Abdominal Reduction (Tummy Tuck)
This is also called an abdominoplasty or tummy tuck. In this procedure excess skin and fat can be removed, abdominal contours and scars improved, and the muscles tightened. Different combinations are combined in the various procedures.
The Standard Abdominoplasty
The excess skin and fat of the abdominal wall between the pubic area and the umbilicus (navel) is removed leaving the umbilicus in place. The skin of the abdominal wall at the level of the umbilicus is then drawn down to suture it to at the pubic level. The patient is left with a long, usually curved scar across the lower part of the abdominal wall at the level of the pubic hair. There is also a scar around the umbilicus. Any looseness of the muscles of the abdominal wall or hernia is repaired at the same time - see Fig.1.
Liposuction may be carried out during this procedure to thin the abdominal wall, or as a separate procedure either before or after the abdominoplasty.
In the mini-abdominoplasty surplus skin below the umbilicus is removed leaving a low abdominal scar at the level of the pubic hair. The umbilicus is not disturbed but liposuction is usually carried out at the same time as the procedure to reduce the thickness of fat in the abdominal wall and any laxity or hernia of the abdominal wall is repaired at the same time - see Fig.2
In the extended abdominoplasty surplus skin and fat of the loins and back are also removed so that the scar extends around the flanks onto the lower back - see Fig.3.
The endoscopic abdominoplasty is used to tighten the muscles of the abdominal wall to give a better contour and is carried out through a short transverse incision above the pubic hair. Skin is not removed but liposuction can be carried out at the same time.
The apronectomy is a modification of the mini-abdominoplasty for patients who have a large excess of skin and fat hanging down over the pubic area. In this procedure only the surplus skin and fat is removed. The scar is long and transverse extending from one side of the apron to the other.
Modifications to the abdominoplasty skin excision are made when the patient has particular problems associated with scars from previous operations.
An alternative procedure which should always be considered instead of many of the above is liposuction on its own. This reduces fat and causes just a little retraction of the skin.
Who is a candidate?
Anyone who has abdominal skin and fat may be a candidate. With women the problem is usually caused by pregnancy, but is greatly aggravated by weight loss. The muscles of the abdominal wall may be weakened by pregnancy and actually pulled apart in the middle (divarification of recti). Men are similarly affected by weight loss. Stretch marks (striae) are simply the scars which are left after extreme stretching of the skin. They are usually most apparent on the lower part of the abdominal wall. There is no specific treatment for these stretch marks, but many of them are excised in an abdominal reduction and those that are left are tightened making them look less obvious.
Patients that are unable to tighten the abdominal wall skin with exercise or wish to achieve a smoother flatter abdomen will also benefit.
What are the consequences?
The patient is left with noticeable scars. The main scar runs transversely across the lower part of the abdomen (see illustrations) and in a standard abdominal reduction there will be a scar around the umbilicus. Other or different scars may be left where the patient has particular individual problems. Some patients make better scars than others and in any case all scars are red initially. It is essential that the patient understands where these scars will be and should discuss them with the surgeon. Although we try and hide them beneath underwear and swim wear fashions can change making previously covered scars visible.
There is numbness in the lower part of the abdominal wall after surgery this is usually temporary but could be permanent. Swelling above the scar is usually present due to a collection of tissue fluid which normally drains to the groin. This swelling or oedema settles within a few months.
What are the limitations?
The skin is usually tightened downwards and this does not tighten the waist. If this is desired then one can consider removing skin vertically, but one should bear in mind that vertical scars of the abdomen are less good. The tissue of the abdominal wall is generally fatter than the groin and if liposuction is not carried out a fatty bulge may remain above the scar.
The beneficial effects of the operation will last well, however, the effects will be maintained better if the patient keeps exercising the muscles and the weight steady. A further pregnancy will of course stretch the skin again, although probably not to the same degree.
What are the risks?
The standard abdominoplasty is a large procedure requiring two to four days hospitalisation. Drains are removed when they stop draining blood and serum a few days after the procedure. This fluid can reaccumulate after the drains are removed requiring drainage or aspiration.
Healing can be slow particularly in the tighter central part of the wound and sometimes dressings are needed for a few weeks. This is more common in patients who are overweight and who smoke. This tends to leave more obvious scars which are tethered - these can be revised.
Secondary procedures are sometimes carried out to tidy up the results and will involve scar revision and limited liposuction. Displacement of the umbilicus to one side has been over publicised and is rare. Deep vein thrombosis and pulmonary embolus are rare complications of any operation including this one.
What would you need to do before the operation?
If you are overweight you would be well advised to diet as best results are obtained in people who are the correct weight for their height. If you are taking the contraceptive pill you should stop doing so for six weeks before surgery and use an alternative method in order to reduce the risk of thrombosis. If you smoke there is a greater risk of chest infection and in particular healing of the abdominal wound is less good.
What you should expect at the time of the operation?
You will need to be in hospital for one to three days. When you wake up for your operation it is likely that you will be having a transfusion of salt solution. This is quite normal and is to provide you with fluid you need whilst you are not drinking. You are likely to have drainage tubes coming out of each side of the lower abdomen which are there to drain any collection of blood or serum. You can expect some moderately severe pain for which you will be given pain killing tablets or injections. You will be asked to keep your knees and hips bent to take the strain off your stitches.
Over activity in the early days reduces healing and increases fluid accumulation. Light activities are comfortable in 10 to 20 days. Sports will not be possible for about 6 weeks particularly when the muscles have been strengthened with sutures. A corset is usually helpful to reduce the swelling and improve comfort in the first month.
Extended abdominoplasty the scar extends around the flanks onto the lower back.
Liposuction, also known as liposculpture or suction assisted lipectomy, is a technique to remove unwanted fat deposits. The unsightly distribution of body fat is usually due to an inborn tendency to deposit fat in one particular area of the body, most commonly the hips. Other areas include; the neck, arms, tummy, loins, thighs, inner side of the knees and the ankles. The growth of a benign fat tumour (lipoma) can also be a disfigurement, and in men fatty swellings can develop under the nipples to look like breasts (gynaecomastia).
What can be done?
If you have a localised area of fat it is possible to reduce its bulk by an operation called Liposuction. A narrow metal tube is inserted through a small incision in the nearby skin. It is attached to a strong vacuum pump which is drawn back and forth within the area of excess fat. The process removes tunnels of fat leaving the small blood vessels and nerves intact. The skin will then retract.
There are some minor variants in the techniques. Some surgeons inject the area to be treated with solutions (wet or tumescent technique) others do not. Suction is usually applied with a powerful vacuum machine, but it is some-times perfectly adequate to use a simple syringe for small areas. Ultrasound assisted lipectomy is another variant.
What are the consequences?
You can expect considerable bruising which will be uncomfortable and at times painful. The larger the area treated the greater it will be. Some people bruise more easily than others. The discoloration of this bruising will usually last for about a month, but the lumpiness and swelling of deep bruising can take up to six months to disappear, particularly when the abdomen or ankles have been treated.
As swelling can take a long time to settle you may not see the full benefit of the operation for up to six months. Rarely, a greyish stripe can discolour the skin for several months and is more commonly seen when the ankles have been treated. If you have a tendency to be anaemic, or if you were to have a large area treated, you may need to take iron tablets for a month. You can expect some numbness in the treated skin which lasts for several months.
You will have small scars 1.0 to 2.0 centimetres long at the sight of insertion of the suction cannulae. There is a small risk in some people that these scars may stay red for a while but they are usually sighted in less obvious areas.
If you are having treatment to your legs you may find that your ankles are swollen for a few weeks and if your ankles themselves have been treated, they may stay swollen for a few months.
Will it last?
Fat cells are thought not to be regenerated in adult life. Therefore their removal by liposuction will give a permanent change in contour and be independent of any changes in your body weight.
What are the limitations?
It is important for you to understand that liposuction is not a treatment for obesity. The amount of fat that can be removed from a localised area is limited by what is safe (maximum of 3 litres) and a natural limitation when no further fat can be removed. Therefore it may not be possible to slim down an area as much as you might like. Further treatments may be carried out in the same area after six months. In certain situations the skin is inelastic and loose. Liposuction in these areas will then tend to leave the skin more loose and it may be recommended that a skin excision be carried out to correct this, either at the same time as the liposuction, or as a second procedure. This is most likely in the abdomen, after pregnancy or weight loss, the buttocks or the neck. Dimples and wrinkles of the skin, sometimes called cellulite will not be improved by liposuction.
What should you expect at the time of your operation?
The procedure is normally carried out under general anaesthesia as a day case. You may wish to stay the night if you have had many areas treated. An epidural is an alternative for the lower part of the body, but a local anaesthetic alone is only suitable for small areas as it is uncomfortable to administer and does not work particularly well.
You are likely to need simple pain killers for a day or so after the operation and you will probably be asked to return a week after surgery to have sutures removed. A snug pressure garment or corset is usually advised around the lower part of the body. This is used to reduce bruising but can be taken off to wash, quickly dried and put back on. You can take this opportunity to bathe yourself. The corset is usually worn for two to three weeks.
You will only need to take a few days off work if a small area is treated, but larger areas may necessitate 7 to 10 days off work. You may be somewhat anaemic and need to take iron. You are welcome to sunbathe but remember that discoloration of bruising will last about a month and you will not achieve your best appearance for three to six months.
What are the risks?
The large majority of patients who have this operation done by an experienced surgeon run into no problems at all. You should, however, take into account the following: Any major operation which is done under general anaesthetic carries with it a small risk of infection and thrombosis of the veins. Heavy bruising can happen particularly in patients who have a tendency to bleed or have been taking aspirin or anti-inflammatory drugs. Serious infection is very rare, but there is sometimes inflammation in the areas that have been treated with perhaps some oozing from the incisions. It normally settles with a course of antibiotics. Thrombophlebitis (which is an inflammation of the veins and not the same as thrombosis) can occur around the inside of the knee and inner part of upper thigh when these areas have been treated. It gradually settles over a period of weeks. The surface contour over the treated areas can sometimes be irregular particularly if a lot of fat has been removed but if the technique is properly carried out these irregularities are minor. Occasionally the skin appears to be tethered to the deep tissues, this is part of the bruising and will settle in time. Risks will be reduced by choosing a surgeon who is an accredited plastic surgeon trained in Liposuction. Members of BAAPS are all on the General Medical Councils Specialist Register in Plastic Surgery.
What should you do before the operation?
You should avoid aspirin and anti-inflammatory drugs for 2 weeks before the operation. You should take iron if you are anaemic. Occasionally your surgeon will advise you to stop taking the contraceptive pill if the liposuction is going to be extensive, perhaps involving skin excision.