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Archive for the 'abdominoplasty' Category
Men have just as many concerns about their waistline and abdominal shape as women. But the anatomic basis for the male abdominal problem is usually different. Exclusive of the morbidly obese or the extreme weight loss patient, men have different skin, fat and muscle compositions of their abdominal shape. Men do not get pregnant so the amount of stretched and/or stretchy skin is less. Fat distribution in men has a more significant intraperitoneal component and usually less between the skin and the underlying muscle. Lastly, men rarely have significant muscle laxity or midline separation.
For these reasons, tummy tuck surgery is performed less on men than women because the excess skin and loose muscle issues are less. For every male that undergoes some form of an excisional abdominoplasty, ten women probably do. This is different in the extreme weight loss patient where the ratios are much more comparable.
Much abdominal reshaping in men can be done with liposuction. Aggressive liposuction of the entire abdomen extending into the flanks is necessary before any consideration of skin excision can be done. For most men with any amount of abdominal protuberance, it is not possible to get a near flat abdomen with liposuction alone. There is too much intraperitoneal fat for that to occur except in the already relatively fit male.
Most of the time whether simultaneous skin resection should be done with liposuction can be determined before surgery but not always. Some men are understandably reluctant to acquire a low horizontal scar which is relatively unnatural in a male. Women accept these scars much better as they have a long history of c-section and tummy tuck scars. When in doubt, it is most logical to use the ‘wait and see’ approach for the amount of skin retraction. But, psychologically, most men are not as tolerant of multiple procedures and are impatient to get to the final result.
Tummy tucks in men are usually more limited in scope of skin resection and length of the horizontal scar. In addition, muscle plication is rarely necessary or that beneficial unless there is an associated umbilical hernia. Infraumbilical skin and fat resections are all that is needed in most cases and the lateral resection should go as far as needed to work out any pleats or dog ears.
In removing the lower abdominal skin and fat, I avoid exposing the abdominal wall fascia and leave a layer of tissue just below Scarpa’s fascia. The upper abdominal skin is then advanced over top. By so doing, this reduces the amount of time a drain will be needed and decreases the risk of seroma later after the drain is removed. Men are not particularly tolerant of tubes exiting their body.
The concept of lipoabdominoplasty in men leans heavily toward the liposuction component in the non-bariatric or large weight loss patients. The tuck and tightening of lower abdominal skin is often quite helpful from a contouring standpoint and probably should be considered in more older male patients who seek a better waistline. In my Indianapolis plastic surgery practice, I find an increasing number of men who benefit by some version of a lower skin resection and do not have objection to the final scar that results.
Barry L. Eppley, M.D., D.M.D.
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Tummy tucks (abdominoplasty) traditionally are a horizontally-oriented operation. This means that excess skin and fat is removed with an elliptical incision that is oriented from one side of the waistline to the other. This results in a fairly low horizontal scar that is some distance below a newly created belly button. (if it is a full tummy tuck)
This conventional tummy tuck is effective for the vast majority of people as their abdominal skin excess is largely located in that direction. However, some patients have abdominal skin issues that have greater dimensional excesses than just in one direction. In my Indianapolis plastic surgery practice, I can determine this before surgery by looking at the sides of the waistline and seeing how much tissue bulges to the side. One can also see how much skin can be pinched in a vertical direction above the belly button.
When there appears to be considerable vertical excess as well, consideration can be given to an extended or combined vertical-horizontal tummy tuck. This is also known as a fleur-de-lis type tummy tuck. By removing both horizontal and vertical tissue, the sides of the waistline are brought in as well as the frontal overhang removed. This creates a better abdominal result but there is a trade-off…a vertical closure as well as the horizontal one creating an anchor or inverted T scar.
In the past, there were many more patients who presented with a history of prior abdominal surgery in which a midline scar was present. But the use of laparoscopic techniques is making such patients fewer and fewer. Therefore, the consideration of adding a vertical abdominal scar when one isn’t already present can be a difficult decision. If a vertical scar is present, however, the choice of an extended tummy tuck is straightforward.
