charges. An abdominoplasty is also often performed in conjunction with fat suctioning of the abdomen, thighs, or buttocks area. The incision for an abdominoplasty is made along the suprapubic margin and extends up the inguinal (groin) creases. Marks for the incision are usually made when the patient is either wearing bikini underwear or their bikini bottoms. A superior flap of skin in then up-raised from the abdominal muscles separating small blood vessels that penetrate the skin to the abdominal wall. Dissection is then made down over the site where the belly button is still remaining on the abdominal wall. A small incision is then made to place the belly button back onto the abdominal skin in the usual anatomical position. The abdominal wall, prior to this, if firmed up by approximately two vertical running rows of sutures to bring closer and to firm up the rectus abdominus muscles. These muscles essentially straddle the belly button and stretch from the level of the sternum or chest plate down to the suprapubic area. By firming up the fascia, which is attached to these muscles, one can firm the abdominal wall and subsequently firm up those muscles which have been stretched over the years. This stretching is caused by weight gain and loss, stretching from pregnancy, and/or loss of muscle tone from previous abdominal surgery. After a certain point, no amount of exercise or dieting can improve these stretched muscles. The muscles, having been approximated, will firm up and tone up such that the residual skin is then pulled in an inferior direction and trimmed at the suprapubic line where it overlaps and has a satisfactory blood supply without undue tension on the abdominal flap. Having done this, the area under the superior skin flap is drained using suction drains that are brought out the corners horizontal incision based at the lower groin area. Any stretch marks or scars pre-existing in the vicinity of the lower abdomen will be displaced inferiorly, but oftentimes not all of them can be excised with this procedure. Also, the area of the abdominal wall where the belly button used to reside can oftentimes not be pulled in an inferior fashion all the way to the suprapubic area. When this occurs, the former site of the umbilicus is connected to the suprapubic area as a vertical incision meeting in the midline to appear as an upside down “T”. In cases of extreme laxity of skin, this vertical component of the scar (the original umbilicus area) can be displaced all the way to the bottom (to horizontal suprapubic incision) such that there is no “T” or vertical component to the scar at all. In some patients a modified abdominoplasty can be done. This is particularly indicated for patients with little excess abdominal skin above the umbilicus, but rather have lax muscle and redundant skin below it. In these patients the suprapubic incision is done as in standard abdominoplasty, but the belly button (umbilicus) is left attached to the abdominal skin and the abdominal wall. Fat below this level is removed from the skin, if necessary, and the rectus abdominus muscles are tightened as in the technique for the standard abdominoplasty. Excess skin is trimmed as in the standard operation, but sometimes not as much skin can be removed as could be removed with the more extensive procedure. The advantages of the modified abdominoplasty are many in that it is a lesser operation with less interruption to the nerves and blood vessels. There is some decreased risk of skin flap loss and the suprapubic scar may not have to be extensive. This operation is indicated for a select type of patient. In both the standard and the modified abdominoplasty, drains are left behind at the corners of the incisions. The drains will have suction units, which will be drained by you at home or by the hospital personnel if you are hospitalized. The patient is requested not to stand in an upright position after the surgery for several days. Tension on the incision line may disrupt the incision as well as further compromise the blood supply to the superior abdominal skin flap. Excess flap tissue underneath the skin is trimmed at the time of the surgery but oftentimes, owing to the differences in the skin thickness of the upper abdominal wall and the groin and suprapubic area, a slight skin overlap of the superior skin flap over the inferior skin flap may appear. The drains are removed once the drainage has stopped. In some cases this may take several days and in very rare cases it may take longer than one or two weeks. The patient is allowed to resume more activity depending upon the appearance of the wound and the course of their comfort. Patients are usually able to stand up straight approximately three to five days after surgery although they may be somewhat uncomfortable owing to the sutures, which have encumbered and tightened their abdominal muscles. Uncomfortable means that any activity requiring the use of these muscles will usually cause a pulling effect. Patients who are active at home or at work are encouraged to refrain from any activity for approximately four to six weeks. Overt and heavy exercise should be avoided for at