Tummy Tucks

A "tummy tuck" (abdominoplasty) is a surgical procedure which tightens a lax abdominal wall and removes excess abdominal skin and fat.  It may be reconstructive or cosmetic. 

Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient’s appearance and self esteem.  Reconstructive surgery is performed on abnormal structures of the body, generally performed to improve function and may also be done to approximate a normal appearance. It has also been found to improve chronic lower back pain due to functional incompetence of the anterior abdominal wall. When considering a Tummy Tuck, there are several elements to be considered. The following links provide important information on Tummy Tucks.

• What is a Tummy Tuck?
• The 4 Main Types of Tummy Tuck
• Abdominal wall types
• Pre Operative Care
• Risks Involved
• Post Operative Care
• Surgical Goals

What is a Tummy Tuck?

This operation has been performed since the turn of the century.  In 1910 a paper by H.A. Kelly (of USA) noted the positive outcomes of this surgery, ie weight reduction, personal comfort, conveniance and comfort in dressing, better pose in standing and walking, increased activity and markedly improved self esteem and self confidence.

It has also been found to improve chronic lower back pain due to functional incompetence of the anterior abdominal wall. 

The structural defects of the anterior abdominal wall can be caused by permanent overstretching by one or more pregnancies, by marked weight loss following treatment for morbid obesity or even moderate obesity, by trauma or surgery to the anterior abdominal wall (including gynaecological surgery) and by abdominal wall herniae.  Pregnancy and surgery can lead to separation of the two strap muscles, decreasing the efficiency of the abdominal wall. 
The anterolateral abdominal wall is largely muscular and aponeurotic with overlying subcutaneous fat and skin.  It consists of 2 “strap” muscles in front and 3 muscles anterolaterally, the external oblique, internal oblique and transversus abdominis muscles. 

Weakness or laxity of these muscles prevents maximum force with contraction and so weakens the support of the lumbar dorsal fascia with resultant back pain.  An excess of 10lbs (4.5kgs) of adipose tissue in the anterior abdominal wall adds 100lbs of strain on the discs of the lower back by exaggeration of the normal "S" curve of the spine.

The 4 Main Types of Tummy Tuck

1. LIPOSUCTION ONLY:  used when there is minimal skin laxity and varying accumulations of subcutaneous fat and muscle laxity.
2. MINIPLASTY:  the excess skin and fat is limited to the lower abdomen.
3. THE MODIFIED ABDOMINOPLASTY:  there is more significant skin excess and flaccidity that may not be confined to the lower abdomen. A greater amount of skin is excised than type 2 patients, but not the entire skin ellipse below the umbilicus.
4. FULL ABDOMINOPLASTY WITH OR WITHOUT LIPOSUCTION:  this is for people with marked skin laxity, manifested by striae (stretch marks), thinning and diminished elasticity.  There is also considerable flaccidity of the upper and lower musculofascial system.  (ie above and below the umbilicus)  However, patients should recognise that surgery does not improve the remaining skin tone. (which is the elasticity – contractility.)

Abdominal Wall Types:

There are three types of Abdominal Walls. All Three types may be viewed in our gallery.

The Pendulous type is recognised by fat accumulation in the lower abdominal wall and around the navel (umbilicus). The weight of the subcutaneous fat causes it and the skin to sag down, folding the skin over the pubis.

The second type is the globus or round abdominal wall. It has the characteristics of generalised distention and a variable thickness of subcutaneous tissue.  The chief complaint here is a thick unaesthetic waistline

The third group has a flaccid abdominal wall, usually with little fat but with excessive and wrinkled skin around the navel.

Striae (or stretch marks) are often present. They can be considered as “scars” that show up during a pregnancy or because of excessive fat accumulation.  The most common sites are around the navel. Patients with striae have skin with a thin dermis and some what scarce elastic fibres that are more susceptible to dermal tearing. Widening of the scars or hypertrophic (raised) scars are common in the post operative period. This is not always the case, as seen in one of the post operative photographs.

Low transverse incisions have changed according to alterations in fashion styles and have shifted from below to above the anterior superior iliac spines.  Consequently, a high-cut "french-line" or "bicycle-handle" type of incision is currently favoured. It is your choice as the current hipster fashion may dictate a lower incision again.

Pre Operative Care

Pre-operative care includes a history and physical examination.  This is followed by a full discussion of the various options, the procedure, possible complications and post operative care. 

Many drugs have an influence on the clotting ability of the blood, especially aspirin and anti-inflammatory agents.  It is imperative that these drugs are discontinued 2 weeks before surgery.  Alcohol has a similar effect and should only be taken in moderation.  The oral contraceptive pill has the opposite effect, thickening the blood and should be discontinued one month prior to surgery.  This is to prevent the possible complication of deep vein thrombosis.
Smoking, similarly, thickens the blood.  More importantly, smoking delays wound healing by causing vasoconstriction of small vessels leading to diminish blood flow and displacing oxygen from haemoglobin and replacing it with carbon monoxide.  Well oxygenated tissue is very important for good wound healing.  I recommend
no smoking for at least one month prior to surgery. 

A healthy diet is also advisable as Vitamin C, Zinc and Iron are all necessary for the healing process.  I often recommend starting a multivitamin preparation one week prior to surgery, or earlier if so desired.

Risks Involved

All surgery has risks attached. There are 2 types of risks; those specific to tummy tucks and those that can apply to any surgery.  These, and the steps taken to minimise them, will be discussed. 

The specific complications include:

• Asymmetry of scars     
• Umbilical malposition, higher or lower or lateral deviations
• Insufficient or excessive resection, with scar widening resulting 
• Partial removal of striae or scars
• Haematomas with bruising of the skin 
• Laterally localised fat pads become more prominent (therefore, calling for liposuction) 
• “Dog ears” laterally (can be excised at the same time) 
• Localised pain or numbness.  Sensations usually returns, can take up to
  6 months
• Post operative pregnancies have shown to have little effect on abdominoplasties.

The non specific complications include:

• Haematoma: can be drained or aspirated, small ones reabsorb 
• Infection: Skin is prepared with Betadine pre-operatively and intra-operative antibiotics given 
• Lipolysis (ie breakdown of fatty tissue): the fluid is aspirated.  Common in abdomens with thick fatty tissue   
• Seroma: clear fluid collection is common.  Diminished with a 3 layer closure and corset applied in theatre after the operation is completed 
• Necrosis of flap: due to poor blood supply. Very rare. 
• Hypertrophic (raised) scars: If there is a history of poor scarring, a silica gel dressing e.g. Cica-Care or Dermatrix can be applied after healing 

Thrombophlebitis or Deep Venous Thrombosis: intra-operative compression stockings and calf stimulation is used and exercise of ankles and lower legs recommended post operatively.  If necessary Clexane is given pre-operatively to thin the blood.

Post Operative Care

Post Operative Care for Tummy Tucks include;

• A visit to the rooms one week after discharge
• Dressing change every 3-4 days. Clean with Betadine liquid and replace strip of Hypafix.  If umbilicus is moist / red, for daily dressings
• After 2 weeks apply Bio oil or Vitamin E oil or Rosehip oil at night. Leave Hypafix off until morning and replace
• Tape wound for approximately 1 month
• Corset to be worn 3 weeks-1 month. After first week, can be removed at night
• Umbilicus may be pierced – when completely healed
• Exercise:
  

  1st week	rest mostly
  2nd-3rd week	walking
  6 weeks	gym

Exercise such as walking, small weights and abdominals will maintain the contour at 2 years.

Additional advantages have also been noted by my patients:

• eating smaller meals as stomach distention uncomfortable due to tightening the “strap” muscles  
• backache improved 
• bladder control markedly improved
• improved self esteem and confidence 
• clothes buying easier and more enjoyable! 

Surgical Goals

The Tummy Tuck Surgical Goals, include;

• Flattening of the abdomen
• Elimination of unsightly scars, surface irregularities, wrinkling and striae
• Restoration of a waist 
• Reduction of overly full hips 
• Tightening of lax skin and muscle.