When most people envision what they consider an ideal or beautiful body, a slender midsection with a small waist and a toned abdomen is usually part of that image. The abdomen however, is unfortunately one of those areas of the body where fat tends to accumulate. Furthermore, with aging and especially after pregnancy, there is also increased laxity of the abdominal wall which includes the skin, muscles, and a dense fibrous layer covering the muscles called fascia. Sometimes pregnancy leaves unsightly "stretch marks" which tend to occur on the lower abdominal skin below the belly-button and compound the problem. Although proper diet, a healthy life style, and exercise can help tone and create a fit mid-section, sometimes the combination of fat deposition and laxity of the abdominal wall make this goal impossible to achieve through those means alone. It is in these circumstances when an operation such as the tummy tuck, or abdominoplasty as it is properly called, can be extremely beneficial, in making profound changes to the midsection.
IS A TUMMY TUCK FOR YOU?
The frustration of trying to deal with a lax abdominal wall through exercise and diet alone has been experienced by many. Patients who experience this problem and are otherwise healthy are good candidates for this operation. In the patient who is a candidate, a tummy tuck can address the following problems:
- a lax, loose abdominal wall including fascia, muscle or skin
- stretch marks in the lower half of the abdomen
- significant fat deposition in the abdominal wall under the skin
- a protruding abdomen out of proportion to the body which is caused by the above. (Sometimes a protruding abdomen can be caused by other conditions including fat deposits around the gastrointestinal organs (intra-abdominal fat) such as the stomach and the intestines. A tummy-tuck will not be able to correct this type of abdominal wall protrusion).
When discussing this operation with your plastic surgeon, he or she will first gather certain information from your medical history which might impact the outcome of your surgery. Besides ensuring that you are healthy to undergo the operation and the anesthesia, your surgeon will inquire about any diseases, such as diabetis or lupus, which might adversely affect wound healing. Habits such as smoking for example, might also put you at increased risk of wound complications and delayed healing. It is important to discuss with your surgeon any prior surgical procedures you might have had, especially in the abdomen. Your surgeon will make detailed notes of all prior surgical scars on your abdomen, as the location of these scars might have implications on the design of the incision.
Your surgeon will also examine you closely to ensure that you do not have abdominal wall hernias, known as ventral hernias. A hernia is a defect in the abdominal wall through which intra-abdominal contents such as the intestines or stomach can pass. These can occur at any time and sometimes are seen around the belly-button or close to prior abdominal surgical incisions. Although the presence of a hernia does not mean that you are not a candidate for a tummy tuck, your surgeon will need to be aware of the presence of any hernias as they will need to be fixed during the operation. Although the hernia might be repaired by your plastic surgeon, often the help of a general surgeon will be sought.
Your plastic surgeon will also explain to you that although any stretch marks in the lower abdominal skin (below the belly-button) will usually disappear with this operation, stretch marks which extend onto the upper abdominal skin will usually remain as will any scars in this region. The incision for this operation is a horizontal one in the lower aspect of the abdomen, similar to that of a C-section although somewhat longer.
It is during this initial consultation that your plastic surgeon might discuss with you other procedures which might be indicated in your case instead of, or as an adjunct to a tummy tuck. Liposuction is sometimes used in conjunction to a tummy tuck to address fat deposits under the skin in areas not easily reached with this operation such as love-handles or lower back. At times, when there is minimal fat deposit and good abdominal wall and skin tone, liposuction of the abdominal wall might be considered in lieu of a tummy tuck. Similarly, a procedure commonly referred to as a mini-tummy tuck or mini-abdominoplasty might be indicated. This procedure is usually done when there is minimal excess skin and fat with moderate abdominal wall laxity which is confined to the lower abdomen only. The procedure involves the removal of a wedge of skin in the lower abdomen through a horizontal incision right above the pubis. This incision is very similar in location and length to that of a C-section.
