Tummy Tuck

The first tummy tuck was performed in 1890 by two physicians named De Mars and Marx. The first tummy tuck in the United States was performed by Kelly nearly a decade later. Over the last century tummy tuck techniques have continued to be refined.

The traditional tummy tuck involves releasing the belly button, lifting of the entire abdominal skin and underlying fat to gain exposure of the abdominal muscles, tightening those abdominal muscles as if sewing in the seems of a dress, then re-draping the lifted skin in order to trim the redundant skin, and finally to replace and repair the belly button as well as the trimmed skin. Of the above steps, tightening the abdominal muscles is the most painful to the patient in the postoperative period and is the reason for a prolonged recovery. Following the standard tummy tuck, you will probably need 3 to 4 weeks to recuperate. Today, we offer two modifications of the standard tummy tuck to our patients (see below) for which if you are a good candidate can put you out of work for only 1 week!

Separating the abdominal skin and underlying fat from the abdominal muscles results in significant compromise of blood flow to the abdominal skin and fat. When other abdominal scars are present, blood flow can be further disrupted to the skin areas around the scar. A physician evaluation may determine if a tummy tuck procedure would be jeopardized by the abdominal scars based on his/her knowledge of blood flow to the abdomen.

Temporary sensory loss of the abdominal skin is a consequence of surgery requiring elevation of the skin and underlying fat from the abdominal muscles. This is because sensory nerves of the abdominal skin which travel around the torso within the muscle layers prior to penetrating the skin from beneath are disrupted during the skin elevation. Once the skin and underlying fat are reattached to the underlying muscles, the disrupted nerves begin to grow through the skin and sensation returns. Return of sensation may take longer than one year so you must be patient.

Liposuction of the lateral flanks is usually required following a tummy tuck procedure. Although the tummy tuck procedure results in narrowing of the mid waist due to the direction of skin redraping, trimming, and repair, the lower waist (love handles) often requires liposuction to improve the silhouette of the torso. Ask your physician during your consultation if he/she will liposuction this area as part of the tummy tuck procedure.

The tummy tuck abdominal incision is placed over the pubic area (or in previous C-Scar incisions) and extends laterally following the bikini line. The placement of the incision may be altered by the presence of prior abdominal scars. Typically, patients are asked to wear their favorite underwear/bikini so that the incisions can be designed to be camouflaged underneath the garment. Scarring can be minimized by repairing a structure, called the superficial fascial system, at the incision line. The fascia refers to a thin, yet tough layer that is found beneath the underlying fat which when reattached during the skin closure will reduce the tension on the skin incision. Reducing the tension on the skin incision will ultimately result in less noticeable scarring. In general, you should remain patient (up to one year) for any incisional scars to fade.

In order to determine if you are a good candidate, your tummy tuck consultation will require evaluation of several items. First, the surgeon must assess degree of skin redundancy or flaccidity. This will determined the extent of the lateral skin incisions and degree of skin and underlying fat undermining. Next, attention must be given to extent of stretch marks. When limited to below the belly button, then the patient maybe a candidate for a mini tummy tuck instead of the standard tummy tuck. When the stretch marks extend above the belly button, then a standard tummy tuck is needed so that the belly button can be released so that the skin above it may be removed. Finally, the abdominal muscle must be evaluated to gauge not only the tone of the muscle but also rule out any hernias (holes of defects in the muscle). If the patient demonstrates poor abdominal tone or presence of a hernia, then a standard tummy tuck is needed to gain access to the muscles in order to repair/tighten the muscles.

The tummy tuck procedure involves accurate marking of the abdominal area. While waiting in the preoperative area, the patient is asked to stand so that skin redundancy or flaccidity can be evaluated and the patient’s incision line can be marked. After induction of anesthesia, the abdominal incision is made down to the muscle, and then the abdominal skin and underlying fat is separated from the muscle all the way to the rib cage. As you might expect, the belly button is released in the process. Next, any hernias (abdominal wall defects) are repaired and the muscle tightened to improve abdominal wall tone. This process is much similar to sewing in the seams of a dress and results in a more curvaceous silhouette.

Drains (small catheters) are placed to remove any oozing of blood during the first 4-5 days. Following placement of drains, the abdominal skin and underlying fat are redraped, trimmed, and repaired. Finally, the belly button is recreated and repaired. Contour garments are fitted to the patient following surgery so that the new abdomen can mold to the desired aesthetic shape.

On your initial visit, the surgeon will evaluate your health status, determine the amount of skin redundancy, and check your blood work. If you are a smoker, then you should quit for 1 month prior to tummy tuck surgery in order to allow your body adequate time to rid itself of any residual nicotine. Nicotine in your system results in shutting off of small blood vessels which carry nutrients to the skin; this event could be catastrophic in tummy tuck surgeries resulting in extensive abdominal wounds requiring months to heal.

