Tummy tuck (abdominoplasty)

A tummy tuck, also known as abdominoplasty, is the surgical removal of tissue from the anterior abdominal wall (skin, subcutaneous tissue, fatty tissue). The tummy tuck is one of the largest and most extensive procedures in plastic surgery. Most often, it is recommended due to aesthetic reasons. In some cases it may be recommended due to health related reasons when, as a result of extensive weight loss, a saggy apron of loose skin and fat impedes normal functioning.

Tummy tuck (abdominoplasty) - characteristics

A tummy tuck, also known as abdominoplasty, is a type of a plastic surgery whose aim is the removal of loose skin and subcutaneous tissue, together with fatty tissue, and possibly stitching together the straight muscles of abdomen.

The extent of a tummy tuck, being one of the largest and most extensive procedures in plastic surgery, depends on the extent of the deformation of abdominal wall. Partial tummy tucks, full tummy tucks with the stitching up of the straight muscles of the abdomen, or combined with liposuction, may be performed. Each patient who decides to have a tummy tuck should be aware that the surgery itself is not a means of losing weight or a magic bullet leading to a beautiful flat stomach or slim waist. To achieve and maintain the best results of the surgery, a patients needs to change his/her lifestyle.

Tummy tuck- benefits

The results of a tummy tuck will vary depending on the level of deformation of the abdominal wall. In small size deformations, aesthetic reasons will prevail, whereas in cases of significant weight loss a tummy tuck will be performed due to health-related reasons. The benefits of a tummy tuck include, among others:

• improved look and shape of the tummy, slimmer waistline;
• improved quality of skin of the abdomen, removal of anaesthetic folds and stretchmarks;
• improved self-esteem and confidence;
• improved quality of life;
• the possibility of getting back to being fully active due to the removal of large skin folds.

Tummy tuck– recommendations

Surgical correction should be reserved for patients in good general condition, who are physically active, who are not happy with the look of their abdomen, but a diet and physical activity are not enough to correct it. In most cases this procedure is performed to due to aesthetic reasons to improve psychological wellbeing in patients. The quality of the abdominal wall usually decreases after significant weight loss and pregnancy. Skin becomes flabby, with anaesthetic folds and stretchmarks. Abdominal muscles may get stretched due to viscera becoming more pronounced.

Another group of patients are those who lost a lot of weight, for example, as a result of bariatric surgery. In these patients excess abdomen skin forms an apron of fat and skin, which may hang loose even beneath the knees. Such deformation of tissue makes such patients handicapped, causing them problems with walking, maintaining hygiene or using the toilet. Blistering, bedsores or non-healing, chronic wounds may occur in the folds. For these group of patients, a tummy tuck is the only way of getting back to being fully active.

Tummy tuck– contraindications

A tummy tuck is a scheduled type of operation. A patient accepted for the procedure must be in good general health, with efficient circulation and respiration with normal vital signs. Surgery is not recommended for patients with chronic diseases impairing their general health, for example, unstable blood pressure, heart failure, bleeding disorders, hormonal disorders and others. Before accepting a patient for surgery, a surgeon may request a consultation with an appropriate specialist to establish whether the patients’ condition permits the performance of the surgery. Inflammation caused by a cold or bacterial infection treated with antibiotics are also contraindications for a tummy tuck. Definite contraindications for tummy tuck are inflamed skin wounds in the area concerned.

In most cases, tummy tucks are recommended for aesthetic reasons. However, this procedure should not be performed on older patients (older than 65) in whose case the risks involved in extensive surgery and general anaesthesia are significantly higher.

One should remember that after a tummy tuck, the abdominal wall is less resistant than before. Therefore, in the case of women planning to have children, it is recommended to postpone the tummy tuck until after pregnancy.

Tummy tuck– before the procedure

During a consultation before a tummy tuck, a doctor conducts an interview and examines the patient. This is also the best time for asking questions. It is important to inform the doctor during the interview and examination about all diseases, medicines taken and allergies. Patients taking antithrombotic medication should stop taking it a week before the procedure, or switch to weaker medication according to the doctor’s recommendations.

The surgeon may also request a consultation with another specialist, for example a cardiologist in the case of a patient having a chronic heart disease. During the consultation, the type of anaesthetic for a given patient will also be chosen.

Before the operation, the patient has to grant his consent to the operation through signing a consent form. Before signing the consent form, a doctor will inform the patient about the course of the procedure, what will be done and what the possible complications and alternative methods of treatment are. The surgeon will agree with the patient on the method and extent of the procedure.