When a tummy tuck is performed on a healthy, motivated patient with the proper indications, the results can be dramatic. For women who become pregnant after a tummy tuck, the procedure will in no way impact the pregnancy. After the pregnancy however, there will most likely be a return of the laxity of the abdominal wall and skin. A second tummy tuck is always an option at that time should the patient desire it. UNDERSTANDING THE SURGERY:
An abdominoplasty is normally a 21/2 to 4 hour procedure which is done under general anesthesia in a hospital, surgery center, or office-based surgical facility. Most surgeons prefer the patient to stay in the hospital the night of the surgery.
To perform the surgery, a horizontal incision is made on the lower part of the abdomen just above the pubic region. Another incision is made around the belly button to separate it temporarily from the rest of the abdominal skin. Although the belly-button is separated from the adjacent abdominal skin, it is left attached to the fascia. The belly-button will later be reattached to the abdominal skin, once this is placed in its final position.
The incision is made down to the level of the fascia, the thick fibrous tissue layer that covers the muscles of the abdominal wall. Once at that level, the entire skin and fat of the abdomen is raised or detached from the fascia up to the level of the ribs as shown. This undermining allows for the skin of the abdomen to be pulled taught and the excess skin and fat to be removed.
In order to tighten up the fascia and the rest of the abdominal wall, stitches are utilzed in a vertical fashion down the middle of the abdomen on the fascia layer. The excess or loose tissue of the abdominal wall is inverted into the abdomen with these stitches and the result is a tight fascia layer. Although the main line of stitches is vertical as shown, sometimes rows of stitches in an oblique orientation are done on either side of the midline in order to create a more tapered waist-line. These stitches are utilized sometimes in several rows until the surgeon is satisfied with the amount of tightening. If any hernias were noted during the initial evaluation, it is at this time that they are repaired.
Once the surgeon is fully satisfied with the tightening of the fascia, he or she will usually have the operating room table flexed at the waist. At this point the abdominal skin is pulled taught and the excess is removed by making another cut at the location where the abdominal skin lines up with the previous incision. The discarded abdominal skin and fat are usually weighed and sent to the pathology laboratory for visual inspection. At this point a new hole is made in the center of the abdominal skin and the belly button, which had been left attached to the fascia is brought out through this hole and secured in placed with stitches. The rest of the operation involves the closure of the lower abdominal incision in multiple layers while the patient is still positioned flexed in the operating room table.
Most surgeons will employ the use of drains (tubes placed under the abdominal skin which are meant to drain any fluid collection in this potential space). Normally, there are two of these drains placed and they are usually positioned around the pubis on either side of the midline. These usually stay in from anywhere from 2 to several days after the operation and are removed in the office during a post-operative visit. Some surgeons also utilize a pain pump which is a small tube inserted under the skin around the incision which delivers a constant flow of an anesthetic to the area, thereby helping alleviate pain for the first couple of days after the procedure. This pump is usually removed from two to three days after the surgery.
Although this operation is very safe, as with any surgery, there are always the potential for risks and complications of which the patient must be aware. As part of the informed consent process, your surgeon will review these complications with you. Some of these complications include:
Wound healing problems: Since the closure of the incision for this operation is done under some tension, there is always the possibility that the wound edges might come apart during the healing process. This complication is rare in healthy patients, but there might be a slightly higher risk in patients with some diseases that affect would healing such as diabetis, and lupus. Smokers might also be at an increased risk.
Loss of sensation to abdominal wall skin: Because of the way this operation is done, the nerves which supply sensation to the skin of the abdomen are severed. This will result almost all patients in a loss of sensation of the abdominal skin. Fortunately however, this loss of sensation is only temporary and will usually return after some weeks or months. At times however, the return of sensation might take a prolonged amount of time or not be totally complete. In some cases, there might be some permanent residual numbness.
Seroma or bleeding: Because a potential space is created between the abdominal wall skin and the deeper layers of the abdominal wall, there is always the potential for blood or fluid (seroma) to accumulate in this space. If the amount of blood or fluid is minimal to moderate, sometimes your own body will metabolize it and no further intervention is needed. If the amount is excessive however, sometimes it requires intervention to evacuate it. This can be done with needles, with aspiration utilizing radiological techniques, or as a last resort, by opening up the original incision and evacuating it surgically.