Since your surgery will require general anesthesia, you must take several precautions prior to surgery. First, you will have to avoid eating and drinking after midnight on the day before surgery. This precaution ensures that your stomach is clear of digested foods that could potentially be aspirated and contaminate your lungs during induction of anesthesia. Since you will have anesthetic medications administered throughout the case, you will remain groggy for some time and will require a ride to and from the surgery center if you decide not to commit to an overnight stay on the premises. You should choose a caretaker who is conscientious and can spend the first several nights with you.

Following tummy tuck surgery, patients can expect an excellent abdominal contour, a more curvaceous silhouette, and a flat and firm abdomen. As your swelling resolves and when you stop wearing your girdle, you will find yourself buying a whole new wardrobe to fit your trim figure.

Since your surgery will require general anesthesia, it must be performed in an operating room that is part of a hospital institution or outpatient surgery center. Less frequently, patients may be operated on in an in-house office based operating room, but it is of utmost importance for patients to make sure that the office facility has been accredited by a surgical accreditation body such as AAAASF.

Since your surgery involves removal of large amounts of skin, you will require general anesthesia. This is because skin possesses a large number of sensory nerves (pain fibers) that would be triggered during trimming of the redundant skin; general anesthesia ensures that these pain fibers are shut down during the operation. Infrequently, an epidural anesthesia may be administered to provide numbness to the lower abdomen. This will minimize the general anesthesia administered and help you have a smoother postoperative recovery with lower propensity for nausea and vomiting.

When you wake up from anesthesia, expect to find a tight garment around your abdomen. Expect to wear this girdle for approximately 4 to 6 weeks! Your main discomfort will result from the abdominal muscle repair which will prevent you from standing straight up. Although you will feel significant tightness, you are encouraged to walk as soon as possible in order to minimize risk of developing blood clots in your legs. Your caretaker will show you how to take care of drains which were placed in the operating room to remove any blood/lymphatic fluid collection in the early postoperative period. These drains are removed usually by postoperative days 4 to 5. Expect your sutures to be removed within the first two weeks when the repaired abdominal incision has gained some integrity. After the first week, you will gradually feel more energetic and desire to return to your daily activities.

For patients who undergo a standard tummy tuck, expect to return to work no earlier than 3 to 4 weeks. The standard tummy tuck utilizes a longer incision, extensive separation of the skin and underlying fat from the abdominal wall muscles up to the rib cage, and tightening of the abdominal muscles. If you are a candidate for the mini tummy tuck, then you can expect to return to work as early as 1 week following surgery. The mini tummy tuck uses a shorter incision, less undermining, and avoids detaching the belly button, all of which result in a shorter recovery period.

There are several side effects that have been associated with tummy tuck surgery and these include:

1. Numbness: Numbness is inevitable due to separation of the skin and underlying fat off of the abdominal muscles. Since the sensory nerves to the skin travel in the muscle layer prior to crossing over into the skin, they are unavoidably disrupted when elevating the skin and underlying fat off of the muscle. The nerves will regrow with time and patients do note return of sensation on average by one year following surgery.
2. Hypertrophic scar: Hypertrophic scar refers to the development of a thick scar in the skin. Based on the extent of redundant skin excised, patients may experience increased tightness surrounding skin incisions and should expect a longer period for incision redness to dissipate (on average 3 to 6 months). Treatments of hypertrophic scars are available and include: steroid injection, laser therapy, and silicone pressure therapy.

