Abdominoplasty:

Are sit-ups not giving you the taut tummy you want? If you’ve got too much flab or excess skin in your abdomen that doesn’t respond to diet or exercise, you may be considering a “tummy tuck,” which doctors call “abdominoplasty.”

One of the most commonly performed aesthetic procedures, abdominoplasty, in which excess skin and fat are removed from the abdomen, has undergone significant evolution over the past several decades.

Abdominoplasty was the fourth most common aesthetic surgical procedure performed in the United States in 2019, with over 140,000 of the operations carried out that year, according to the Aesthetic Plastic Surgery National Databank.

The most common cause of abdominal deformity is pregnancy, most often multiple pregnancies. Pregnancy stretches the skin beyond its biomechanical capability to spring back and stretches the musculoaponeurotic structures of the abdominal wall. The result is stretching and thinning of these structures and diastasis of the rectus muscle. Postpartum weight loss also contributes to the process. If skin retraction has not occurred in approximately 6 months, it probably will not occur. Massive weight loss, whether from dieting or after a gastric bypass surgery, also plays a role in excess skin and laxity of the abdominal wall.

Pathophysiology

The pathophysiology of the abdominal deformity is 2-fold. It includes (1) excess skin and subcutaneous tissue and (2) laxity of the abdominal wall musculature.

The most significant area of the defect is around and below the umbilicus, where excess skin over a diastasis of the rectus muscles is most apparent.

In 1972, Georgiade and Katras classified fat deposits on the trunk as lower medial or upper medial, based on the umbilicus. Patients are divided into 3 categories:

1. Those with normal weight.
2. Those who have mild-to-moderate obesity.
3. Those with massive weight loss.

History

The medical history is extremely important. Previous pregnancies and their effects on the abdomen should be noted. Previous surgical procedures (including laparoscopic procedures) should be documented. The patient’s history of weight gain and loss should be discussed. Finally, any future plans for pregnancy should be noted. A detailed inquiry into the patient’s history of medical problems should be performed. Severe heart disease, diabetes, and a history of thromboembolic disease should be noted. Less severe but also important information is the occurrence of wound problems, either from infection or connective tissue diseases.

Ensure that patients aren’t smoking and are exercising before the surgery to promote overall well-being. Advise patients to be as close as possible to their desired weight before surgery. If patients are planning another pregnancy or planning to lose more than 10 lb, advise them to postpone the procedure.

Physical examination

The abdominoplasty is targeted at addressing abdominal deformities characterized by excess skin and subcutaneous tissue and laxity of the abdominal wall musculature.

Preoperative planning

The physical examination should be thorough. Concerning the abdomen, the location of all scars should be documented and the presence of abdominal hernias should be noted. Diastasis of the rectus muscles should be noted. The condition and strength of the abdominal wall should be evaluated. The amount, quality, and elasticity of the abdominal wall skin should be thoroughly evaluated.

Preoperative photographs should be taken and printed on 8.5 X 11-in paper. These can be used when discussing the procedure with the patient. Alternatively, an imaging system can be used.

Mass media influences drive what patients expect and desire from an abdominoplasty. Inflated patient expectations must be addressed.

Therefore, understanding the patient’s aesthetic goals prior to the procedure is critical. For instance, the patient should understand that the excision of excess skin and fat does not flatten an abdominal wall distended from inside by a large omentum. In addition, multiparous patients with striae should not expect results exactly as they see in magazines. The patient should be as close to his or her ideal body weight as is practical prior to the surgery.

The location of scars should be marked directly on the patient’s skin or, at minimum, on the photographs. Candid discussions regarding the quality of these scars and potential wound problems should occur. Early wound problems include hematoma, seroma, marginal necrosis, and dehiscence. Late wound problems include hypertrophic scars, keloids, umbilical malpositions, and thromboembolic events.

Indications

Patients usually seek abdominoplasty for abdominal wall laxity, excess skin, striae, or diastasis of the rectus muscles. The ideal patient is within normal limits for his or her weight and height (ie, body mass index), has no plans for future pregnancies, has a moderate amount of excess of skin and fat, and has a mild diastasis of the rectus muscles. Patients who seek body contouring following massive weight loss have their own set of criteria. They need to be evaluated regarding their candidacy for a belt lipectomy instead of abdominoplasty.

Contraindications

Contraindications to abdominoplasty include right, left, or bilateral upper quadrant scars (relative); severe comorbid conditions (eg, heart disease, diabetes, morbid obesity, cigarette smoking); future plans for pregnancy (relative); a history of thromboembolic disease (relative); morbid obesity (BMI >40); and unrealistic patient expectations.

The prevalence of obesity in health care settings is increasing to alarming levels. Plastic surgeons need to be aware of the comorbidities that are associated with obesity. In addition, only 5% of Americans are candidates for bariatric weight loss surgery. According to the American Society of Bariatric Surgery (ASBS), 200,000 patients will undergo massive weight loss surgery this year, and 75% of them will seek a plastic surgeon for body contouring after the weight loss surgery.