least three months in order to allow for healing of the muscles and continuing firming up of the muscle fascia. Many patients find that their level of activity is tolerable sooner, but it is best to figure for the long run rather than the short run. Some sutures are removed between five and seven days and the final sutures are removed by the fourteenth day after surgery. The hospital stay may average two to five days depending upon the amount of discomfort and drainage as well as the type of surgery performed along with the abdominoplasty. When patients are allowed to go home immediately after the surgery, it will be necessary to observe the patient closely by a friend or relative for at least the first 48 hours, and preferable up to five days. Patients will require oral analgesics within the first day and may have some nausea and vomiting owing to the pressure of the abdominal wall muscles pressing against the abdominal contents. Patients can ambulate to the restroom beginning on the day of their surgery in a slightly stooped position. They can take a shower the first day after surgery in a similar position. In bed, patients’ legs are propped up with two to three pillows in order to release tension on the incision site and the muscles. This posturing of the patient is usually discontinued after one week. A patient can, of course, ambulate during this time in a stooped position and patients usually find that they can stand erect by the end of the week. The side effects of the operation are fairly straightforward and are concomitant with any surgical procedure. The chance of bleeding is probably the most commonly seen side effect, which is in part controlled with local hemostasis (control of bleeding) as well as with the suction drains left at the time of surgery. However, oozing will occasionally occur postoperatively requiring return to the operating room, removal of any blood clots, and coagulation of any small bleeders. If an abdominoplasty procedure is planned with extensive fat suctioning or with other major abdominal procedures, we recommend patient donate their own blood prior to surgery. Iron therapy is started prior to blood donation and blood can be kept fresh for one month, or frozen for up to five years. If there is a problem of donating your own blood, designated blood donors can donate for you. Concomitant with bleeding is compromise of blood supply to the superior skin flap. This is noted particularly when fluid collects beneath the skin flap. Such a compromise can cause loss of some skin at the margins of the incision, which may require further skin wound revision inclusive of even skin grafts. Since smoking compromises the blood flow to these skin flaps, we insist that our patients refrain from chewing Nicoret gum or smoking two weeks before and one week after surgery. Patients who undergo this procedure have variable results regarding the incision scars. There is no way to predict the outcome of the scar in this area. However, with everyday activity, there will be some spreading of the scars even though they will be hidden in the bikini line. Loss of blood supply or infection to the belly button may cause excessive scarring or even loss of the belly button. This will later require an umbilicus reconstruction (a minor procedure) under local anesthesia in the office surgery unit. There is the possibility of wound infection owing to the slightly higher amount of bacteria on the skin in the groin and perineal area. Antibiotics are given prior to and after surgery, but cannot consistently prevent an infection from occurring. There is numbness of the abdominal wall, which will persist for several months owing to separation of the small nerve branches, which penetrate the skin. Some areas of numbness may be permanent but are usually not bothersome to patients. Patients who have undergone this procedure have noted a slight incidence of increased discomfort, which may require injection of these nerves. On very rare occasions, these nerves will even require excision. It has been reported in the surgical literature that in a very small group of patients undergoing abdominoplasty, there is a slight incidence of pulmonary emboli. This occurs when blood clots in the lower extremities pass up to the lung area. This incidence of blood clot formation is probably due to inactivity of immobilization. Today, many of us have patients out of bed, as mentioned, for showering and ambulating as soon as possible in order to avoid formation of these clots in the lower extremities. We attempt to avoid bleeding preoperatively by having patients refrain from aspirin and Vitamin E products for at least two weeks prior to surgery. However, we will place patients on aspirin within 24 hours of surgery in order to assist in the prevention of the blood clot phenomenon. We also advocate that patients perform toe-wiggling exercises to pump the blood from their feet and legs once the threat of bleeding from the operative site has cleared. Please feel free to ask questions on any of these points raised in this letter of Dr. Kennedy, or any members of his staff.
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