While this type of tummy tuck always produces a better abdominal result, it does bring some increased risks of wound complications. The intersection of the vertical and horizontal closures at the inverted T creates a zone of tension. Combined with upper skin flaps that may have a blood supply to the skin edges which is compromised, it is not uncommon that these incisions can develop an opening at this intersection several weeks after surgery. This wound problem can be magnified based on where the new belly button is brought through on the vertical closure. Most of the time, this is only a few inches above the horizontal closure. These wound problems are self-limiting although it can take four to six weeks to close if the opening is significant.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
The traditional tummy tuck (abdominoplasty) is primarily what I call a frontal approach where skin and fat is removed from the lower abdomen. The skin cutout is done horizontally in the shape of a football. Often times, liposuction is also performed on the sides around the waistline to get more of a 270 degree result. When the skin excess is not large, this is a perfectly fine approach and will immensely satisfy the vast majority of people who seek abdominal contouring.
When the amount of abdominal skin increases, however, the dimensions of the skin problem change. Redundant skin and fat is present not only in the horizontal direction but in the vertical dimension as well. Such abdominal problems exist in the larger abdominal pannus patient (skin overhang onto the thighs) and in the extreme weight loss patient. (greater than 100 lbs.)
If this additional dimension is not taken into consideration during the planning, patients may be disappointed with the result at the sides of the waistline. They may wonder why the side of the waistline does look as flat or as contoured as the front. Herein enters the concept of the extended tummy tuck, also known as the anchor tummy tuck or the fleur-de-lis tummy tuck.
The extended tummy tuck adds a upper vertical cutout of skin along with the lower horizontally oriented skin removal. By so doing, the skin closure pulls in on the sides of the waistline as well as pulling down in the front. This effectively helps narrow the waistline as well and helps reduce the amount of redundant skin in that area. By adding this ‘third’ dimension to the tummy tuck, the length of the operation is increased but it does not result in any significant increase in the risk of postoperative problems.
The extended tummy tuck does result in an additional scar that runs vertically from below the sternum down to the pubis. This creates the anchor scar result. Whether this extra scar is worth the trade-off for the improvement in the waistline is a personal choice. That choice is an easy one if an existing midline abdominal scar is already present. If no such midline scar exists, then one has to decide which ‘negative’ they can live with the best….loose skin on the sides or a vertical scar.
In my Indianapolis plastic surgery practice, I have noted that most patients with a lot of excess abdominal skin opt for the most skin removal and the best abdominal contour result. My general approach to the consideration of incisional scarring in non-hidden areas is…if you have to think about whether the scar is worth it…don’t do it. If the answer is an immediate yes and one could care less about the scar (compared to the existing problem), then the scar is not very likely to be a regrettable concern after surgery.
Dr. Barry Eppley
Http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Tummy tuck surgery remains as one of the most sought after elective plastic surgery procedures. To the person struggling with a loose or unsightly stomach area that has not changed with diet and exercise (and it almost never does), tummy tuck surgery offers a result that is otherwise unobtainable. But tummy tuck surgery has evolved over the years into an increasingly more sophisticated operation. No longer is it just the simple removal of some loose skin and fat. Recognizing that this area is aesthetically more complex than just be a flatter surface, newer techniques are being incorporated into the old traditional tummy tuck.
Lipoabdominoplasty is an advanced technique bringing significant change to the old-style tummy tuck. This procedure, which incorporates liposuction into the skin and fat cut out, has allowed plastic surgeons to transform patients’ tummies after child birth and/ or significant weight loss into improved shapes. Liposuction has historically been shunned at the same time as a tummy tuck due to blood supply concerns and the risk of creating wound healing problems and skin loss.
In my Indianapolis plastic surgery practice, I now use liposuction to help shape the upper portion of the abdomen. This is an area that often remains full after a standard tummy tuck because the fat in this area is not thinned out. With the skin pull down at the time fo skin closure, this area does get a little thinner I(as the fat is stretched out like an accordion) but often the upper abdomen pouches out more than the lower part after surgery in some patients. Liposuction, particularly laser-assisted liposuction, selectively melts fatty tissue and helps remove some of this fat without a lot of additional trauma. This enables better sculpting and definition to be achieved in the upper portion of the abdomen.
To shape the waistline better, liposuction is also carried out around the sides into the back area. If this area is not addressed as well, many patients will develop what I call the ‘muffin-top’ deformity, where the stomach area is flat but the tissue over the hips now sticks out. Performing liposuction beyond the ends of the tummy tuck incision into the back helps create a better waistline appearance, creating a near 270 degree waistline improvement.
The use of a newly developed suture known as the Quill suture for repair of the separated abdominal muscles and tying down the underside of the skin is now also used. The Quill suture is a sophisticated, bi-directional barbed suture, which adjusts its tension with each stitch. This locks tissue in place for a snug and secure closure. This type of suture material is a marked improvement over traditional sutures in terms of holding strength. This suture technique also makes it possible to not have to use drains in some tummy tucks, which is a huge relief for these patients.
Many tummy tuck patients are sometimes surprised to learn that removing the excess skin and fat on the lower abdomen is just one step or level of the procedure. In this more contemporary lipoabdominoplasty procedure, an improved abdominal appearance can be obtained due to the concomitant use of liposuction and muscle tightening.
Dr. Barry Eppley
Clarian North Medical Center,Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Tummy Tucks (Abdominoplasty) and Liposuction (Smartlipo) on Indianapolis Doc Chat Radio Show
Author: barryeppley
On this week’s Doc Chat Radio show on WXNT 1430AM in Indianapolis from 1:00 - 2:00PM on Saturday afternoon, hosted by Dr. Barry Eppley, the topics of tummy tucks (abdominoplasty and liposuction (Smartlipo) were discussed. With guest Dr. Lee Corbett, plastic surgeon from Louisville Kentucky, an open discussion on reshaping the abdomen and waistline and laser lipolysis for fat removal were reviewed over the hour. What a tummy tuck is, how it is done, what the different types are, how do they differ in men vs. women, and what recovery is involved was reviewed.
The newest version of liposuction, Smartlipo which uses laser energy to melt fat and tighten skin, was reviewed for what its advantages were, how it works, and what type of patient would best benefit by it. Its use in combination with tummy tuck surgery was highlighted.
Tummy tuck surgery, or abdominoplasty, can make a dramatic difference in the shape of one’s abdomen and waistline. In addition to removing excess skin and fat, many tummy tuck surgeries have the muscles tightened as well. What muscles and how they are tightened is a frequent point of confusion.
The muscles that a tummy tuck usually tightens are the rectus muscles. They are a large paired vertical muscles that run down the midline from the ribcage to the pubic bone. They are quite wide, often 4 to 6″ inches in diameter that provide a strong band of vertical support to the abdominal area. These muscles, like all muscles, are enveloped in a sheath of tissue known as fascia.
In women due to pregnancy and childbirth, these paired muscles that are normally joined in the midline can become separated. Technically this is known as rectus diastasis or split rectus muscles. This is not to be confused with a hernia, which is not just a separation, but an actual hole between the muscles where the bowel is poking through.A hernia is most likely to occur at the belly button or umbilicus since this is a natural area of weakness of the muscle fascia. Men rarely have rectus diastasis or umbilical hernias so they never stretch out the muscle from pregnancies.
In tummy tuck surgery, the rectus muscles can be sewn together down the middle to tighten them like a bowstring. In reality, the rectus muscles are not really sewn together but the fascia that contains them is. This is why the official name for this portion of the tummy tuck is known as rectus fascial plication. By sewing the fascia together, the muscles are securely held closer together by permanent sutures. The manipulation of these muscles is what causes most of the pain from tummy tuck surgery. No other abdominal mucles are plicated since they will produce no significant benefits in changing the shape of the abdominal wall.
Not every tummy tuck requires rectus muscle tightening. It is only done if the examination prior to surgery demonstrates that a portion of one’s abdominal bulge is due to muscle looseness or laxity. A good examination with the patient standing and laying down can demonstrate whether muscle tightening is worth the effort and discomfort.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Tummy tuck or abdominoplasty surgery still remains as one of the most dramatic and satisfying of the many body plastic surgery procedures that are available. Removing loose skin and fat, tightening the rectus muscles, and narrowing the side of the waistline with liposuction always makes for a significant change in one’s waistline. Even when done in a more limited version (mini-tummy tuck), the flattening effect is always appreciated. Despite these improvements, the one aspect of tummy tuck surgery that patients, and I, did not like was the need for postoperative wound drainage.