Belly-button complications: As earlier described, during this operation the belly-button is separated from the rest of the abdominal skin temporarily and re-attached to the abdominal skin once this skin is re-drapped. This repositioning of the belly-button can lead to minor asymmetries or alterations of position-for example a belly-button which is not totally in the midline. Because of the manipulation of the skin in the area, there is also the small potential risk that some or even all of the skin of the umbilicus could suffer partial loss of the supply of blood (ischemia) or potentially lead to the death of some of the skin (necrosis). This complication is very rare and usually requires removal of the dead skin and packing of the resultant wound until complete healing occurs. This type of healing could potentially result in scar formation.
Scar concerns: Although tummy tuck scars tend to be rather long, they are usually positioned in a very strategic area of the abdomen where they can be easily concealed even when wearing a bathing suit. Incisions in this area of the body usually heal with fine scars, but there is always the potential that the incision might be slightly asymmetrical or that the scar might end up thick or irregular. Usually, the scar is allowed to mature (one year or more) before any corrective surgery is contemplated. In order to optimize better healing, it is imperative that all surgical scars be protected from sunlight for the first six months to a year. WHAT TO EXPECT AFTER THE SURGERY:
During the surgery, your surgeon will place the drains, possibly a local pain pump catheter, and dressings on your incision. You will also most likely be wearing a compressive corset (abdominal binder) around your lower abdomen. Your surgeon might also prescribe an intravenous pain pump (PCA pump), which might be partially under your control and will allow you to self administer pain medication as needed. The nursing staff might instruct you on how to care for the drains at home, and will advise you to measure and record the amount of liquid drained on a regular schedule. This will help your doctor decide when to remove the drains. Usually this is done twice per day, unless the amount of drainage fills up the drains in less than 12 hours.
Since the closure of the tummy tuck incision is made while the patient is flexed at the waist in order to get a tight abdominal wall skin, for the first couple of days after the surgery, you might find it hard to stand completely erect. This tightness will ameliorate over the course of the first few days after the surgery and soon, you will be able to stand and walk normally.
You will usually be sent home from the hospital on the first or second day after the surgery. Although you can anticipate some discomfort, there might be more of a feeling of tightness than pain, and this is usually managed very easily with moderate pain medications that you take by mouth. At home, you will need to follow the instructions given by your surgeon or the nurses regarding changing the bandages and caring for the drains and the pain catheter. You will probably feel more comfortable wearing the abdominal binder as this will provide more support while you perform normal daily activities.
Your surgeon will establish a follow-up schedule in which you will come to the office for examination of the wound. The drains and the pain catheter will be removed in the first few postoperative days. You will be asked not to participate in any strenuous physical activity for several weeks after the surgery, but you should be able to resume normal activities including going back to work within the first one to two weeks.
Over the course of the first few weeks, there will be some swelling at the surgical site which will slowly resolve. There will also be some numbness of the abdominal skin which will also slowly resolve. The scar will go through a maturation process that will take up to one year. Your surgeon will tell you when it is ok for you to shower and will instruct you on proper care of your incision and maturing scar. Keeping the scar from exposure to sunlight is paramount to optimize
THE NEW YOU:
The changes in abdominal contour due to this operation will become evident soon after the operation. Not only will they be easily visible despite the initial swelling, but you will also feel the abdominal wall much tighter than before. Over the ensuing few weeks as the surgical swelling (edema) resolves, the full potential of the operation will materialize before your eyes. You will note that the excess abdominal wall skin along with the stretch marks on the lower portion of the abdomen would have disappeared. Your clothes will fit much better, and you will have a much more youthful and fit mid-torso. Once the scar fully matures, it will become a very fine line, which will not be readily evident. The scar will also be strategically placed where it can be easily concealed, even with beach wear. Although with the passage of time there might be some relapse in terms of some laxity of the abdominal wall and some mild loosening of the skin, the tummy tuck operation offers a long-lasting effect which will greatly rejuvenate your midsection for many years to come, as long as you maintain a sensible and healthy lifestyle.
The information provided above is for educational purposes only. Individual results may vary. A personal consultation with your plastic surgeon is the best way to gain information about your particular complaint, and about potential treatment options to address the same.
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