During the consultation before the tummy tuck, the surgeon will also appraise the type and extent of the deformation of abdominal wall. Pictures for records will be also taken.
The best results of a tummy tuck are achieved when the patient maintains the right lifestyle before and after the treatment. It is recommended to strengthen the abdominal muscles through exercise for a few months before the operation and to maintain a diet to reduce the amount of fatty tissue and improve the quality of the abdominal muscles. An additional benefit of such an approach is the possibility of limiting the extent of the surgical intervention and lowering the cost of the operation.

Right before the surgery, the doctor will plan and draw the incisions and places where the procedure will be performed. Additionally, another interview will be conducted and an examination performed. In this time, a consultation with an anaesthetist will also take place.

Before the procedure and general anaesthesia a patient is not allowed to eat or drink for 6 hours.

Type of anaesthetic

A tummy tuck is performed under general anaesthesia. Local anaesthetic may be also applied in the place of the skin incision to extend and improve the painkilling effect after the procedure.

Tummy tuck– what is the course of the procedure?

Depending on the extent of the deformation of the anterior abdominal wall, the surgeon will decide individually on the extent of the operation: a partial tummy tuck of the lower abdomen or upper abdomen, or a full tummy tuck combined with the stitching up of muscles, or liposuction, may be performed.

The procedure starts with a long skin incision along the lower part of the abdomen, from one iliac spine to the other. The incision is made so low that it is possible to hide it beneath underwear without any problem. Following that, a flap of skin, fat and fascia up to the belly button is prepared. If the deformation of the abdominal wall is not too extensive and the surgeon planned to perform only a partial tummy tuck of the lower abdomen, then the so-prepared excessive tissue will be trimmed, finishing the surgery. In the case of excessive deformation of the abdominal wall, a full tummy tuck will be performed. This will involve preparing a flap of skin and fat up to the ribs. Also, the belly button will be cut out and moved. It is also common to pull together and stich up the medial edges of the straight muscles of the abdomen, which improves the look of the waistline. An endoscopic tummy tuck is also possible. An endoscope will be introduced through a small incision by a surgeon to perform the procedure. This kind of procedure is performed when there is no excess skin but there is a separation of the straight muscles of the abdomen, for example, after pregnancy. A standard tummy tuck is followed by haemostasis (to stop small bleeding) and inserting surgical drains (rubber pipes). They will be kept for a few days after the procedure to remove excess blood and wound secretions. The skin will be stitched up in layers with dissolvable stitches in the lower layers and non-dissolvable stitches on the skin. The wound will be dressed with sterile dressing and a truss.

Sometimes after the removal of excess skin, characteristic folds at the ends of the incision may appear. They are called “dog ears” in surgeons’ jargon. They may be resorbed on their own a few weeks after the surgery, however their removal may also require additional surgery.

In some cases, a tummy tuck may be combined with liposuction, which may improve the quality of the skin. In the case when a patient has an umbilical hernia or a linea alba hernia, they are also repaired during the tummy tuck.

The procedure takes from one hour up to as many as three hours.

Tummy tuck– length and course of recovery

Right after the tummy tuck in the operating theatre and before waking the patient up, a special truss is put on the dressing. The truss will have to be worn by the patient for a few weeks after the surgery. For a few hours after the tummy tuck, the patient will be still under the influence of pain killers. Pain will be less severe in this time, however nausea and vomiting may occur. In the following days the patient will be given weaker pain killers until the pain goes completely. After the operation, apart from pain killers, a patient should also be given antithrombotic medication. After tummy tucks, patients usually spend around 3 days in the clinic. During this time, dressings are changed every day and the condition of the area subjected to the procedure and the amount and content of the fluid in the drains is checked. The drains are removed after a few days. The skin stitches are removed two weeks after the surgery. In this period, a patient should also have a check-up with his/her doctor. Until the wound from the incision has properly healed, it should not get wet (no bathing in a bathtub or submerging in water). Showers may be taken and the wound should be towelled dry before dressing. Work may usually be restarted after a month. Heavy lifting is not allowed, though, for 3-6 months after the surgery.

Tummy tuck– results

The result of a tummy tuck is visible right after surgery. However, its full result may only be appraised after about 6 months (that is how long it takes for a bruise in the human body to form). The best results may be achieved when a patient co-operates actively with the doctor and maintains an appropriate life-style before and after the surgery. A tummy tuck is not a procedure aimed at reducing body weight, rather, its aim is to improve the anterior abdominal wall. Those patients who maintain a healthy diet after the surgery, and at a later stage stay physically active, achieve the best long-term results. It is also important to know that in an adult human body, the number of fat cells is constant. When certain amount of fatty-tissue from the tummy is removed but we keep eating too much fattening food, it will be stored in other places. As a result of not sticking to the appropriate diet, it is possible that the buttocks, thighs, or other areas will store excessive amounts of fat. One should also remember that this fat will be stored to a larger extent in the abdominal cavity and on the internal organs such as, for example, the heart, which may lead to high blood pressure and heart diseases.