1. Deep vein thrombosis (DVT) may occur in the legs immediately following surgery. DVT refers to the clotting off of leg veins which may result in compromised blood flow return from the legs; a more critical consequence may develop from this clot if it is dislodged and travels to the lungs causing a pulmonary emboli. Although rare, pulmonary emboli are the leading cause of death following surgery. DVT’s are avoided with routine use of pneumatic compression boots during surgery and encouraging patients to walk as soon as possible following surgery.
2. Hematoma: Hematoma refers to the accumulation of blood in the early postoperative period which pools into a pocket. Hematomas provide a perfect medium for harboring growth of bacteria. So if you have an infection anywhere in your body, the bacteria will travel through the blood stream and grow in the hematoma; this can lead to an infection as well as an open wound. In order to avoid a hematoma, drains are placed in surgery so that any fluid accumulation can be drained. Drains are usually kept in place for 4 to 5 days.
3. Seroma: Seroma formation refers to the accumulation of plasma fluid in pockets created by surgical elevation of the soft tissue and disruption of lymphatic vessels. This fluid accumulates due to a low blood count and protein deficiency both of which may be present in tummy tuck patients. This fluid can be a nuisance to patients requiring several aspirations in the office prior to their resolution. More importantly, these plasma fluid pockets may harbor bacterial growth and result in a clinical infection. Drains which are placed in surgery are very effective in preventing seroma formation. Consequently, seromas may become apparent following premature removal of drains.
4. Infection: An infection can occur after tummy tuck surgery. The infection will disrupt the incision line and may leave the patient with an open wound. Prolonged antibiotics are required to fight the infection and to prevent further extension of the infection. Infections are usually avoided by using drains which will prevent hematoma formation. In addition, infections are less likely in patients who don’t smoke cigarettes or in patients who quit smoking for at least 1 month prior to surgery.
5. Skin edge death/open wound: The skin incision can be disrupted if the skin edge dies or if there is local infection. This complication is best avoided by counseling patients on the terrible consequences of nicotine in cigarettes. Nicotine will literally clog all the small vessels found in the skin which are critical for the healing of the skin edge. Tummy tuck patients are usually mandated to quit smoking for at least 1 month prior to surgery. In addition, uncontrolled diabetes can lead to the undesired sloughing of the skin. Diabetic patients are urged to be vigilant about controlling their blood sugar levels prior to surgery. If patients develop an open wound, they will require prolonged local wound care with frequent dressing changes. Unfortunately, any delays in healing of the skin edges will compromise your aesthetic outcome.
6. Asymmetry in abdominal contour can occur and is secondary to several factors including: 1)Uneven skin redundancy that is hopefully improved following redraping, trimming, and repair; 2)Stretch marks are areas of the skin which have lost their elasticity and are prone to re-stretching. The surgeon attempts to remove as much of the stretch marks as possible. However, if there are stretch marks left and they are uneven (more on one side than the other), this will result in asymmetric restretching of the skin and a resultant asymmetric contour. Asymmetry in contour can usually be repaired with a revision using only a mini tummy tuck.

Women undergo several changes around their bellies during pregnancy that are undesirable. When the tummy expands to accommodate a growing baby, several unwanted changes are observed. First, the muscles covering the belly and overlying the internal organs expand and stretch around the head of the baby. Following delivery, the muscles fail to shrink back to their pre-pregnancy state. This results in a bloated look even though women may return to their pre-pregnancy weight. In addition, women may notice stretch marks that extend up to and even surround the belly button. A tummy tuck offers an opportunity to sew up the stretched muscles, much like “taking in” the seams of a dress. This results in narrowing of the torso and providing an hour glass shape. Finally, tummy tuck surgery allows for removing the “stretch marks” of the skin up to above the belly button.

Women who haven’t had children may demonstrate changes of their tummies that mimic pregnancy changes by virtue of their having gained and then lost weight. These changes often demonstrate stretch marks and redundancy of skin, but most do not demonstrate stretching of tummy muscles. Such women will benefit from a tummy tuck surgery, which will remove redundant skin. However, tightening of their tummy muscles is not required and should be avoided in order to prevent future expansion of the abdominal muscles required to accommodate a growing fetus.

A tummy tuck involves making a low incision over the tummy which is positioned to fall below the bikini line. The length of the incision is chosen by the extent of redundant skin present. If there is redundant skin that extends to the flanks, i.e. the love handles, then the incision line must be made longer to get rid of the excess. Next, the belly muscle is dissected all the way up to the ribs. When lifting the belly skin, the belly button must be released. The belly skin is then redraped, trimmed, and sewn back down. Finally, the belly button is remade.

The belly button must be recreated following draping and trimming of the redundant skin. Recreating the belly button requires making a hole which is reattached to the previous belly button stalk. This requires a circular surgical incision line that is often the give away of a tummy tuck surgery. When properly created, this incision line should be made in the natural shadow of the belly button so that it is not easily visible. Making the belly button an “inny”is critical to recreating a natural and aesthetically pleasing tummy.

Unfortunately, many surgeons perform this procedure without attention to recreating a feminine silhouette. Although this procedure involves elevating, redraping, and trimming the redundant belly fat and skin, the vector of pull when redraping the skin and limiting the degree of lateral skin elevation is critical to creating a feminine silhouette. Specifically, the vector of pull should be in a medial oblique direction rather than directly inferior. In addition, by minimizing the skin elevation laterally, the pull created when redraping the skin will pull in the flanks, i.e. love handles.

In order to optimize healing and minimize the inferior tummy surgical incision line, the redraped skin is repaired in a manner to eliminate unnecessary tension. A special stitch is performed of an internal “fascial” layer that is tough like a “tendon” which relieves the tension on the skin closure. By utilizing multiple layers to repair the trimmed and redraped skin, the surgical incision line healing is optimized. Finally, the suture utilized for the skin closure today is far superior to those utilized even in the past decade. The internal sutures that are utilized today are retained for approximately three months, thus allowing for near complete healing of the incision line prior to being absorbed. Furthermore, external glue and tape that are maintained for one month prior to being removed further enhance incision line healing. Finally, Intense Pulse lasers are utilized in our armamentarium to treat the surgical incision lines as early as 4 weeks following surgery after removal of the external tape and glue.