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Archive for the ‘abdominoplasty’ Category

Case Study – Chronic Abdominal Seroma after Tummy Tuck

Saturday, February 11th, 2017

 

Background:  A tummy tuck is a remarkably effective procedure that achieves its effect through wide excision of loose abdominal skin and fat and underlying muscle tightening. The raising of the upper abdominal skin flap to cover the removed lower abdominal tissue creates a large surface area of wounded tissue. This results in an expected serous fluid leak from these injured wound edges after surgery. This has been the historic reason that drains are placed during tummy tuck surgery and maintained for variable periods of time in the early healing period.

While there has been a recent trend towards the concept of the drainless tummy tuck, which strives to slow down or eliminate abdominal seromas through the use of quilting sutures, the risk of a subsequent fluid collection is not zero. Drained and drainless tummy tucks both have abdominal seroma risks.

The typical and usually very effective treatment for a seroma is needle aspirations and time. Once the internal tissues heal more the fluid leak usually ceases. In some cases a drain may be placed if the needle aspiration volumes are persistently high. But in very rare cases fluid colletion persist for a very long time or seemingly redevelop in an abdominal area with a prior history of a fluid collection.

Chronic Abdominal SeromaCase Study: This 50 year-old female had a history of having a tummy tuck nearly two years previously with the prolonged use of a drain. (8 weeks after surgery) Thereafter, she had a persistent area of firmness between the belly button and the lower abdominal scar line but it remained flat for a long time. Then six months ago (1 1/2 years after the surgery) the area mysteriously began to enlarge. She underwent radiofrequency treatments by her initial surgeon but it did not help and the area kept getting bigger.

Mini Tummy Tuck Sero0ma Surgery design Dr Barry Eppley IndianapolisChronic Abdominal Seroma Surgery Dr Barry Eppley IndianapolisUnder general anesthesia, a skin excision pattern was marked out for removal of excess skin that have been created from the expanding abdominal mass. The original tummy tuck scar was opened and dissection was carried down until a dark mass was encountered. This was an obvious encapsulated mass which expressed a large amount of dark fluid when it was entered. The cavity opened revealing a very thick encapsulated  lining on the abdominal fascia and into the overlying subcutaneous fat. The entire capsule  was removed, quilting sutures used and a small drain placed. The excess skin was removed, in the form of a mini-tummy tuck, and the outer abdomen thus re-tightened.

A delayed chronic seroma after a tummy tuck is very rare. This is only the second one that I have ever seen. They both have been associated with an early persistent fluid collection that either required prolonged use of a drain or the need for frequent needle aspirations. A firm abdominal mass that persisted thereafter for a long time as a bulge would represent an original undrained seroma. But this case represents an area that was flat (albeit firm) and then started to grow long after surgery. The exact mechanism for this phenomeon is not clear but its treatment would be the same for a chronic seroma that persisted much earlier after surgery.

Highlights:

1) The most common ‘complication’ after tummy tuck surgery is  seroma or fluid collection.

2) Most abdominal seromas are solved through healing time, needle aspirations and, ocasionally, the use of drain.

3) A chronic seroma is a very rare late tummy tuck complication that appears months to years later as a firm abdominal bulge that must be treated by open excision.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Weight Loss Tummy Tuck

Tuesday, February 7th, 2017

 

Background: Weight loss creates a lot of external body changes that is usually most manifest in the trunk region. In the anterior abdominal region the deflated skin hangs often hangs over the waistline tethered by the belly button attachment. How mucb skin overhangs the waistline depends on how much weight loss one undergoes and what one looked like before the weight loss.

The tummy tuck is the standard treatment in the weight loss abdomen. Depending upon how much skin needs to removed the length of the horizontal can range from hip to hip or can extend completely around the waistline in a circumferential manner. When the extent of the tummy tuck matches the magnitude of the loose skin present, the abdominal contour change can be dramatic.

Case Study: This 23 year-old Hispanic female lost 60 lbs through diet and exercise over a one year period. (185lbs down to 125lbs) This left her with a central mound  of loose skin that was mainly restricted to the anterior abdomen.

MO Tummy Tuck result front viewUnder general anesthesia, a full tummy tuck as performed through a wide horizontal excision of skin with umbilical transposition. It was not necessary to extend the tummy tuck incision further back into the flanks areas.

MO Tummy Tuck result oblique viewMO Tummy Tuck result side viewAt one year after her surgery, her abdomen was reasonably flat. Her tummy tuck scar healed beautifully, being barely detectable even in her darker skin. She still had a fair amount of stretch marks but these were expected since they were outside the zone of the skin excision pattern.

Many weight loss tummy tucks produce good scars. The the skin closure, even though it is under tension,  heals favorably because of the loss of skin elasticity from the weight gain/loss on the dermal architecture of the skin.

Highlights:

1) Large amounts of weight loss causes unsightly loose skin on the abdomen.

2) A full tummy tuck removes much of the loose abdominal skin but can not remove all the stretch marks.

3) The stretched out abdominal skin heals well and creates a good tummy tuck scar.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – The Abdominal Panniculectomy (Apron Removal)

Tuesday, January 3rd, 2017

 

The abdominal panniculectomy procedure is well known to be a ‘big’ operation. It is the supersized version of the traditional tummy tuck and is often judged by the weight of the pannus removed. The largest abdominal pannus I have ever removed is 85lbs and that was back in the pre-bariatric surgery era…when the abdominal panniculecomy was the only form of bariatric or weight loss surgery.

abdominal-panniculectomy-surgery-dr-barry-eppley-indianapolisOne of the challenges in this operation is to manage the considerable soft tissue mass, removing the most abdominal tissue that one can while still being able to close the wound without creating after surgery healing problems. When removed the abdominal pannus looks even bigger than when it is attached and hanging on the patient. The term ‘pannus’ is often associated with the word ‘apron’. It is easy to see why it might have that name as seen in this intraoperative picture where it could be worn like an apron once removed.

Beyond the light-hearted clothing analogy, the abdominal panniculectomy produces a dramatic improvement for the patient in many ways. It eliminates chronic skin infections and sores that develop underneath it and removes stressful weight from the back and knees that have to support and carry it around. It also allows the patient better clothing options, often allowing them to find outfits that fit better.

The abdominal panniculectomy is often thought of as a tummy tuck…and it is. But it is an operation that is much bigger in magnitude than most traditional tummy tucks as can be seen by the type of patient on which it is performed. White it is associated with a relatively significant rate of complications, like fluid collections and wound healing issues, these are often self-resolving issues and do not ultimately detract from the huge benefit that patients receive as a result from undergoing the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Clinic Snapshots – Good Riddance Abdominal Panniculectomy

Thursday, December 29th, 2016

Cosmetic surgery of the abdomen and waistline is one the most common body contouring surgeries for either women or men. Women in particular are inclined to undergo these surgeries as they are victims of a lot of body changes from pregnancy and/or weight gain/loss. Liposuction and tummy tucks make up the bulk of these surgeries as they fall into the norm of the type of body changes that need to be treated.

But amongst tummy tuck surgeries there is a ‘supersize’ version due to the magnitude of the tissues that need to be removed. This enlarged version of a tummy tuck is known as an abdominal panniculectomy. The abdominal panniculectomy differs from all forms of a  tummy tuck as it removes a large segment of overhanging tissues known as a panniculus. Also known as an abdominal apron, this is a large amount of abdominal tissue that overhangs the waistline down on the thighs. In large abdominal pannuses it can even hang down as low as the knees!

abdominal-panniculectomy-indianapolis-dr-barry-eppleyThe abdominal pannus and its weight causes a constellation of problems for the person from chronic skin infections and moisture underneath it to the strain of its weight on the back and knees. This is not to mention the limitations imposed on clothing options to hold it in or try and hide it. It is no surprise then that when the day comes for their abdominal panniculectomy surgery there are no regrets in losing a bit of oneself!

While an abdominal panniculectomy may not be as eloquent as an operation as many smaller tummy tucks, patients are usually even more grateful.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Abdominal Panniculectomy

Tuesday, November 15th, 2016

 

The surgical procedure ‘abdominal panniculectomy’ is the bigger cousin to the more common tummy tuck or abdominoplasty procedure. What differentiates it is the size of the abdomen and the amount of tissue removed which is often substantially larger than the typical cosmetic abdominoplasty.

The abdominal panniculectomy procedure is a removal of excess waistline tissue. While often call an abdominal pannus, this is really an inaccurate term. The proper term is a panniculus. Medically, a pannus is an abnormal later of fibrovascular or granulation tissue and is commonly referenced to eye conditions of the cornea. A panniculus describes a collection of excess subcutaneous fat in the lower abdomen that hangs over the waistline like an apron. It almost always occur from pregnancy or a lot of weight loss.

abdominal-panniculectomy-dr-barry-eppley-indianapolisCutting off this apron of abdominal tissue often produces large segments of tissue as specimens. They often can be impressive and far exceed what is removed in a more ‘simple’ tummy tuck. While an abdominal panniculectomy creates tremendous improvement in a patient’s medical symptoms (skin infections, comfort, fitting of clothes), the waistline reduction result is never quite as good as many less extensive tummy tucks. But then the original abdominal problem is also much bigger.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Vertical Tummy Tuck

Wednesday, July 6th, 2016

 

Background: Tummy tuck surgery is the most aggressive form of abdominal reshaping. By removing large segments of skin and fat, improvement of the waistline shape is inevitable. The horizontal excision pattern ensures that there is a vertical tightening effect on the central abdomen. Differing lengths of the excision pattern will determine how far to the sides of the waistline this effect will occur.

The history of midline abdominal incisions from either intra-abdominal surgery or c-sections is waning. Laparoscopic surgery has replaced most midline incisions for open intra-abdominal access and most c-sections today are done with a low horizontal incision.

But occasionally a vertical midline abdominal scar is seen. The most common reason it exists today is because the patient either had abdominal surgery as an infant or child or an emergency c-section was done. Such a scar can end up as a midline depression either due to scar contracture or because fat has accumulated around it with weight gain. The combination of a depressed midline scar and thicker sidewalls due to fat thickness creates the impression of a ‘buttocks’ appearance on the stomach

Case Study: This 50 year-old female had a history of multiple intra-abdominal surgeries as an adult through a midline vertical incision from above the umbilicus down to the pubis.  Her vertical scar was stuck down to the abdominal wall and the umbilicus was distorted. Even though she was not overweight, the combination of more normal fat thickness on her abdomen with an indented scar created the frontal buttocks appearance.

Vertical Tummy Tuck markings Dr Barry Eppley IndianapolisUnder general anesthesia she had power-assisted liposuction (PAL) performed on her full abdomen and love handle areas. removing a total of nearly 800cc of aspirate. A vertical excision of skin and fat was done down to the abdominal wall. The umbilicus was reconstructed to a midline location within the closure with a more normal shape.

Vertical Tummy Tuck result Dr Barry Eppley IndianapolisHer three months after surgery results show significant improvement in the shape of her lower abdomen and the elimination of the buttocks appearance. Her scars were slightly hypertrophic which may settle down as they mature over the next year.

The role of the vertical tummy tuck is usually limited to treating pre-existing proboematic abdominal scars. Eve when scars exist between the umbilicus and the pubis, they would be excised with a more traditional horizontal tummy tuck provided there is enough tissue laxity to do so. In this patient’s case her thinner frame and tighter skin precluded the horizontal tummy tuck option.

Highlights:

1) A vertical tummy tuck is a very uncommon abdominal reshaping procedure.

2) It is most commonly used when a pre-existing depressed midline abdominal scar is present with an associated umbilical deformity.

3) A vertically-oriented tummy tuck  allows for simultaneous liposuction, muscle tightening and an umbilicoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Large Abdominal Panniculectomy

Monday, May 23rd, 2016

 

Background: The abdominal pannus is a well known medical condition of a large overhanging apron of skin and fat that extends well beyond the waistline. Technically the proper term is a panniculus but it is far more commonly referred to as a pannus. What defines a pannus is how large the actual overhang is.

There are five degrees of an abdominal pannus from a grade 1 that rests on the mons pubis to a grade 5 that hangs down to the knees. While no abdominal pannus is pleasant for the patient the grade 5 pannus is the most disabling. It not only obstructs the urinary stream and causes associated hygiene issues but its sheer weight makes mobility difficult. It causes tremendous strain on the back and knees and leads to early deterioration of both.

An abdominal panniculectomy procedure should not be confused with a more traditional tummy tuck. The scope of the problem being treated would indicate such but how the operation is performed and under what circumstance is also vastly different. This is no more manifest than in the massive type 5 abdominal panniculectomy operation.

Case Study: This 40 year-old male reached out from Canada because he could not find a surgeon to perform his abdominal panniculectomy procedure.  He had a prior gastric bypass which dropped his weight from over 500 lbs down to 325lbs.  This resulted in the creation of a massive type 5 pannus. Surprisingly he had no otherwise medical problems. Because of chronic skin infections and urinary obstruction he had been to the hospital numerous times. But despite his obvious need for a surgical solution, he stated that no one would take on his case because it was too dangerous or difficult.

Large Abdominal Panniculectomy flaps intraop Dr Barry Eppley IndianapolisLarge Abdominal Panniculectomy tissue removals initraop Dr Barry Eppley IndianapolisUnder general anesthesia a large portion of his abdominal pannus was removed in two sections.  Its total weight was 40 lbs.  It was determined before surgery not to reconstruct his umbilicus. The long umbilical stalk and the umbilical hernia created by its removal were repaired. Closure was done over a large single drain.

Large Abdominal Panniculectomy result intraop Dr Barry Eppley IndianapolisLarge Abdominal Panniculectomy result intraop right oblique view Dr Barry Eppley IndianapolisLarge Abdominal Panniculectomy intraop result left oblique view Dr Barry Eppley IndianapolisHe stayed overnight in the facility and was released to a hotel the morning after. He remained in town for one week for monitoring and flew back to Canada thereafter. His drain will be removed at home after two weeks.

Large abdominal panniculectomies are challenging for a variety of reasons. Their sheer size makes intraoperative positioning and maneuvering difficult. There are many large blood vessels that supply the abdominal pannus and intra- as well as postoperative bleeding is always a risk. The operation needs to be performed as expeditiously as possible to get the patient off the operating room table as soon as possible. When performing the operation as just an overnight stay, the patient must have few other medical problems and be motivated to get up and moving as soon as possible after surgery. Drains are always needed and should stay in at least several weeks. For the out of town patient this means that they will have to get some medical care at home to get it removed.

Highlights:

1) Large abdominal panniculectomies can be safely done in an outpatient surgery center if the patient is otherwise healthy.

2) Enough abdominal pannus is removed to relief the obstruction on the pubic area and eliminate any overhang on the groin creases.

3) The most likely complication from any abdominal panniculectomy is a seroma or fluid collection.

Dr. Barry Eppley

Indianapolis, Indiana

The Body Lift or Extended Tummy Tuck

Thursday, February 11th, 2016

 

A tummy tuck is a well recognized body contouring operation because it has been around for many years. It is generally perceived as a hip to hip excisional and tightening abdominal operation as it only affects the front side of the torso. The term ‘body lift’ however is less well defined in the eye of the patient and can be open to interpretation.

It is recognized that a body lift is more than just a tummy tuck but how much more can be debated. It is an operation that is closely associated with managing the abundant loose and hanging tissues in the extreme weight loss patient, whether the weight loss was surgically induced or not. In this context, a body lift is a circumferential or 360 degree operation removing tissues completely around the waistline.

Body Lift Dr Barry Eppley IndianapolisBut a modification of the body lift can be used in non-weight loss patients. Rather than going completely around the waistline or 360 degrees, the excision extends about halfway between the spine and the side of the waist. (270 or 300 degrees) This captures more loose skin that might otherwise not be adequately addressed by liposuction. This extended skin excision is best done in patients with poor quality skin with little contractile ability around into the back, when a large skin rolls extends into the back and/or when sagging skin exists over the outer thighs.

In the February 2016 issue of the journal Plastic and Reconstructive Surgery, an article was printed entitled the ‘Cosmetic Body Lift’. In this paper the author reviewed 72 patients over a ten year period who had a body lift defined as a  270 degree extended lipoabdominoplasty. (tummy tuck) The amount of liposuction aspirate removed was just over 3,000cc. Complications included a near 3% incidence of seroma (drains were used),  a 4% infection occurrence, and skin necrosis in 4%.  No hematomas occurred. One patient developed a deep vein thrombosis. (DVT) Secondary revisions were done in 18%

Extended Tummy Tuck of Body Lift Indianapolis Dr Barry EppleyThis series demonstrates that the body lift procedure in non-weight loss patients can be done safely and with a similar low rate of complications as that of standard tummy tuck. The critical question for most patients who may benefit from having this ‘bigger’ tummy tuck is whether the extra scar length is perceived as a good trade-off.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Extended Tummy Tuck

Friday, January 22nd, 2016

 

Background: The well known tummy tuck or abdominoplasty procedure is most commonly used in women who have had abdominal shape changes due to pregnancy or some moderate weight loss. But since the era of bariatric surgery, large amounts of weight loss have created skin excesses who require modified forms of tummy tuck surgery.

Since the skin rolls often extend around the hips in extreme weight loss patients, a tummy tuck must go beyond its normal parameters to adequately remove it. Such an extended tummy tuck design can have an extension anywhere from the back of the hips to the whole way around the back. (known as a belt lipectomy or a circumferential tummy tuck) While these type of tummy tucks are extensive, the severe weight loss has made the tissues relatively thin and straightforward to manipulate.

More moderate weight loss patients (35 to 50 lbs for example) generate abdominal skin rolls but they are often thicker. Manipulating these thicker abdominal and back tissues is more difficult because the tissues are ‘stiffer’ and slightly hard to move. Liposuction is usually used concurrently with the tummy tuck to help thin the tissues and help create a better overall result.

Case Study: This 44 year-old female wanted to get rid of her abdominal overhang and narrow her waistline around into her back. She had lost about 50 lbs on her own with diet and exercise. She was now at a weight which she felt was comfortable and able to be maintained.

Realistic Extended Tummy Tuck result front view Dr Barry EppleyUnder general anesthesia, she had a large extended tummy tuck done exclusively from the supine position. Liposuction was performed in the pubic region as well as the flanks into the back and the upper abdomen, removing 2.2 liters of aspirate.

Realistic Tummy Tuck result oblique view Dr Barry Eppley IndianapolisRealistic Extended Tummy Tuck result side view Dr Barry Eppley IndianapolisHer postoperative results at one year after surgery show a dramatic change in the shape of her stomach and her waistline. While her stomach was not flat, it was not predicted to be so before surgery. Her thicker abdominal tissues, which could only be modestly treated by liposuction due to safety concerns, as bound to leave her with an abdominal convexity above the the most narrow portion of her stomach at the waistline where her scar was located.

Moderate weight loss patients with thick skin rolls pose challenges in tummy tuck surgery that bariatric or more extreme weight loss patients do not. These thicker skin rolls require more extended incisions. Liposuction will have a impact on the size of the sin rolls and the wasitline shape but a secondary lipsuction surgery may still be needed to maximize the reduction in the subcutaneous fat layer. This is why, when possible, that patients should maximize their weight loss before undergoing tummy tuck when possible.

Highlights:

  1. A conventional tummy tuck is often not enough to adequately improve abdominal rolls that extend around the waistline.
  2. An extended tummy tuck is usually needed in women that have lost some weight but still remain with significant fat layers and skin rolls.

3. A extended tummy tuck removes skin and fat around the hip area into the back.

Dr. Barry Eppley

Indianapolis, Indiana

Tummy tuck with Abdominal Liposuction

Sunday, May 31st, 2015

 

A tummy tuck is a major abdominal operation that usually removes a large horizontal ellipse of lower abdominal skin and fat. While tremendously effective, many patients having the procedure have excess fat beyond the zone of the tummy tuck excision whose reduction would improve the overall abdominal contouring result. While liposuction of the flanks is commonly done with a tummy tuck, liposuction of the abdominal area above the cut out has been frowned upon because of concerns of impairing healing of the tummy tuck excision.

Tummy Tuck without Abdominal Liposuction Dr Barry Eppley IndianapolisAvoidance of any upper abdominal liposuction at the time of a tummy tuck is certainly the safest approach as there is no chance of vascular compromise by not doing so. But this can leave an upper abdominal fullness that protrudes out beyond the more inwardly located tummy tuck scar the entire lower abdominal area. Many patients interpret this postoperative finding as swelling only to discover it never goes away. This is due to a simple anatomic fact the thickness of the upper abdominal fat largely remains the same while the lower abdominal contour is better because a large segment of tissue has been removed.

In the May 2015 issue of the journal Plastic and Reconstructive Surgery, an article appeared in print entitled ‘Safely Combining Abdominoplasty with Aggressive Abdominal Liposuction Based on Perforator Vessels: Technique and a Review of 300 Cases’.  A retrospective review of 300 consecutive patients who had a tummy tuck combined with liposuction. The tummy tuck was performed saving several perforators from the deep superior epigastric artery.  The abdominal liposuction was fairly aggressive removing an average of 660cc. Their overall complication rate was 17% (52 patients) of which the vast majority of the patients suffered minor complications (the need for scar revision, seroma evacuations, and non-surgical treatment of incisional dehiscences being the most common) and 1% encountered major complications. (non-fatal pulmonary embolus, severe infection and need for blood transfusion)

Tummy Tuck with Abdominal Liposuction Dr Barry Eppley IndianapolisCombining extensive liposuction with a tummy tuck has been a somewhat controversial combination since the early 2000s. What has changed since then is a better appreciation of the blood supply to the abdomen. This study uses a tummy tuck technique that preserves perforator vessels to the central abdominal  skin flap. This then permits the central abdominal area to safely undergo liposuction with impairing perfusion to the central abdominal skin above the incision line.

In the standard lipoabdominoplasty technique the liposuction is performed first followed by the tummy tuck. The liposuction loosens up enough of the upper abdominal tissues that extensive abdominal flap undermining is not needed and all perforators are preserved. This tummy tuck technique performs the liposuction after the tummy tuck. The difference is that some upper abdominal flap undermining is done and the perforators are deliberately seen and preserved.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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