In the past, tummy tuck surgery (abdominoplasty) always required the use of drains after surgery. Staying in place for up to two weeks after the procedure, they were necessary to remove fluids that accumulated from the open space or layer left behind. (between the underside of the skin and the muscle)They could not be removed until enough internal healing had occurred as evidenced by a decrease in the amount of drainage that came out of the tubes. By the time this happened, many patients had a fair amount of soreness from the skin areas where the drains exited. In some cases, even though drains were used and removed when their output was low, patients still developed fluid collections weeks later that required multiple in-office drainage procedures.
As an improvement to the tummy tuck procedure and to eliminate their inconvenience and discomfort, I have adopted an innovation that makes the use of drains unnecessary in many abdominal contouring procedures. This is a technique known as ‘quilting’ or partially closing off the space in which fluids can accumulate. Using special sutures that tie-down the underside of the skin to the muscle, the typical ‘dead space’ left behind is closed down. Dead space refers to the unhealed open area or layer between the muscle and the overlying skin which is created from the way that a tummy tuck has to be done. With little space for fluids to accumulate, the need for drains after surgery can be eliminated in many cases. This does add some extra surgery time, but to any patient who has ever had drains, that extra time would be viewed as a good investment!
While not useful for every tummy tuck (really big ones still need drains), the majority of cosmetic abdominal contouring procedures can now be done without drains. Even if a fluid collection or seroma does occur, it is much smaller and needs less in-office drainage procedures later.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Tummy tuck or abdominoplasty surgery is a dramatic operation that offers an unparalleled change in your waistline shape and contour. It can be so significant that I frequently refer to it as the ‘facelift’ of the body. Like all dramatic surgical changes, there will be some equally dramatic immediate after effects that all patients should be aware of with the understanding that these are normal but temporary inconveniences.
Most importantly, most tummy tucks are significant surgery. You should plan an adequate time for recovery with particular emphasis on how long it will take to return to the type of work you do. Don’t short change yourself. I can make one assumption for most patients…..they don’t have a good idea (why would they?) as to what a tummy tuck operation is like after. Most of us are not as tough as we think. Plan accordingly!
Without question, pain is a common immediate feeling after a tummy tuck. Whether the pain is significant or surprisingly moderate is determined by whether your abdominal fascia (covering of the rectus abdominal muscles) has been tightened down the middle. This is what gives tummy tucks their pain afterwards. Not all tummy tucks are done with muscle tightening. Some can be simple skin and fat cutouts (simple abdominoplasty or panniculectomy) which do not have much discomfort at all. If your plastic surgeon is going to tighten the muscles (which you should know and discuss beforehand), then ask if there will be some type of pain relief offered after surgery such as a 24 or 48 hour pain pump. Pain does get better within a few days but the first week can be a rough one for some patients.
Tummy tucks do not usually have a much swelling and rarely any bruising. If you have a lot of bruising across the abdomen after surgery, call your plastic surgeon. This might be the development of a hematoma. (bleeding) This is of particular concern in the first day or two after surgery. Small insignificant amounts of bruising may appear later but these are not of any concern.
The skin over the stomach area will feel very numb. This numbness will persist for many months and the feeling may take up to a year to come back, particularly down close to the incision area. This occurs as the tiny skin nerves that give feeling to the skin are cut (they can’t be seen) as the upper abdominal skin is raised and stretched down to meet the lower incision. The numbness gradually gets smaller as the feeling comes in from the side, closer to the center and down near the incision. Some patients may have a small area in the center of the incision just above it which may always be numb.
Difficulty standing straight after a tummy tuck is common…if the muscles have been tightened. In those abdominal procedures where muscles are not tightened, then standing straight is not a problem. If the muscles have been tightened and you can stand straight right away…that is a good sign. That will get better by the end of the first week after surgery. This means they have been tightened enough to make a real difference.
Almost all tummy tucks require a drain after surgery. Some plastic surgeons use one drain, others use two. Either way, they will need to stay in place for 7 to 10 days until their fluid output drops considerably. They help immensely in decreasing the risk of a fluid-build-up after surgery under the skin. They are necessary evils of the procedure.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana]
Clarian West Medical Center, Avon, Indiana
Indianapolis
The Abdominal Panniculectomy vs Tummy Tuck in the Extreme Weight Loss Patient
Author: barryeppley
A panniculectomy is a very close cousin to a tummy tuck or abdominoplasty. The term pannus refers to a large apron of skin and fat that hangs over the waistline.
