Abdominoplasty (Tummy Tuck)

Plastic surgeons are particularly interested in the abdominal trunk because it offers a big area for body contouring. The area between the inferior aspect of the breasts and the beginning of the pelvis is referred to as the trunk. Abdominoplasty, also known as a "tummy tuck," is a technique that removes extra skin and fat from the abdomen while also strengthening the abdominal wall muscles. The purpose of this surgery is to create an aesthetically attractive abdomen, and it might use both direct excisional and liposuction procedures. With the development in bariatric surgery, abdominoplasty has become a valuable option for patients who have excess abdominal tissue following their weight loss.

Tummy Tuck

A list of common desires for abdominoplasty patients includes the desire to reduce loose, draping skin, have a tighter, flatter abdomen, and improve the abdominal shape. Exercise and diet are widely acknowledged as the most effective ways for achieving many of these objectives. Despite proper exercise and diet, however, many groups of people are unable to achieve their intended outcomes. Weight loss can improve loose, draping skin by reducing the subcutaneous fat layer and intra-abdominal volume. Pregnancy also causes changes in the vertebral column, ribs, and pelvis, resulting in an increase in the abdominal transverse diameter. The musculoaponeurotic system's tone may be compromised. Furthermore, procedures on the abdominal wall and hernias (outpouching of organs from the cavity normally containing them) might weaken and partially denervate the musculoaponeurotic system. The typical abdominoplasty is one of the numerous abdominal aesthetic surgery techniques. In most patients, this procedure, which includes dermo-lipectomy and musculoaponeurotic tightening, is quite effective in restoring the abdomen to its healthy shape.

Anatomy and Pathophysiology

The fat in the trunk is divided into different areas. Scarpa's fascia divides it into superficial and deep layers. Perforating branches of the superior and inferior epigastric arteries give blood to the skin and fat in this area. The anterior superior iliac spine and therefore the umbilicus are anchoring fascial regions that give structural support for the abdominal skin. Because they preserve structural integrity following abdominoplasty, the inguinal and mons pubis zones of adhesion are the most critical.

Indications of Abdominoplasty

Abdominoplasty is performed for a variety of reasons, including men and women who want to improve the appearance of their abdomens, women who have significant skin and abdominal wall laxity after multiple pregnancies, and bariatric patients who have excess skin and/or pannus after significant weight loss. It is critical to gather a complete history when selecting individuals for surgery. Wound healing is critical, and patients must have a healthy nutritional state as well as good general medical health. Plastic surgeons face unique challenges when working with bariatric patients.

Because of the laxity of the skin following severe weight loss, as well as the potentially large size of the skin apron, additional dissection and adjunct treatments to raise the thigh, back, arm, and flank areas may be required to maintain overall body symmetry. Those with a lower BMI had better outcomes, whereas patients with diabetes mellitus are more likely to develop problems. Liposuction alone is best for patients who have little to no fat and no abdominal wall laxity. Candidates for the "mini-abdominoplasty" have minimum to moderate subcutaneous fat and minimal to moderate abdominal wall laxity, mainly in the infra-umbilical (infra means below) region. A full abdominoplasty is recommended for patients with excessive skin laxity, obesity, and abdominal wall weakness.

Contraindications of Abdominoplasty

This technique is not recommended for patients who have advanced cardiac disease, cirrhosis (end-stage liver disease), or uncontrolled diabetes mellitus. Smoking has a negative impact on abdominoplasty because it needs a sufficient blood supply. Current smoking is considered a contraindication to surgery by many plastic surgeons.

Equipment

This process does not necessitate the use of any specific equipment. Liposuction equipment should be provided if liposuction is to be included in the surgery. Closed-suction should be easy to get.

Types of Abdominoplasty 

Abdominoplasty comes in two varieties, both of which are performed under general anesthesia.