Current weight demographics in the United States include the following statistics

• 66% of adults are overweight.
  • 31% are obese (categories I and II).
  • 1% are morbidly obese (category III).
• 32% of teens are overweight.

The most commonly accepted criterion for measuring obesity is the body mass index (BMI). This is defined by weight in kg divided by height in meters squared.

The BMI categories are as follows:

20-25 healthy

26-29 overweight

30-34.9 obese (category I)

35-39.9 obese (category II)

>40 morbidly obese (category III)

Additional relative contraindications include moderate obesity in a patient who expects a perfectly flat abdomen. Also, patients who tend to form keloids or hypertrophic scars should not undergo an abdominoplasty unless they are willing to accept the scarring associated with these conditions.

This is a major surgery, so if you’re considering it, you should know the facts before you decide whether to go forward or not.

Who Are the Best Candidates For a Tummy Tuck?

A tummy tuck is suitable for men and women who are in good health. Women who have had several pregnancies may find the procedure useful for tightening their abdominal muscles and reducing skin.

A tummy tuck is also an option for men or women who were once obese and still have excess fat deposits or loose skin around the belly.

Who Should Not Consider a Tummy Tuck?

If you’re a woman who plans to get pregnant, then you may want to postpone a tummy tuck until you’re done having children. During surgery, your vertical muscles are tightened, and future pregnancies can separate those muscles.

Are you planning to lose a lot of weight? Then a tummy tuck also is not for you. A tummy tuck should be a last resort after you’ve tried everything else. It should not be used as an alternative to weight loss.

You should also consider the appearance of scars after a tummy tuck. You can talk about scar placement and length with the doctor before the surgery.

How to Prepare for Tummy Tuck Surgery

The first step is to choose a surgeon and see them for a consultation. At that meeting, you’ll talk about your goals and the following options:

• Complete abdominoplasty

 The surgeon will cut your abdomen from hipbone to hipbone and then contour the skin, tissue, and muscle as needed. The surgery will involve moving your belly button, and you may need drainage tubes under your skin for a few days.

• Partial or mini abdominoplasty

 Mini-abdominoplasties are often done on people whose fat deposits are located below the navel. During this procedure, the surgeon most likely will not move your belly button, and the procedure may only take up to two hours, depending on your case.

If you smoke, your doctor will ask that you quit smoking from at least two weeks before the surgery until two weeks after the surgery. It is not enough to just cut down on smoking. You must stop completely since smoking makes complications more likely and slows healing.

Don’t try a drastic diet before the surgery. Eat well-balanced, complete meals. A healthy diet may help you heal better.

Tell your doctor about everything you take, including prescription drugs, herbal medicines, and other supplements. Your surgeon may instruct you to stop taking certain medications for a time before and after the surgery.

Before getting the surgery, get your home ready. You’ll need:

Ice packs

Loose, comfortable clothing that can be put on and off very easily

Petroleum jelly

Hand-held shower head and bathroom chair

You’ll also need someone to drive you home after the tummy tuck. If you live alone, you’ll want someone to stay with you for at least the first night. Make a plan for that.

How a Tummy Tuck Is Done

This surgery can take anywhere from one to five hours. You may need to stay overnight in the hospital, depending on your case.

You will get general anesthesia, which will put you to “sleep” during the operation.

Possible Complications

You will have pain and swelling in the days following surgery. Your doctor will prescribe pain medicine and tell you how to best handle the pain. You may be sore for several weeks or months.

You may also experience numbness, bruising, and tiredness during that time.

As with any surgery, there are risks. Though they’re rare, complications can include infection, bleeding under the skin flap, or blood clots. You may be more likely to have complications if you have poor circulation, diabetes, or heart, lung, or liver disease.

You may experience insufficient healing, which can cause more significant scarring or loss of skin. If you do heal poorly, you may require a second surgery.

A tummy tuck leaves scars. Though they may fade slightly, they will never completely disappear. Your surgeon may recommend certain creams or ointments to use after you’ve completely healed to help with scars.

Taking Care of Yourself after Surgery

Whether you’re having a partial or complete tummy tuck, the area that’s operated on will be stitched and bandaged. It’s very important to follow all your surgeon’s instructions on how to care for the bandage in the days following surgery. The bandage used will be a firm, elastic band that promotes proper healing. Your surgeon will also instruct you on how to have best position while sitting or lying down to help ease pain.

You will have to severely limit strenuous activity for at least six weeks. You may need to take up to one month off work after the surgery to ensure proper recovery. Your doctor will advise you on what you need to do or not do.

Returning to Daily Life

Generally, most people love how they look after this procedure. That can take time, though. You may not feel like your normal self for months after the surgery. Diet and exercise can help you maintain the results.

References:

https://www.rcseng.ac.uk/

The Royal College of Surgeons of England

www.plasticsurgery.org

American Society of Plastic Surgeons

https://my.clevelandclinic.org/

https://medscape.com

https://webmd.com