Background: The tummy tuck procedure is one of the common and successful body contouring surgery. Whether it is a woman who is battling the loose and stretched skin from pregnancies or either sex whose has developed a lower abdominal overhang after weight loss or bariatric surgery, the tummy tuck provides a permanent solution in just a few hours.
In a traditional full tummy tuck, skin and fat excision is the first part of the procedure. The amount of skin and fat removed extends vertically from above the belly button down to the pubis. The wide elliptical excision of skin and fat extends horizontally from one hip to the other hip. With its removal leaves a very large lower abdominal defect that easily accounts for 1/3 or more of the total abdominal surface area.
The coverage of this lower abdominal defect is the second part of a tummy tuck and is obviously necessary for its completion. This is done by using the remaining abdominal skin from above and bringing it down over the defect to meet the lower pubic skin. The ability of the upper abdominal skin flap to bridge this gap depends on two factors; actual tissue movement and skin elasticity and stretch. Skin flap movement comes from undermining and releasing attachments, often as far up as the bottom of the rib cage. Stretching of the skin depends on how much elasticity it has. While both factors contribute to allow this tissue coverage, which one is more significant?
Case Study: This 52 year-old female was to undergo a combined abdominal and breast augmentation. The abdominal procedure was a full tummy tuck combined with liposuction of the flank or love handle area. She had a tattoo of a green frog just above the umbilicus which she wanted to preserve. She was aware, however, that it would change position from above the belly button to below it. How much it would move and what it would look like remained to be seen.
After her initial breast augmentation, a large skin and fat excision was done from the anterior superior iliac spine from one side to the other and going just above above the belly button but just below the base of the tattoo. A central tunnel was made under the upper abdominal skin flap to the xiphoid process. The rectus fascia was tightened and sutured together in the midline from below the xiphoid process down to the pubis. After the placement of a drain, the upper abdominal skin flap was stretched down to the lower incision line and closed. A new location of the original belly button stalk was made through the moved abdominakl skin flap above the frog tattoo.
While this was a standard tummy tuck and otherwise was uneventful, the change in the position of the frog tattoo was interesting. Not only did it move way down to just above the final incision line closure at the pubis, but the tattoo could be seen to be distorted and vertically elongated. This indicates that the stretch component of the upper abdominal skin flap closure of a tummy tuck is significant and probably equal to if not greater than actual skin flap movement.
Case Highlights:
1) The fundamental principle of a tummy tuck is that the remaining upper abdominal skin flap must be freed and stretched downward to replace what was removed.
2) In this patient with a pre-existing tattoo just above the belly button, the location of the tattoo after surgery confirms how much the upper abdominal skin flap actually moves
3) The distortion of the tattoo shows that the downward movement of the skin flap depends on a combination of actual tissue movement and skin stretch.
Dr. Barry Eppley
Indianapolis, Indiana