It is very important to stick to the recommendations of the doctor, maintain appropriate hygiene and use the truss.

Tummy tuck– recommendations following the procedure

• strictly following the recommendations of the doctor and recommendations included in the medical records given on the day of discharge;
• changing the dressing every day, maintaining bodily hygiene, washing the wound with appropriate skin disinfecting products (Octanisept, Scinsept), or with water with soap. Once washed, the wound should be towelled dry;
• the wound should not be soaked in water, so baths may not be taken and the wound should not be submerged in water. Until the wound heals fully, only showers may be taken;
• a hernia truss should be used from after the surgery until even a few months after it, depending on the extent of the surgery and deformations;
• showing up for check-ups as scheduled;
• having the stitches removed after 14 days;
• restraining from lifting above 1.5 kg for the first month and above 5 kg for the first 3 months;
• restraining from doing physical exercise for 2 months on average;
• for the best quality bruise- protecting the skin from cold and sun as sun may cause discoloration. Additionally, special silicone creams or plasters may be used to make the bruise softer and smoother.

Tummy tuck– how long do the results last?

A tummy tuck is a cosmetic procedure which requires the full co-operation from the patient. One should remember that its aim is not to reduce body weight. It is a procedure which assists in the fight for a beautiful body. A patient is required to stick to a healthy diet and regular physical exercise to maintain their appropriate body weight. On proviso of maintaining the right lifestyle, the result of the procedure may last many years.

Tummy tuck– how to avoid complications?

• follow the doctor’s recommendations,
• show up for check-ups as scheduled,
• change the dressing every day and maintain hygiene of the place where the procedure was performed,
• wear a truss for a few weeks after the surgery,
• refrain from physical exercise for a few weeks after the surgery,
• refrain from lifting heavy objects for 3-6 months after the surgery,
• it is recommended to postpone a tummy tuck until after all planned pregnancies, as tummy tucks increase to a large extent the risk of separation of the abdomen muscles and the risk of hernia;
• maintain the right body weight.

Tummy tuck– possible complications

As with any other surgery, a tummy tuck involves the risk of certain complications. Depending on the extent of the procedure and the extent of the deformations before the surgery, the frequency of complications varies and the most common ones include:

• surgical wound dehiscence
• creation of serum or puss deposits
• infection of the surgical wound
• intraoperative and postoperative bleeding,
• numbness or skin paraesthesia in the area of the surgery resulting from damage to cutaneous nerves; the numbness usually subsides after a few months,
• damage to internal organs, perforation of the gastrointestinal tract,
• separation of muscles as a result of the surgery, which may require another operation. However, muscle separation is usually a result of getting pregnant or gaining weight after a tummy tuck.

In the case of a tummy tuck in very obese patients, in whose case the procedure is performed due to health related reasons, the risk of complications is much higher. The removal of an extensive surface of skin with subcutaneous tissue and fatty tissue may lead to considerable blood loss, which may require blood product transfusions after the surgery. The risk of inflammation of the postsurgical wound is also increased in the case of this group of patients, which is caused by massive necrosis of fatty tissue damaged during the operation.

Tummy tuck– recommended additional treatment

A tummy tuck may be combined with other procedures such as, among others: liposuction, repair of an umbilical hernia or a linea alba hernia.

A few days after the surgery, special physiotherapeutic massages such as lymphatic massage may be taken. Taking regular massages speeds up full recovery, reduces swelling and the amount of serum and relaxes the patient after such a stressful event as an operation.

Some surgical clinics actually employ masseurs, which allows a patient to enjoy the benefits of physiotherapy right after the surgery. After an extensive tummy tuck, getting back to full physical fitness may require co-operation between the patient and a physiotherapist.

Author: Piotr Bargiel, MD
Literature::
A. Aly, S.C. Rotemberg, A. Cram; “Abdominoplasty”; Aesthetic Surgery; Elsevier Health; n 122; s.1609-1625;
Pollock, Harlan M.D.; Pollock, Todd M.D.; “Progressive Tension Sutures: A Technique to Reduce Local Complications in Abdominoplasty”; Plastic & Reconstructive Surgery: June 2000 - Volume 105 - Issue 7 - pp 2583-2586