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Abdominoplasty

Patients who have been through significant weight loss or, more commonly, pregnancy, may be left with a tummy affected by many stretch marks, redundancy/looseness of the lower skin, which may hang like an apron, and a bulge to the central part of the tummy due to weakness and incompetence of the tummy wall muscles. The aesthetics of the lower tummy may be compromised additionally by the presence of caesarean or hysterectomy scars, which exacerbate the tendency for lower abdominal skin to hang over the bikini line. I have treated a number of women over the years, who have very unsightly vertical scars (up and down) following previous general surgical and/or gynaecological interventions. Because of the way in which the surgery is carried out, it may be possible to completely eliminate these previous scars from the lower tummy, and to greatly enhance the overall aesthetics of the abdomen.

Although exercise is good for helping to restore the integrity and strength of the tummy wall muscles, which also have a major contribution to the aesthetics and shape of the tummy, no amount of exercise after weight loss or pregnancy will deal with redundancy in the skin. During examination of patients who are unhappy with their tummy wall, I look for the presence and distribution of stretch marks and examine the integrity of the tummy wall muscles, and the redundancy/slackness of skin in the lower tummy. A pinch test is carried out to ascertain whether it is possible to surgically remove all of the skin, from the top of the pubic hair area to the top of the tummy button, the area of skin that is typically resected during abdominoplasty surgery. If it is judged that this skin cannot be fully excised, then options for patients will include either mini-abdominoplasty, liposuction of the lower abdomen alone, or, a modification of the usual technique, in which a short vertical scar is left in the midline of the tummy at the end of the operation, in addition to the typical transverse scarring that is left by tummy tuck surgery.

Surgery

Surgery is carried out under general anaesthesia as an inpatient. Patients will typically remain in hospital for two nights after surgery. The operation begins with an incision around the tummy button, which is retained. An extended "smile" incision, (which may incorporate the scar from a previous caesarean section or hysterectomy) is made before undermining and lifting the skin and fatty tissues off of the muscle layer from the lower tummy to the level of the ribcage. This undermining process creates more mobility in the skin layer, which is typically then removed to a level corresponding with the top of the tummy button. Occasionally, particularly in massive weight loss patients, the resection may go further up the tummy than this, but of course there must be enough left to allow the wound to be closed without undue tension.

With the muscle exposed, it is possible to carry out a repair of that layer, which contributes very significantly to the quality of the final outcome, and improves in particular the profile of the abdomen, and to a degree the waistline. After repairing the muscle layer the wound is closed by advancing the skin downwards over the old tummy button, which is brought out to the surface, so that it is visible once more. At the end of the operation, all wounds will have been closed using dissolving stitches and light dressings are applied. A binder/surgical corset is applied to the wound to provide support, which is easily opened by nursing/medical staff to allow regular inspection of the abdomen in the post-operative period.

On the day of surgery I don't expect patients to do more than make sure they are comfortable and to be restful, fidgiting their feet, as one would on a long haul flight to maintain circulation in the limbs, and taking whatever analgesia is necessary. A light diet is typically possible within hours of surgery. I have abandoned the use of wound drains, which means that patients no longer have to go through the painful process of having these removed, and has the very important benefit of allowing early confident mobilisation and quicker discharge from hospital. This has been possible because I now routinely quilt all abdominoplasty wounds at closure, in other words I repair the skin and fatty layer back to the muscle layer to close the space that was created during surgery.

The surgical binder that is applied during surgery is typically removed after 24-48 hours, at which point a supportive garment such as lycra cycling shorts or gym shorts should be worn, to provide a degree of support and confidence and are better tolerated than the hospital surgical binders.

Patients will be expected to be mobile by the time they leave hospital. This means that when they go home they should be getting dressed and pottering around their homes and getting involved in light activities. It does not mean that they should be going home and taking care of all the normal household chores! The presence of the lower abdominal wound and tenderness there means that driving is typically unsafe for several weeks, and patients should commence with short easy drives thereafter before attempting a long journey Once the dressings are removed in the outpatient clinic at two weeks, most patients will not thereafter require additional dressings, and advice will be given on wound management such as massage, using a moisturiser. I recommend for this purpose either E45 or nivea cream, or if the patient has a preferred body moisturiser, then stick with their usual choice. It is probably worthwhile continuing with supportive underwear for 4-6 weeks – patients make their own choices.

Abdominoplasty is one of the commonest procedures I perform in my practice and I find that, for most patients, it is a very rewarding procedure that leads to great improvements in the shape of the tummy and also confidence.

Complications

Abdominoplasty surgery leaves extensive scarring that is permanent and of uncertain quality. Scars typically heal to leave faint, narrow lines, which are cosmetically very acceptable. A small percentage of patients will have problems with over-healing scars, which may require additional treatment.

Haematoma (blood collection in the wound) occurs in 5% of cases and is an early complication, typically occurring within the first 24 hours. The treatment is to evacuate the blood collection and arrest any bleeding under general anaesthetic. This does not normally have any long term consequences.

The risk of infection is 3%. Infections do not normally develop until several days after surgery, i.e after discharge from hospital. Typical symptoms and signs include redness of the wounds, increased swelling, increasing pain, fever, feeling unwell, and discharge of pus from the wound. Superficial infections may be treated with antibiotics alone, but neglected infections or those which are severe, sometimes additional surgery is required and the outcome may be adversely affected.

General complications may occur, including deep vein thrombosis and pulmonary embolism, (blood clots in the veins and the legs which may dislodge to the heart/lungs and may be life threatening). This risk is significantly higher on women taking oral contraceptive pills but this risk can be normalised by discontinuing the pill for six weeks prior to surgery. Some patients choose to continue taking the oral contraceptive – blood thinning injections can be given to mitigate the risk.

Some patients experience a build up of fluid in their healing wounds, called seroma, which is not related to infection. This will not, therefore, produce the typical signs of infection including fever and feeling unwell, but instead produces a painless distension of the wound, typically in its lower part, in which fluid can be displaced by applying external pressure. Seroma formation used to be relatively common in my practice, but since the introduction of quilting techniques, which have allowed me to close the internal wounds, I have found that the incidence of seroma formation has dropped off dramatically and is now a relatively rare occurrence. Seroma formation for most patients is a nuisance problem, which is managed by drawing fluid off with a needle and syringe, (which is not painful), but the problem may go on for weeks in some cases, and very occasionally may have an adverse effect on the healing process and the final aesthetic outcome.

The shape of the new umbilicus (tummy button) may be different from the old one, but usually is very good.

If stretch marks are present in the upper abdominal area, these will remain after surgery because it is not possible to remove the entire abdominal skin (it would not be possible to close the wounds if this were done!). Stretch marks or scars in the area above the tummy button will move downwards because of the manner in which she skin is removed from the lower tummy and then closed.

The skin of the lower tummy is typically quite numb after abdominoplasty surgery and remains affected in this way for approximately nine months. Ultimately, most patients would expect to recover the ability to feel pain and temperature, but sensation never returns to normal. It is extremely important to remember that the numbness that is present after surgery means that patients will not be able to feel pain or heat; the skin may burn if something hot is placed upon it, such as a hot water bottle! I have seen this happen and of course it produces additional scarring.

Secondary surgery: approximately 1 in 3 patients undergoing abdominoplasty will have some kind of revision in the future carried out. Typically this will involve minor surgery under local anaesthesia and most commonly is designed to smooth out the ends of the main scar across the low tummy. Patients often ask me why this is not simply addressed during the first operation, and the answer is very simple. Surgery is carried out with the patient lying flat on the operating table, and no matter how perfect things look in that position, appearances sometimes change when standing. For this reason, some patients will benefit from a tidy up procedure and I am always happy to do this to provide pleasing results.

Key Points - Abdominoplasty

• Abdominoplasty is particularly suited to patients who have been through pregnancy or significant weight loss.
• Surgery removes excess skin and repairs/tightens the muscles of tummy wall
• Patients typically stay in hospital for 2 nights after surgery
• Patients should not drive for 2-4 weeks after surgery
• Office workers will be fit to return to work after a fortnight