Partial Abdominoplasty

detaching the skin from the abdominal wall below the belly button with a big cut (incision), removing excess fat and skin, then drawing the remaining skin together and sewing it in place

Full Abdominoplasty

a big incision from hip to hip, right above the pubic area, across the lower tummy, then, detaching the skin from the abdominal wall and realigning the abdominal muscles with a second incision to release the belly button from the tissue that surrounds it, and finally, cutting a new hole for the belly button and stitching it back.

The procedure can take anything from 2 to 5 hours. Most individuals will need to spend a few nights in the hospital.

When you wake up from the general anesthesia, you will most likely be in pain. If necessary, painkilling medication can be supplied.

You will be discharged from the hospital with dressings and a tummy-control garment (corset) or tummy-control pants. Someone must drive you home and remain with you for the next 24 hours.

Tummy Tuck Surgery

Preoperative Evaluation

Some important factors may be highlighted during the preoperative evaluation. The pinch test is used to determine the vertical amount of skin to be removed. It is noted that there are flank rolls or fullness, which may necessitate liposuction or an extended lateral excision. Abdominal scars are detected, which may compromise the viability of the skin flap. Examinations in the upright and supine positions, with and without the Valsalva maneuver, are used to rule out ventral hernias. A hernia can be concealed by a thick covering of subcutaneous fat. With the patient bends forward at the waist, musculofascial laxity is most visible from the lateral aspect. In the supine sit-up or leg-raise position, muscle firmness and rectus diastasis can be assessed. The rectus boundaries may be apparent if the fat layer is thin enough. An apparent lax muscle wall may be caused by lumbar lordosis. The vertical distance between the iliac crest and the thoracic cage in proportion to the pelvic breadth determines whether the patient is short-waisted or long-waisted. To achieve the most pleasant frontal contour, the skin flap design can be modified according to a long or short waist.

Tummy Tuck procedure

The patient is positioned supine with pillows under the knees to alleviate pressure on the sciatic nerve. The abdomen is prepped and draped from the mid-chest to the groins. To mark the midline, long 2 –0 silk is put at the xiphoid and stretched down to the vulvar commissure. On the superior and inferior lines at the rectus' lateral edge, four sites are marked. At each of these sites, temporary sutures are applied. Along the planned lines of skin resection, half-percent lidocaine with epinephrine 1:200,000 is injected.

The umbilicus is incised all the way down to the muscular fascia. Single hooks at the 12 and 6 o'clock positions on the umbilicus, upward retraction, and incision with an 11-blade perpendicular to the umbilicus stalk on either side of the umbilicus aid this. The skin hooks are then repositioned at 3 o'clock and 9 o'clock, retracted upward, and the incision is finished across the superior and inferior umbilicus edges. Metzenbaum scissors are used to complete the dissection down to the fascia. The muscular fascia is reached with a low transverse incision. The inferior epigastric vessels are split and controlled on the surface.

From the previously incised umbilicus to the lower incision, a low midline cut is made. The top incision line is reached by elevating each hemi-flap. Rectus perforators are divided and hem-clipped twice. To avoid bothersome bleeding or rectus sheath hematoma, it's critical to keep these perforators under control.

Above the muscle fascia, the undermining continues to the costal margins and xiphoid. Large perforating vessels are identified and preserved as much as possible along the anterior axillary line.  The abdominal wall will be tightened as part of the procedure and finished prior to the excision of the skin.  The rectus diastasis is addressed. The medial borders of the rectus muscle's anterior rectus sheath are plicated with a running double-stranded O-nylon, effectively reconstructing the diastasis.

External oblique advancement tightens and shapes the abdominal wall even more. With the upper limbs softly curving laterally and the lower limbs gently curving medially, the medial edge of the external oblique fascia lateral to the rectus abdominis muscle is incised. This aponeurosis and the external oblique muscle are elevated laterally to the anterior axillary line from the internal oblique fascia and muscle. The external oblique fascia and muscle on the opposite side are also raised. On the margins of the external oblique aponeurosis, Allis clamps are used.