The abdominal panniculectomy, surgical removal of a pannus, is a somewhat historic term now as it really refers to the pre-bariatric surgery era when obese individuals had a large pannus that hung down. At that time, many abdominal panniculectomy procedures were done to relieve the medical symptoms that the pannus caused. Specifically, skin irritations and rashes (known as panniculitis) resulted from the always present moisture and heat in the underlying skin fold. In some cases, the size of the pannus and its amount of overhang actually cut off some of the blood supply and lymphatic outflow resulting in swelling and infection. Surgically removing the pannus was common then but the complication rate was high due to the patient’s obesity. Today, surgical removal of any abdominal overhang would await weight loss through bariatic surgery.
The abdominal panniculectomy refers to simply cutting off the pannus. This is different than a true tummy tuck in that the skin edges are not as undermined, no muscles are tightened, and no areas are treated by liposuction. It is simply an amputation of whatever overhangs the waistline. In the obese patient, this pannus may have considerable weight anywhere from 30 lbs or higher. (the largest I have removed was 96 lbs) In today’s bariatric patient, the pannus may weigh only from 5lbs. to 10 lbs due to the prior weight loss.
In the historic obese patient, there was a significant improvement in the patient’s quality of life as the skin and infectious symptoms that it caused were eliminated as well as the weight removal improved back and knee pain. Because of the relief of medical symptoms, the abdominal panniculectomy was often covered by insurance. Since the panniculectomy procedure in the bariatric surgery patient today weighs considerably less and often only involves improvement of an undesired contour, it is often called cosmetic by one’s health insurance. To be considered medically eligible for insurance coverage, there has to be very specific criteria that are met and a documented trail of medical records that substantiate symptoms related to the pannus. Often times even with solid medical evidence, it will be denied coverage.
Most simple abdominal panniculectomy procedures are largely done in men. Men don’t need muscle tightening and a simple skin overhang removal is often enough. Women usually require a true tummy tuck to get the abdominal contour that they desire.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
The abdominal skin excess that is created from extreme weight loss requires a different approach than that used in the traditional tummy tuck in many cases. The skin overhang is more extensive horizontally and often wraps around the hips into the back area. Often skin excess is evident in the vertical dimension as well due to the three-dimensional expansion and deflation of the abdominal ‘balloon’. The design of the tummy tuck, therefore, must take the extent the total abdominal skin excess into consideration.
As the excess skin wraps around into the back so must the cutout pattern go. Unlike the more traditional tummy tuck where the scar stops at the front part of the hips, the extended tummy tuck scar goes further back. Whether it just goes slightly beyond the hip to almost to the middle of the back will depend on how much excess skin there is. If you can grab more than an inch or two between your fingers at your sides, there is too much skin. While in the traditional cosmetic patient, liposuction of this area may suffice, the loss of elasticity of this skin from weight loss makes its excision more predictable. Liposuction depends on skin shrinking (which happens poorly in the weight loss patient), cutting it out is guaranteed to make it tighter.
The decision to extend the tummy tuck further into the back is not a hard one. Whether to manage the vertical skin excess can be more difficult. Cutting out a strip of skin vertically can help tighten the waistline and smooth out any rolls at the side of the waist. Doing so creates an ‘anchor’ or fleur-de-lis type of tummy tuck, a vertical incision running down the middle of the stomach (from the end of the breast bone) to join with the low horizontal incision. This type of tummy tuck always produces a better overall result but the question is….is it worth the extra scar? If one already has a midline scar from their bariatric surgery, this decision is an easy one. But most bariatric surgeries done today use a laparoscopic approach, so fewer people are now seen with this scar. I leave this decision up to patient. In addition to the extra scar, the risk of postoperative fluid collections is higher (more underlying dead space), an extra drain is needed, and a potential for some wound separation at the junction of the inverted T is always possible. All of these issues, if they occur, are only temporary so the real issue to consider is the permanent vertical scar. In my experience, most bariatric or extreme weight loss patients are most interested in how they look in clothes first and foremost.
When the extra skin become so extensive that it literally wraps around the waistline and extends completely across the back (with sagging of the buttocks), the tummy tuck must be combined with a back or buttock lift. In essence, a front and back operation. This is known as a body lift or circumferential body lift.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis