BEFORE AND AFTER PHOTOS
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HOW IT IS DONE
Abdominoplasty and Anesthesia
Traditionally, abdominoplasties have been performed under general anesthesia, including paralysis, intubation, and ventilation—the maximum degree of anesthesia. However, this operation may be performed under unconscious sedation, using an LMA and propofol (Diprivan) infusion, just like other cosmetic procedures. This modified type of anesthetic avoids possible problems sometimes caused by traditional general anesthetics.
After the patient is asleep, the abdomen is infused with a dilute solution containing Marcaine, a long-acting local anesthetic, and epinephrine to reduce blood loss. By injecting the abdomen this way and then allowing time for the epinephrine to constrict the small blood vessels, there is a remarkable reduction in bleeding at surgery. Patient comfort is enhanced with the use of Marcaine, which continues to work for many hours after surgery. This local anesthetic also reduces the amount of anesthetic necessary during surgery, so that the patient recovers faster afterward.
While abdominoplasties have been traditionally done in a hospital setting with an overnight stay, they are being done more commonly today in ambulatory surgery centers, for healthy patients without medical conditions. This is made possible by advances in technique and anesthesia to reduce surgery times, restrict blood loss, improve pain management, and shorten recovery times. We recognize the importance of early ambulation to help avoid blood clots. Also, treatment in outpatient surgical settings helps contain costs and make it more affordable.
The incision for a tummy tuck is long, running from hip to hip. Patients are concerned about it before surgery but don’t seem to mind after surgery. The incision needs to be long enough to allow removal of a wide apron of excess skin. The shorter the incision, the less skin may be removed. Patients readily agree that it is better to make the incision a little longer and remove extra skin, than leave unsightly puckering at each end. It is important for the incision to be low. A common surgical error is to place the incision too high, so that it is above the bikini line. Some patients who have had previous abdominoplasties complain about a high-riding scar that is hard to hide. It may be possible to lower the scar at a subsequent procedure, but obviously this is best avoided.
Why Don’t All Plastic Surgeons Place the Incision Low, Within the Bikini Line?
A low incision is not usually a problem in a patient with a large apron of extra skin. It is more difficult in the thin patient with less loose skin. Of course, this is usually a discriminating patient that is going to want a low incision that she can hide. The difficulty in placing the incision low is that the upper margin of the skin to be removed is fixed at the level of the belly button (if a vertical scar is to be avoided). The lower the incision is placed, the more skin is removed between this incision and the level of the belly button. The wider this distance is, the more the upper skin flap needs to come down to meet it. Moving this upper flap down to meet the lower skin edge can be difficult unless the operating table can be adjusted to provide flexion at the hips by bending in the middle. Also, the tighter the repair, the more the patient will be stooped over after surgery. Deep fixation sutures are used to prevent the pubic tissue from being dragged up, bringing pubic hair up onto the abdomen (not good). Experienced plastic surgeons use these technical maneuvers to keep the incision low, avoid upward traction on the hair-bearing pubic skin, and avoid a vertical scar, delivering the best possible cosmetic result.
A Vertical “Inverted-T” Scar Is to Be Avoided, Because It Is Unattractive.
Abdominoplasty incisions have been made in the shape of a W (I used to do this.), in the shape of bicycle handlebars, or as a gentle concave curve like a saucer. The gentle curve is the most attractive scar, if a scar can be attractive.
Most surgeons mark the incision with the patient standing before surgery. The “photo panties” are used as reference along with the natural skin creases (the “inguinal crease”). The incision courses below any existing scars from previous C-sections or other surgery. This way, any existing lower abdominal scar is removed along with the extra skin. Typically, the new scar ends up at about the same level as an old C-section scar, because it is pulled up a little by tension from above. For patients with an existing C-section scar, the trade-off in scarring is limited to the extra length of the abdominoplasty scar beyond what they had already from the C-section scar and the umbilical scar around the belly button.
One of the benefits of an abdominoplasty is the capability of removing unsightly old scars, particularly vertical scars that may leave an unsightly cleavage, giving the abdomen the unwelcome appearance of buttocks. These old scars are contained in the extra skin which is discarded.
A horizontal elliptical excision is performed, removing the skin and fat from the lower abdomen. All the skin from the level of the belly button (“umbilicus”) to the pubic area is removed. The skin flap is released from the underlying muscle all the way up to the lower border of the rib cage (“costal margin”) to allow the remaining skin of the upper abdomen to be pulled like a bed sheet down to the lower incision, which is tucked just inside the bikini line. This is how a vertical scar is avoided. It is necessary to flex the hips to do this (the operating table is adjusted to flex the hips). The lower the incision line, the more the hips must be flexed to allow this flap to reach.
It is also important for the surgeon to anchor the flap with deep sutures. This helps to prevent upward pulling on the pubic skin which can displace pubic hair upward, which is obviously undesirable. The deep fascial closure also helps preserve a flat skin contour, and avoid a depression along the incision, which can create a ledge just above the incision line. It also helps take some of the tension off the skin closure, optimizing the scar.
Patients often ask about a mini-tummy tuck. They know that there is a long scar with a regular tummy tuck and wonder if a “mini tummy tuck” might offer the best combination of results and minimal scarring.
How is a mini-tummy tuck different from a regular tummy tuck? In a regular tummy tuck, or “full abdominoplasty,” the umbilicus is released from the surrounding abdominal skin and then reintroduced through a new hole once the skin drape has been pulled down. In a mini-tummy tuck, the umbilicus is not released. It stays attached to the surrounding abdominal skin and can be pulled down due to skin tension from below. A much smaller ellipse of skin is removed from the lower abdomen. The scar is shorter and ends up looking much like a C-section scar. There is no tightening of skin of the upper abdomen because the umbilicus remains anchored, preventing any tightening of the skin above it. It may be possible to tighten the muscles of the lower abdomen but it is difficult to tighten the muscles above the level of the umbilicus because the upper abdomen is not exposed.
So a mini-tummy tuck is really just a removal of extra lower abdominal skin. It does not treat the upper abdomen. If the patient is concerned about loose skin above the belly button, or a roll that borders the belly button, and most are, she will not be adequately treated with a mini-tummy tuck. Not surprisingly, I perform very few mini-abdominoplasties, about one for every 100 full tummy tucks.
One of the most satisfying components of an abdominoplasty is the muscle repair. Pregnancy and weight gain stretch the abdominal wall. The two rectus abdominis muscles which are oriented vertically in the abdomen are stretched apart. The muscles become bowed apart, often separated by several inches at the level of the umbilicus. Exercise cannot bring these muscles back together. They can only be realigned surgically. This is done by sewing the muscle borders together, up and down the abdomen like a zipper. Actually, the “fascial” envelope that contains the muscle is sewn together, not the muscle itself because muscles are too elastic and don’t hold sutures well. After surgery, and after the swelling has gone down, the borders of the muscle can now be seen, moved in closer to the midline. The muscles have been replaced in their original position, where they were prior to being stretched apart from pregnancy or weight gain. It is an anatomical restoration. This realignment also improves the mechanical advantage of the abdominal muscles. This can help alleviate back pain due to muscle imbalance. It is possible that this may also help bowel function in some patients. The muscle repair helps flatten the abdomen and correct excessive protuberance. It is important to recognize that the abdomen is not typically flat, even in lean, muscular individuals. However, the muscle repair can correct excess protuberance and leave a pleasing gentle convexity.