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Although infection is very unusual after liposuction, it happens from time to time after abdominoplasty. It presents with increasing redness (“cellulitis”), fever, and possibly a purulent drainage from the incision. A yellow drainage is normal and to be expected, but a greenish or white drainage or any foul-smelling drainage is not. This indicates infection. Antibiotics are prescribed and any purulent drainage is cultured. Infections typically respond to antibiotics, although drug-resistant strains of Staphylococcus (MRSA) are becoming more prevalent. It may be necessary to drain an abscess and irrigate the wound, which is done under local anesthesia in the office.




A fluid collection under the skin is called a seroma. If the swelling seems to be getting worse, this may indicate that such a fluid collection has developed. Patients may reasonably wonder why the drain did not prevent such a problem. Should the drain simply be left in longer? The problem is that the longer the drain is left in, the greater the risk of infection. That is why we prefer to remove the drain 3 or 4 days after surgery. If a seroma develops, it is treated by injecting a needle into the swollen area and draining off the fluid. This maneuver immediately corrects the excess swelling and patients are more comfortable. Fortunately, it is not particularly painful because the skin where the needle is introduced is still numb. This aspiration typically needs to be repeated several times. Eventually, the lymphatics start working again to absorb the fluid and it is no longer necessary.


Surgeons find this problem a nuisance (as do their patients) and try to avoid it by preserving the “areolar” tissue layer over the abdominal wall during the abdominoplasty. The skin undermining is limited to just what is necessary to gain adequate release of the flap. (This also helps preserve blood supply and sensation). I personally find it helpful to avoid the use of cautery during the dissection. Pretreatment with the Marcaine/epinephrine solution reduces blood loss sufficiently to allow dissection using a scalpel (as well as providing long-lasting anesthesia of the tissues). This technique limits tissue injury and inflammation that might otherwise cause more fluid release. The risk of seroma is minimized. In my series of patients the seroma rate was a very manageable 5.4% (Swanson E. Prospective clinical study of 551 cases of liposuction and abdominoplasty performed individually and in combination. Plast Reconstr Surg Glob Open 2013;1:e32). This rate compares with much higher rates in other series—as high as 60%.


Abdominoplasty complication-hematoma

Draining a seroma in the office after an abdominoplasty.




Hematomas (collections of blood) can occur after an abdominoplasty, and can possibly necessitate a return to the operating room for evacuation, although this is very unusual. Prompt recognition and treatment is the key. Surgeons who routinely prescribe blood thinners report increased bleeding and hematomas. I prefer safer methods to reduce the risk of blood clots (Swanson E. The case against chemoprophylaxis for venous thromboembolism prevention and the rationale for SAFE anesthesia. Plast Reconstr Surg Glob Open 2014;2:e160).


Deep Venous Thrombosis (DVT)


A blood clot in the deep vein of the thigh (“deep venous thrombosis”) is a serious and potentially life-threatening complication of surgery. The risk of a DVT is that a clot may break off, travel to the lungs and cause a pulmonary embolus, which can be fatal. The risk is increased by immobilization of the lower extremities. It can even occur in patients after long plane flights. The risk may be reduced with the avoidance of paralysis (so as to preserve the calf muscle pump) and early ambulation. My patients are turned from side to side during surgery (during the liposuction treatment) to keep the legs mobile. The prone position, which exerts pressure at the hips, is avoided entirely.


Even doing “everything right,” a DVT can still occur. It can even happen without surgery. Some surgeons advocate the use of blood thinners (heparin or Lovenox) immediately before surgery, but their use has to be balanced against the risks of easier bleeding after surgery. I believe the risks outweigh any possible benefits.


Ultrasound Surveillance


Doppler ultrasound provides a highly accurate method to detect early blood clots and treat them before they become dangerous. It avoids routine anticoagulation in patients who do not need it. I use it on all abdominoplasty patients (Swanson E. Ultrasound screening for deep venous thrombosis detection: Prospective evaluation of 200 plastic surgery outpatients. Plast Reconstr Surg Glob Open 2015;3:e332).


abdominoplasty complication-swelling

This 39-year-old woman is seen before surgery, 2 weeks after an abdominoplasty and liposuction of her lower body, and 3½ months after surgery. She developed swelling of the left lower extremity 9 days after surgery. A Doppler ultrasound scan revealed a deep venous thrombosis. She did not develop pulmonary emboli. She was treated with anticoagulation and made a full recovery.


Skin Loss


Skin loss typically occurs where the skin circulation is most at risk. This is typically the central portion of the upper skin flap, that has been undermined the most in performing the abdominoplasty. Smoking causes constriction of the small blood vessels which can make the difference between tissue survival and loss. Cessation of smoking greatly reduces the risk of this complication.


Abdominoplasty complication-delayed healing

This 63-year-old nonsmoker had a tummy tuck and liposuction. She had an old scar across her right upper abdomen, from removal of her gall bladder 35 years ago. Prior to surgery, we discussed the fact that this scar would compromise circulation to the abdominal skin and possibly cause some skin loss, which is exactly what happened. The wound healed in gradually on its own. The patient was pleased despite the scar (which could have been revised but the patient did not find it a problem). The key to her satisfaction was knowing that this complication could occur and accepting that possibility.




Abdominoplasty complication-skin loss

Abdominoplasty and ultrasonic liposuction of lower body.


Comments: This 50-year-old smoker did not follow advice to stop smoking. Her daughter scolded her and told her she’d better stop “or you won’t look good in a bikini, Mom.” Once she stopped smoking, the wound healed quickly and was completely healed 2 months after surgery. She has some increased scar tissue along the midportion of the incision. This excess scar tissue may be revised later to give a thinner scar, but with time the scar will continue to soften and this may not be necessary.


Excessive Scarring


The central portion of the abdominoplasty may spread, depending on the patient’s healing characteristics and wound tension. Any factor that interferes with wound healing, such as an infection or skin loss (see above) can contribute to a wider, more conspicuous scar. After 6 months to a year, the tension has been relieved. At this point, the scar may be revised.


Dr. Eric Swanson patient before and after photo-abdominoplasty

Revision of previous abdominoplasty and liposuction of abdomen, flanks, and inner thighs.


This patient had an unsightly scar from a previous tummy tuck performed elsewhere. The scar ran slightly above her bikini line and had widened. There was a contour depression associated with it. At surgery, I revised the scar, using anchoring sutures to keep it low and avoid upward migration. A deep tissue repair corrected the contour deformity. Liposuction was used to correct her muffin top deformity of the flanks and also taper the inner thighs. The umbilicus was lowered slightly, correcting its unnatural orientation.





Abdominoplasty complication-hematoma

abdominoplasty complication-swelling

Abdominoplasty complication-delayed healing

Abdominoplasty complication-skin loss

Dr. Eric Swanson patient before and after photo-abdominoplasty