The abdominal wall and waist shape are tightened by medial traction until the appropriate tightening and shape are achieved. Methylene blue is used to identify the new position of the external oblique aponeurosis. To secure the advanced fascial, O-proline stitches are used in a figure of eight pattern. an Incision and advancement of the external oblique aponeurosis. Medial advancement of external oblique aponeurosis margins. A running double-strand O-nylon is then added. Within the frontal aspect, wall tightening improves abdominal protrusion and forms the edges of the abdomen.

After the abdominal tightening, the abdominoplasty flap is resected. To remove excess skin, the superior skin edges are dragged down over the inferior edge and marked. This should match the better key stitching you made earlier. The skin flap is resected, and the edges are hemostatized. Lipectomy is performed currently, if necessary. Direct lipectomy is performed in the central belly, deep to the Scarpa's fascia.

If necessary, a careful suction-assisted lipectomy is performed above the Scarpa's fascia, but crosshatching is avoided. Suction-assisted lipectomy or direct lipectomy may be required at the wound's lateral apices to give a smooth contour in this area, which is prone to dog ears. Suction-assisted lipectomy can be performed safely no more than 5–10 cm from the undermining's edges or vigorously in only one of the three neighboring regions (lateral costal, flank, or hip). A suitable medial sulcus is created by selective defatting in the supraumbilical region to produce a midline depression, which accentuates the medial rectus border.

Lateral selective defatting helps to emphasize the lateral rectus edges. The umbilical stock is prolonged, so the umbilicus is plicated to the abdominal wall and 3-O nylon dermal to fascial sutures are put every 120 degrees around the umbilicus. This plication contributes to the desired periumbilical depression. 

The new skin site of the umbilicus is marked within the midline, at least 10 cm far-away from the skin edge but above the plicated umbilicus, with the corners of the skin temporarily opposed with staples. A chevron incision is formed within the skin, somewhat broader than the diameter of the umbilicus. Selective defatting is superior at creating a natural periumbilical depression with slight hooding. To interrupt up circumferential cicatrice, the tip of the chevron is inset into an incision at the 6 o'clock radian of the umbilicus. Downward traction on the superior skin flap to take care of the natural shape of the umbilicus' inferior edge.

Place three triangulating 3-O nylon sutures into the skin edges of the umbilicus and pass through the new skin site to be sutured to the new umbilical site skin margins after the abdominal flaps are approximated as a technical procedure to facilitate exteriorizing the umbilicus. To prevent the umbilicus from dehiscence away from the skin edge, additional 5-O nylon sutures are put in the inset umbilicus. Two flat multi-perforated drains exiting in the pubic skin are implanted behind the abdominal flap. To prevent dog-ear formation, the superior and inferior abdominal flap borders are rounded from lateral to medial. Scarpa's fascia is roughly estimated. The deep dermis is sutured with absorbable monofilament 3-O sutures, and the skin is finely closed.

Postoperative Care

The patient is moved to a bed in a flexed position with his knees elevated. Fluid replacement is provided as needed. Antibiotics for perioperative prophylaxis are still being used. The patient is moved to ambulation as soon as possible, and compression stockings are used until then. It's best to avoid coughing and deep breathing. The liquid diet is started slowly and gradually increased as GI function improves. The Jackson-Pratt drains are left in place until there is no evidence of fluid collection and less than 30 cc of drainage per 24 hours. The drains are typically left in for 5 to 7 days. Within one week, the patient should be able to stand upright.

Side Effects of Tummy Tuck

The development of serosanguineous collections is the most common complication of conventional abdominoplasty. This is primarily due to the extensive undermining that takes place during the procedure. It is advised that drains be installed properly and left in place until the drainage drops to less than 30 cc/day. This problem has also been addressed with the use of elastic compression clothing and fibrin glue. If seromas develop after a drain is removed, meticulous needle aspiration may be required instead of opening and inserting a new drain.

