Background: A tummy tuck, or abdominoplasty, is one of the great plastic surgery body contouring procedures. It can do for many patients what no diet and exercise program can…get rid of loose skin and fat along the waistline. While there is always the trade-off of a scar (and a significant recovery), the results usually justify those significant trade-offs.

Like most every other plastic surgery procedure, a tummy tuck can be done multiple ways. The amount of loose skin and fat removed can be adjusted through either a more limited resection of tissues (limited or mini-tummy tuck) and a more complete or full tummy tuck. What differentiates these two variations is the amount or length of horizontal scar that is needed to complete the tissue resection. Mini-tummy tucks remove tissues below the belly button and result in a shorter horizontal scar and no scar around the belly button. A full tummy tuck includes a resection of abdominal tissues that extends to just above the belly button, ultimately resulting in a longer low horizontal scar and a scar around the new belly button.

This 32 year-old female, who is serving in the military, wanted improvement in her abdominal region. After the delivery of her twins a year ago, she has been unable to get her tummy back in any reasonable shape. She had a very large amount of abdominal muscle looseness (laxity) which accounted for a significant amount of her tummy protrusion. She also had loose skin with an extreme number of stretch marks around her belly button and throughout her entire lower abdomen.

In discussing her tummy tuck options, she was what I call in my Indianapolis plastic surgery practice a ‘tweaner’. This means she could have either a smaller or a larger procedure, in this case being either a mini- vs. a full tummy tuck. She had enough loose skin and stretch marks to justify a full tummy tuck to get all of them out. But by doing so, she would have a scar that went past her hips. With a mini-tummy tuck, her scar would be less but a significant portion of her stretch marks would remain. With her tummy tuck option, her abdominal muscles would be sutured back together. Which one is best for her? As you can see, her approach will make a big improvement but each one has trade-offs.

Because she did not want a longer scar, she was willing to accept  much of stretch marks to remain. She opted for the mini-tummy tuck which included liposuction through the entire abdomen and into the flank (back) areas. She had a drain for a week and wore a binder for two weeks. She returned to her service duties in three weeks and exercise four weeks after surgery.

Case Highlights:

1)      The decision between the two tummy tuck options in the ‘tweaner patient’ is a

   balance between much scar one can tolerate  vs the amount of improvement that

   one expects.

2)      Scars are always a consideration in a tummy tuck procedure. Once they are

      placed, there is no way to remove them. A long tummy tuck scar is not a

      choice if it would bother someone as much as the original abdominal problem.

3)      While the scar may be different between a mini- vs. a full tummy tuck, the

      recovery is not much different. The concern about recovery should be the least

      consideration when making a decision between the tummy tuck options.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

Without question, the number one concern of bariatric surgery patients after their weight loss is abdominal reshaping. When the weight loss is in the neighborhood of 75 to 100 lbs., the abdominal skin does not redrape or shrink back down. Rather, a large amount of redundant skin results which both hangs and has multiple rolls.

The traditional tummy tuck or abdominoplasty is almost always inadequate to create the best abdominal result in the massive weight loss patient. This is because the excess skin exists in a true three-dimensional fashion, being excessive in both horizontal and vertical dimensions. As a result, I almost always use the combined vertical and horizontal tummy tuck procedure known as the fleur-de-lis abdominoplasty in my Indianapolis plastic surgery practice for bariatric patients. This results in abdominal scars that have a midline vertical and a low horizontal line, known as the anchor scar pattern. Adding the vertical part to the traditional tummy tuck does require more surgery time for dissection and closure, but most relevantly increases the amount of deep space underneath the skin after closure.

In theory, the fleur-de-lis abdominoplasty should be associated with more complications than a traditional abdominoplasty. It takes longer to do and has incisions that meet at an inverted-T area. It also removes a very large segment of skin which leaves more dead space uinderneath. To investigate if this seemingly truth is reality, the May 2010 issue of Plastic and Reconstructive Surgery published a study conducted by the University of Pittsburgh Division of Plastic Surgery on this very question. Over 400 abdominoplasty patient were evaluated of whom 154 (31%) had a fleur-de-lis abdominoplasty operation. The overall abdominal complication rate was 26%. This included all types of complications of which 5% would be considered major. (requiring further surgery) Traditional horizontal excision abdominoplasties and fleur-de-lis abdominoplasties were very similar in complication rates with the exception of a higher rate of wound infections in the more extensive abdominoplasty.

My Indianapolis plastic surgery experience is slightly different than that reported in this very extensive and thorough study. I have seen no greater incidence of wound infection between the two types but have certainly seen more wound openings/separations at the inverted-T area. A traditional abdominoplasty does not have this zone and, as a result, significant wound openings are very uncommon. The dead space in the fleur-de-lis abdominoplasty is managed with an extra drain and I am more conservative about their removal, keeping at least one in place for two weeks after surgery.

The fleur-de-lis creates a better abdominal result in the bariatric patient if they feel that the trade-off of a vertical scar is worth an improved upper abdominal area. In days gone by with open gastric bypass surgery, a vertical scar already was present so the decision for the fleur-de-lis was easy. With laparoscopic gastric bypass today, the patient must consider a new obvious vertical scar.

Another consideration for bariatric patients considering the fleur-de-lis abdominoplasty is insurance coverage. If one’s health insurance will provide an abdominoplasty coverage, that does not include the vertical component of the fleur-de-lis. The insurance company covers the horizontal abdominal excision only. There will be an extra out-of-pocket charge for adding the vertical component to the procedure.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

Abdominoplasty or tummy tuck is one of the top five cosmetic procedures for women but is performed much less frequently in men. Because men do not get pregnant, their abdominal skin does not suffer as much loss of elasticity and can ‘snap’ back better after weight loss. Men are also less tolerant of a low abdominal scar than women who may already have had a c-section.

Even though it is far less than women,  more men are considering or undergoing tummy tuck surgery than ever before. Some of this is fueled by the large increase in bariatric surgeries which has equal distributions between men and women. Another mitigating factor is that men are increasingly concerned about their appearance and are willing to go to greater lengths to get the best body shape as possible.

There are some significant differences between a male and a female tummy tuck that affects recovery from the procedure. Most importantly, muscle plication is rarely done or needed. In my Indianapolis plastic surgery practice, I have never done muscle tightening in a man. Men do not suffer from rectus diastasis, again due to never being pregnant. As a result, there is no cosmetic or functional advantage to sewing the rectus muscles tighter.

Because the rectus muscles don’t need tightening, undermining of an abdominal skin flap to do so is not needed. This enables just the overhanging loose skin and fat to be removed in a direct cut out fashion. The need for prolonged use of drains is reduced because there is less undermined skin space.

The avoidance of muscle manipulation also impacts one very important aspect of recovery…a significant reduction in pain after surgery. Sewing muscle is the single main contributor to postoperative tummy tuck pain and the restriction in standing up straight right afterwards. The removal of skin and fat causes surprisingly little pain for most people. At best it gives some incisional discomfort but not severe or restrictive pain.

The length of the incision line in men is determined by how much loose skin exists and how far back it goes from the hips…if it does at all. Unlike women, most male tummy tucks require skin and fat removal at least between the front edge of the hips. (anterior superior iliac crests) Most men wouldn’t undergo a tummy tuck if the amount of skin removal would be less than that amount. In some cases, the skin removed may go into the back area of significant weight loss has occurred.

Men should not fear a tummy tuck because of how they perceive it to be done in women. The male tummy tuck is simpler to do and less involved. The lack of a  need to tighten the abdominal muscles makes for less pain after surgery and a reduced need for prolonged drain use.    

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Liposuction and abdominoplasty are two of the most popular plastic surgery procedures. While commonly used to treat different body areas, they can be combined to improve one’s abdominal contour and shape. When done together and weaved into a single procedure, it is known as lipoabdominoplasty or liposuction abdominoplasty.

A traditional abdominoplasty or tummy tuck involves removing lower abdominal skin and fat and undermining the skin up to the lower margins of the ribs. After sewing the rectus muscles together, the remaining upper abdominal skin flap is brought down and closed under tension. By undermining this skin and placing it under such tension, a flatter abdomen is obtained but  this skin flap has less blood circulating through it. This accounts for why some small percentage of tummy tucks suffer skin death (necrosis) at the center part of the incision line underneath the new belly button. It is also why drains are almost always used afterwards, to remove fluid that accumulates in this wide open space.

In contrast, liposuction abdominoplasty does not undermine this upper skin flap to any degree and relies on the use of the liposuction cannula as the dissection tool. This saves more blood vessels to the skin than undermining with cautery while disrupting ligaments that helps the skin move downward. The skin ligaments are released by a combination of initial liposuction followed by blunt dissection with scissors and/or fingers. Because large undermined skin flaps are not created, the use of drains after surgery is often not needed.

The question is…is lipoabdominoplasty a  replacement over a traditional tummy tuck or is it more of an option for properly selected patients. Some tout it as a better tummy tuck although it is yet not widely adopted by the majority of plastic surgeons. Currently, I am using it in my Indianapolis plastic surgery practice as the latter. In some patients with tight and thin supraumbilical tissues, liposuction and blunt dissection alone is not enough to get the skin flap to adequately move downward. It does require some loose skin above the umbilicus to execute a lipoabdominoplasty.

This lipoabdominoplasty operation, however, is ideal for smokers. Smoking is well known to cause blood supply problems to stretched skin under tension. This concern is significant enough that some plastic surgeons will not do a tummy tuck in someone who smokes or has smoked recently. Because it preserves more blood supply to the skin, this operation makes the tummy tuck less risky for healing problems.

In the right patient, liposuction abdominoplasty produces similar results to conventional techniques with improved safety and a faster recovery. It is not a passing fad or a procedure of theoretical benefit but an improvement proffered by an amalgamation of two well-established plastic surgery treatment methods.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

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

http://www.ologyspa.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

http://www.ologyspa.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.

http://www.ologyspa.com

Clarian North Medical Center,Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

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

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis