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Abdominoplasty

Sharon Y. Giese, MD

Abdominoplasty or “tummy-tuck” is a surgical procedure that removes excess abdominal skin, resulting in dramatic and immediate changes in body contour. In some women, pregnancy leaves loose, possibly sagging skin; others develop loose, excessive skin after weight gain and fluctuations in weight. The anterior abdominal wall, weakened secondary to pregnancy and/or age, can be tightened simultaneously with the abdominoplasty. Abdominal hernias can also be repaired at this time. Abdominoplasty is also the anterior portion of a lower body lift operation to treat excess body skin after massive weight loss. The removal of a massive apron of abdominal skin and fat is referred to as a panniculectomy. Abdominoplasty is most frequently performed for cosmetic reasons; however, it is also performed for medical and functional reasons, such as for hygiene and mobility, and is then considered a reconstructive procedure and covered by insurance.

INDICATIONS FOR SURGERY

Surgical excision of excess abdominal skin dates to the early 1900s. In 1910, Kelly reported positive outcomes including weight loss, improved comfort, increased activity, and improved hygiene following surgery.¹ Anterior abdominal wall laxity is the primary medical indication for an abdominoplasty, since it is responsible for structural defects of the abdominal wall and chronic low back pain (Figures 1 and 2). Abdominal wall laxity can increase the work support of the lumbar dorsal fascia, resulting in lower back pain. Ten extra pounds of adipose tissue in the abdominal wall adds 100 lb of strain on the disks of the lower back by exaggerating the normal “S” curve of the spine. Diastasis recti, congenital or secondary to pregnancy, decrease the efficiency of the abdominal musculature, contributing to lower back strain.

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Figures 1 and 2. Overweight Patient with hanging abdominal pannus and evidence of diastasis recti with a bulging abdomen. Note flatter, tighter abdominal contour after surgery.

Cosmetic Abdominoplasty

Abdominoplasty is considered cosmetic when it is done to enhance the patient’s appearance in the absence of functional abnormalities. Typically, the operation is performed to remove unsightly stretch marks and flatten the lower abdomen (Figures 3 and 4). Other aesthetic benefits of abdominoplasty include the following:

• “Supra-pubic lift,” which relocates the mons pubis to a higher, more youthful location.
• Waist cinching by creating an “internal-corset” with rectus muscle plication.
• Anterior and medial thigh lift secondary to the vertical pull on closing the abdominal incision.
• Smaller, more youthful umbilicus by “umbilicoplasty,” a requisite part of the abdominoplasty procedure that enhances the appearance of the umbilicus.

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PREPARATION FOR SURGERY

Abdominoplasty is an elective operation; therefore, patients should be otherwise good surgical candidates. Patients should have a recent physical exam, complete blood count, and a negative pregnancy test. In fact, patients who are considering additional pregnancies are strongly advised against abdominoplasty. While it is possible to successfully complete additional pregnancies following abdominoplasty (skin excision and muscle plication), a patient will negate many of the positive results of the operation with additional births. Smoking cigarettes should cease at least 2 weeks prior to surgery. Smoking significantly increases wound-healing complications, including wound dehiscence, skin loss, and infection. Ideal candidates are at an ideal, stable body weight (body mass index [BMI] of 25 or less). Patients who are medically obese (BMI >30) are a higher surgical risk but are considered for surgery following an individual risk-benefit analysis of other pre-existing medical problems of dysfunction secondary to the abdominal pannus or abdominal wall laxity.

SURGICAL TREATMENT

Many techniques have been described over the past decades to accomplish the goal of skin excision. The resultant closures include high to low horizontal or vertical scars. Most common is the excision of the excess abdominal skin between the umbilicus and mons pubis resulting in a low U-shaped abdominal scar extending from one iliac crest to the other. This incision is easily covered by underwear or a bathing suit. The second, a potentially visible scar, is around the umbilicus at its new position where it exits the tightened abdominal skin.

Once the lower abdominal skin is excised, the upper abdominal skin flap is raised toward the sternal notch. The anterior rectus sheath is clearly exposed at this point and the medial edges of the rectus muscle are plicated with permanent sutures. Any abdominal hernia can be repaired at this time as well.
Less severe deformities can be treated with a “mini-abdominoplasty.” This procedure simply removes excess lower abdominal skin without movement of the umbilicus and complete rectus plication.

Operating time for an abdominoplasty is 2 to 4 hours. It can be performed in an ambulatory center or a hospital, generally, on an outpatient basis. Overweight patients with any medical problems should have the surgery performed in a hospital and observed overnight. Most surgeons who perform abdominoplasty use a general anesthetic, but the surgery can be performed safely using local anesthesia with deep sedation or an epidural. Drains are placed and remain for 1 to 2 weeks following surgery. Sequential compression devices are always used. Urinary catheters are not routinely used. Blood loss of less than 100 cc is customary; therefore, transfusion is not anticipated for this procedure.

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ALTERNATIVES TO ABDOMINOPLASTY

Abdominal liposuction may be suggested to some patients who do not have severe skin laxity. A significant amount of skin retraction can be achieved with aggressive subcutaneous fat removal (Figures 5 and 6). Some patients may accept the slight abdominal bulging from rectus diastasis for not having a low abdominal scar.

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Figures 5 and 6. slightly overweight patient before and after liposuction. Note significant skin shrinkage following aggressive removal of subcutaneous fat with internal ultrasonic liposuction.

COMBINED PROCEDURES

Abdominoplasty can be combined with limited liposuction of the abdomen or other small procedures such as medial thigh or arm liposuction. However, opinions are turning against combining larger operations or extending the time of surgery. Therefore, additional procedures should be kept to a minimum. Safe abdominoplasty combined with gynecologic procedures (eg, hysterectomy) may increase complications,² but evidence for safe combination has been presented.^3-5

RECOVERY

Patients should anticipate a recovery period of 1 to 2 weeks. They can ambulate immediately following the operation but will experience the most pain in the first 4 days following surgery. At 3 weeks, patients can increase their activity level with a full return to normal at 6 weeks. If rectus muscles were plicated, it is absolutely necessary that patients not strain the abdominal muscle for a full 6 weeks following surgery, including lifting any items heavier than 5 lb.

COMPLICATIONS

Local complications include scars, contour deformities, seroma, infection, skin loss, wound dehiscence, and diminished sensation of the lower abdominal skin. Systemic complications include deep venous thrombosis, pulmonary embolism, bleeding, transfusion, anesthetic complications, and death.

Sharon Y. Giese, MD, FACS, is a board-certified surgeon, specializing in cosmetic surgery, in private practice in New York, NY. She is clinical assistant professor of plastic surgery at SUNY Downstate, Brooklyn, NY. She is attending surgeon at Manhattan Eye, Ear, and Throat Hospital and New York Eye and Ear Infirmary.

References:

1. Kelly, HA. Excision of fat of the abdominal wall—lipectomy. Surgical Gynecology and Obstetrics. 1910; 10:229.
2. Voss SC, Sharp HC, Scott JR. Abdominoplasty combined with gynecologic surgical procedures. Obstet. Gynecol. 1986;67(2):181.
3. Hester TR Jr, Baird W, Bostwick J 3rd, et al. Abdominoplasty combined with other major surgical procedures: safe or sorry? Plast Reconstr Surg. 1989; 83(6):997-1004.
4. Shull BL, Verheyden CN. Combined plastic and gynecological surgical procedures. Ann Plast Surg. 1988:20(6): 552-557.
5. Savage RC. Abdominoplasty combined with other surgical procedures. Plast Reconstr Surg. 1982;70(4):437.

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