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Archive for the ‘tummy tuck’ Category

Case Study – Full Tummy Tuck and Flank Liposuction Before Weight Loss

Sunday, July 23rd, 2017

 

Background: The tummy tuck is one of the most commonly performed procedures in body contouring surgery. It is used in a wide range of body types that have developed excessive abdominal skin and fat. As a result the procedure can be modified in many ways to suit the patient’s tissue removal needs. How long the tummy tuck incision needs to be and whether liposuction is performed as part of the same procedure are always the two main considerations.\

Another important consideration is what should the patient’s weight be at the time of the procedure. Many patients seek a tummy tuck that are more than their ideal body weight. They may want to lose weight before having surgery and may even have a target weight in mind. Others say they can not lose any more weight and need the surgery to get them ‘jumpstarted’ on their weight loss.

While a tummy tuck and/or liposuction should never be thought of as a weight loss procedure, it obviously will cause some amount of weight loss afterwards due to tissue removal and the catabolic effects of the surgical trauma. It is a good general rule that patients should be within 10 to 15 lbs of their goal weight before having body contouring surgery to get the best resuilts.

Case Study: This 28 year-old female had always been overweight but became more so having several children. Despite her best efforts she was unable to get close to her ideal body weight and had the body type that was never going to get close anyway.

Under general anesthesia, she underwent a full tummy tuck with umbilical transposition. Liposuction was done on the upper abdomen and out into the flanks removing 1,800ccs of aspirate. Her six week after results showed major improvement with the elimination of any tissue overhang and the noticeable improvement in her waistline. Her scars remained red as expected at this early point after surgery and will take another six months to maximally fade.

While tummy tucks should ideally be performed when someone is close to their ideal body weight or weight loss goal, this is not always possible. Some people just don’t have the body type attain an ideal weight and others can not always make the commitment needed to do it even if it were possible. While the result may not always be as good than if the patient’s weight was lower, noticeable improvements will be seen. The favorable change may provide some additional incentive for the patient to see how much better they can now due on their own.

Highlights:

  1. A tummy tuck can be performed in anyone that has excessive abdominal skin and fat. But the lower one’s weight at the time of the surgery the better the result will be.
  2. Most full tummy tucks in larger abdomens will require liposuction into the flanks along the sides for better contouring.
  3. The maturation of tummy tuck scars can take up to six months or longer.

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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 – Tummy Tuck in Severely Damaged Abdomen

Sunday, May 1st, 2016

 

Background: Tummy tuck surgery is one of the most common of all body contouring procedures and can create some dramatic waistline changes. The operation is designed to reverse some of the tissue expanding effects caused by pregnancies and/or weight loss. While it can be tremendously effective at this purpose, its main effects are largely limited to the area of tissue excision. What lies beyond this zone is less significantly changed as it is pulled closer to the location of the suture line.

While the severe stretching effects of pregnancy affect women’s abdominal areas differently, some women develop a tremendous amount of stretch marks and loose skin. Large amounts of weight gain, small body frames and thin skin all lends themselves to the development of such abdominal skin damage. In these cases stretch mark radiate outward from the belly button like the rays of the sun. The redundant skin can be so significant that the loose and thinned out tissues can be stretched and pulled out like a piece of taffy.

Case Study: This very petite 36 year-old Hispanic female had two children that left here with a ‘wrecked’ abdominal area. She was very thin and had little subcutaneous fat but the loose skin on her abdomen was considerable. She had stretch marks from the pubic region all the way up to just below her lower ribcage.

MR Tummyb Tuck result front viewUnder general anesthesia,  a full tummy tuck was performed from hip to hip removing a large abdominal skin segment that measured 18 inches in the midline. The skin was so loose that no skin undermining was needed of the upper abdominal skin flap other than to free up the tissues around the umbilicus. With such little tissue undermining, no drains were used due to the small dead space at closure. She was so thin than no liposuction was needed around the perimeter of the tummy tuck zone to reduce tissue fullness.

MR Tummy Tuck result oblique viewMR Tummy Tuck result side viewWith extensive abdominal tissue damage as exemplified by a large number of stretch marks, only those stretch marks within the outline of the excised tissues will be removed. Stretch marks will remain with many mid- to upper abdominal marks being pulled down lower closer to the incision line.

Highlights:

1) The extent of tummy tuck surgery due to stretched out abdominal tissues depends on how large the zone of damaged tissues emanates out from the belly button area.

2) Large amounts of loose and damaged abdominal skin can often be removed during tummy tuck surgery with limited tissue undermining.

3) The quality of a tummy tuck result is influenced by the scar’s location, amount of pubic hairline distortion, appearance of the new umbilicus and whether dog ears are present at either end of the horizontal scar.

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 – Mini Tummy Tuck with Liposuction

Tuesday, January 26th, 2016

 

Background: Pregnancy affects most women adversely from an abdominal standpoint. The expansion and stretching of the abdominal skin is most severely seen in its central aspect around the umbilicus. The peri-umbilical region is well known to develop radiating stretch marks, loose skin and be a reservoir for refractory fat collections.

For most women the amount of peri-umbilical deformity requires a full tummy tuck to adequately resolve. But for some women the amount of skin excess in the lower abdomen does not justify the long lower abdominal scar. Conversely, liposuction alone will make the area less full but will leave an irregular contour due to the skin excess. Skin with stretch marks has a dubious ability to shrink down smoothly after underlying fat removal.

For those women with an intermediate peri-umbilical abdominal problem, a strategy that combines both fat and skin removal makes the most sense. Aggressive liposuction can be supplemented by skin removal and tightening to lessen the risk of skin irregularities. A limited or mini tummy tuck an keep the lower abdominal incision very low with less scar length while creating the needed abdominal skin tightening.

Case Study: This 44 year-old female had a very large but discrete fat collection around her belly button. Given her body size and type, the amount of peri-umbilical tissue excess was disproportionate. She has reached her potential for what she could change by weight loss and exercise.

Mini Tummy Tuck with liposuction result front viewUnder general anesthesia, full abdominal and flank liposuction was initially performed. A total of 3.5 liters of liposuction aspirate was surprisingly obtained. This was not expected given her body size. A low mini tummy tuck was then performed with release of the umbilicus and allowing it to float downward and then reattached from the inside.

Mini Tummy Tuck with liposuction result obloique viewMini Tummy Tuck withu liposuction  result side viewHer six month results showed a completely flat abdomen with a much improved waistline shape. Her mini tummy tuck scar was low enough that it was situated below her underwear line.

For women that do not have enough excess tissues to warrant a full tummy tuck, combining overall liposuction with a smaller tummy tuck can be a good alternative. Some plastic surgeons feel that there is no good role for a mimi tummy tuck procedure as it does not produce enough of a result. While this may be true for many women who seek abdominal improvement, it clearly is not the case for all as this patient’s result demonstrates.

Highlights:

  1. Central abdominal peri-umbilical tissues distortions are common for many women after pregnancies.
  2. With loose stretched periumbilical skin, liposuction alone will produce an inadequate result.

3. Combining liposuction with slower skin removal and repositioning (mini tummy tuck) produces the best result in profound cases of peri-umbilical lipodystrophy.

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

Case Study – Male Tummy Tuck after Weight Loss

Sunday, December 27th, 2015

 

Background: Large amounts of weight loss has created a need for some patients to pursue secondary body contouring procedures. While the initial weight loss, whether achieved by surgery or on their own, may have been initially satisfying the goals of even improved results drives some to go even further.

There is a unique subset of extreme weight loss patients that ‘graduates’ on to having plastic surgery. They almost always have done their weight loss on their own through a near addictive approach to diet and exercise. Once the weight is off they continue to work  diligently to hone and shape their bodies. But they reach a limit, even with extreme efforts, that is limited by whatever abdominal skin excess remains. They reach a point where the realization is that you simply can’t exercise off loose skin.

The most common body contouring procedure after weight loss is a tummy tuck. But a tummy tuck can have numerous variations in how it is performed and it must be tailored to each patient’s needs. In the male tummy tuck, for example, there is no need for muscle tightening and the incision will be ultimately obscured by hair in many men.

Case Study: This 48 year-old male had lost 60 lbs through diligent diet and exercise over a several year period. While he was in terrific shape, there remained a lower roll of excess abdominal skin that extended around into his flanks that he could not get rid of no matte what he did.

Mark Tummy Tuck result front viewUnder general anesthesia, he had a tummy tuck done through removal of a horizontal segment of abdominal skin that reached up just above his existing belly button. It extended back just to the hips. No rectus fascial plication was done. Aggressive liposuction was done around the waistline through the flanks back to the near the midline spine.

Mark Tummy Tuck result oblique viewThe male tummy tuck after weight loss is different from women in that no muscle tightening is usually needed. When done in men that achieved their weight loss by their own personal efforts and have continued to reshape their body, any loose lower abdominal skin is a frustrating problem. The low horizontal excision of abdominal skin can be the final change that they seek.

Highlights:

  1. Significant weight loss results in excessive abdominal skin and small fat collections that can not be exercised off.
  2. Loose lower abdominal skin in men after weight loss can be unraveled and removed through an ‘simple’ tummy tuck approach.

3) The acceptance of a low horizontal scar must be seen as a worthy trade-off instead of the loose abdominal skin.

Dr. Barry Eppley

Indianapolis, Indiana

Tummy Tuck Rib Removal

Monday, November 9th, 2015

 

Waistline narrowing by rib removal is almost an urban myth. There is a lot of internet chatter and interest in the procedure but it is hard to actually find a surgeon who does it or a patient who has had it. In reality, it is a plastic surgery procedure that is done but only by those few surgeons who feel comfortable working around the rib structures and can do it with small incisions and a low risk of any serious complications. (e.g., pneumothorax)

Typically the ribs removed for waistline narrowing have been described as that of the free floating 11th and 12th ribs. This is done through a small incision in the back. While these are the ‘easiest’ ribs to remove because they are well below the lowest level of the pleura, they often are not enough to get the best waistline narrowing result. I prefer to also remove rib 10 or do an intermediate resection of it (so that the distal end will naturally move inward without a posterior attachment) to get maximal waistline narrowing. The addition of rib #10 removal can make a dramatic difference as this rib turns the corner around the waistline much more so than the free floating ribs below it.

Tummy Tuck Exposure of Ribs Dr Barry Eppley IndianapolisRib Removal through Tummy Tuck Incision for Rib Protrusion Dr Barry Eppley IndianapolisRib removal can also be done through a tummy tuck approach.  But this is for a different torso effect. The ribs removed through a tummy tuck are #8 and #9 ribs. This is done by splitting the rectus muscle vertically which allows  access to the subcostal area. Ribs # 8 and 9 are easily removed but they will not have a waistline narrowing effect per se as they lie above the anatomic waist.  They may help to vertically lengthen the torso but their anterior position prevents from creating a true inward waistline effect.They are removed to reduce a subcostal prominence or protrusion.

While it seems like a long way from a low abdominal incision (and it is), the subcostal margin is well within reach. It does require a full length tummy tuck to do so however. It is best and less uncomfortable for patients after surgery to vertically split the rectus muscle rather than transecting it horizontally. The intraoperative injection of Exparel into the muscle as well as an intercostal block goes a long way with managing postoperative discomfort with this surgery.

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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