Cellulitis (skin infection), wound infection, enlarged scars, keloid formation, suture reactions, partial skin loss, wound dehiscence, contour irregularities, pulmonary risks, and pulmonary embolism are all possible risks of this surgery. Infection rates in most series are from 1 to 2%, but they can rise when there is an immunological compromise, such as in diabetic patients.

Keloids are possible in certain forms of strongly pigmented skin. The growth of keloid scars can be reduced by gently manipulating the skin's margins. Laser therapy can help with erythematous elevated hypertrophic scars. Injections of cortisone may be beneficial in the case of more troublesome scars. As a result of a lack of blood supply to the anterior abdominal skin, partial skin loss and wound dehiscence may ensue. Patients who are smokers or diabetics have a higher prevalence of this. The skin necrosis is usually treated conservatively until the blood supply to the abdominal skin flaps stabilizes.

The most concerning side effects of this procedure are pulmonary problems. Pulmonary embolism is a rare but potentially fatal side effect of abdominoplasty. In the postoperative phase, any patient with pulmonary deterioration or symptoms of shortness of breath or chest pain should be treated with caution. The gold standard to diagnose pulmonary embolism is spiral CT scans. Lower extremity ultrasonography investigations provide reported documentation. This potential consequence should be evaluated and treated as soon as possible.

Tummy Tuck Cost

According to 2020 data from the American Society of Plastic Surgeons, the average cost of a tummy tuck is $5,000. This is only some of the whole cost; it excludes anesthesia, facilities, and other related costs. To establish your final charge, you have to contact the hospital you intended to undergo a tummy tuck in it.

The cost of a tummy tuck surgery depends on the surgeon's experience, the procedure performed, and the location of the clinic.

Although most health insurance plans do not cover tummy tuck surgery or its consequences, many plastic surgeons offer patient payment plans.

Tummy Tuck Scar

It may take several months to a year for the tummy tuck scar to disappear completely.  There are certain things you can do once you've got a scar to make it less obvious. But keep in mind that the goal is to reduce the look of the scar, not to completely obliterate it.

1. Care instructions must be followed. Begin following the incision care instructions doctor provide you with as soon as possible after your operation. Your incisions will heal more quickly and properly if you follow the hygiene and wound care instructions.
2. Keep an eye out for signs of infection. If you have any suspicions that your incision is infected, please contact the doctor right away. Infected incisions can cause scarring to become more visible.
3. Start topical treatments. You can begin topical treatments once the incision is no longer covered by scabs and has completely healed. The simplest solution is to use a silicone-containing product, such as a gel, cream, or sheeting. Silicone mimics the occlusion qualities of the stratum corneum (the outer layer of the skin), allowing scar tissue hydration to return to normal and possibly halting excessive collagen formation.
4. Maintain a healthy level of moisture in your skin. Only when the wounds have healed may you apply moisturizers directly to your scars. If you do so ahead of time, your incisions may not close properly, increasing your risk of infection.
5. Don't expose your scars to the sun. UV exposure can make your scars darker and thicker, so protect them from the sun whenever possible. Using clothing rather than sunscreen is preferable.
6. Stay away from irritable goods and clothing. Any friction to a scar will aggravate it. Use only skin-friendly products on your skin.

Conclusion

Patients with excessive, loose, drooping abdominal skin, a lax abdominal muscle fascial wall, and/or diastasis recti are candidates for a standard abdominoplasty. Preoperative testing enables the proper selection of patients who may need this surgery. Preoperative skin marks in the upright posture aid in achieving a symmetrical skin excision and an aesthetic result. Skin undermining, abdominal wall plication, excess skin excision, lipectomy, umbilicoplasty, and final closure with resection of dog ears are all part of the basic abdominoplasty operation. To avoid skin flap necrosis, the blood flow to the skin flap must be kept as indicated. The goal of postoperative care is to prevent seroma buildup.