Abdominoplasty

Definition

Also known as a tummy tuck, abdominoplasty is a surgical procedure in which excess skin and fat in the abdominal area is removed and the abdominal muscles are tightened.

Purpose

Abdominoplasty is a cosmetic procedure that treats loose or sagging abdominal skin, leading to a protruding abdomen that typically occurs after significant weight loss. Good candidates for abdominoplasty are individuals in good health who have one or more of the above conditions and who have tried to address these issues with diet and exercise with little or no results.

Women who have had multiple pregnancies often seek abdominoplasty as a means of ridding themselves of loose abdominal skin. While in many cases diet and exercise are sufficient in reducing abdominal fat and loose skin after pregnancy, in some women these conditions may persist. Abdominoplasty is not recommended for women who wish to have further pregnancies, as the beneficial effects of the surgery may be undone.

Another common reason for abdominoplasty is to remove excess skin from a person who has lost a large amount of weight or is obese. A large area of overhanging skin is called a pannus. Older patients are at an increased risk of developing a pannus because skin loses elasticity as one ages. Problems with hygiene or wound formation can result in a patient who has multiple hanging folds of abdominal skin and fat. If a large area of excess tissue is removed, the procedure is called a panniculectomy.

In some instances, abdominoplasty is performed simultaneously or directly following gynecologic surgery such as hysterectomy (removal of the uterus). One study found that the removal of a large amount of excess abdominal skin and fat from morbidly obese patients during

Abdominoplasty (tummy tuck) surgery. Portions of the lower abdominal tissues have been removed and the navel repositioned. The remaining skin flaps will be sutured. (

Photography by MM Michele Del Guercio. Reproduced by permission.

)

Contraindications

Certain patients should not undergo abdominoplasty. Poor candidates for the surgery include:

• Women who wish to have subsequent pregnancies.
• Individuals who wish to lose a large amount of weight following surgery.
• Patients with unrealistic expectations (those who think the surgery will give them a "perfect" figure).
• Those who are unable to deal with the post-surgical scars.
• Patients who have had previous abdominal surgery.
• Heavy smokers.

Demographics

According to the American Academy of Plastic Surgeons, in 2001 there were approximately 58,567 abdominoplasties performed in the United States, relating to 4% of all plastic surgery patients and less than 0.5% of all plastic surgery procedures. Female patients accounted for 97% of all abdominoplasties. Most patients were between the ages of 35 and 50 (58%), with patients under 35 accounting for 20% and patients over 50 accounting for 22%. Eighty-two percent of all plastic surgery patients during 2001 were white, 7% were Hispanic, 5% were African American, and 5% were Asian American.

Description

The patient is usually placed under general anesthesia for the duration of surgery. The advantages to general anesthesia are that the patient remains unconscious during the procedure, which may take from two to five hours to complete; no pain will be experienced nor will the patient have any memory of the procedure; and the patient's muscles remain completely relaxed, lending to safer surgery.

Once an adequate level of anesthesia has been reached, an incision is made across the lower abdomen. For a complete abdominoplasty, the incision will stretch from hipbone to hipbone. The skin will be lifted off the abdominal muscles from the incision up to the ribs, with a separate incision being made to free the umbilicus (belly button). The vertical abdominal muscles may be tightened by stitching them closer together. The skin is then stretched back over the abdomen and excess skin and fat are cut away. Another incision will be made across the stretched skin through which the umbilicus will be located and stitched into position. A temporary drain may be placed to remove excess fluid from beneath the incision. All incisions are then stitched closed and covered with dressings.

Individuals who have excess skin and fat limited to the lower abdomen (i.e., below the navel) may be candidates for partial abdominoplasty. During this procedure, the muscle wall is not tightened. Rather, the skin is stretched over a smaller incision made just above the pubic hairline and excess skin is cut away. The incision is then closed with stitches. The umbilicus is not repositioned during a partial abdominoplasty; its shape, therefore, may change as the skin is stretched downward.

Additional procedures

In some cases, additional procedures may be performed during or directly following abdominoplasty. Liposuction , also called suction lipectomy or lipoplasty, is a technique that removes fat that cannot be removed by diet or exercise. During the procedure, which is generally performed in an outpatient surgical facility, the patient is anesthetized and a hollow tube called a cannula is inserted under the skin into a fat deposit. By physical manipulation, the fat deposit is loosened and sucked out of the body. Liposuction may be used during abdominoplasty to remove fat deposits from the torso, hips, or other areas. This may create a more desired body contour.

Some patients may choose to undergo breast augmentation, reduction, or lift during abdominoplasty. Breast augmentation involves the insertion of a silicone- or saline-filled implant into the breast, most often behind the breast tissue or chest muscle wall. A breast reduction may be performed on patients who have large breasts that cause an array of symptoms such as back and neck pain. Breast reduction removes excess breast skin and fat and moves the nipple and area around the nipple (called the areola) to a higher position. A breast lift, also called a mastopexy, is performed on women who have low, sagging breasts, often due to pregnancy, nursing, or aging. The surgical procedure is similar to a breast reduction, but only excess skin is removed; breast implants may also be inserted.

Breast reconstruction

A modified version of abdominoplasty may be used to reconstruct a breast in a patient who has undergone mastectomy (surgical removal of the breast, usually as a treatment for cancer). Transverse rectus abdominis myocutaneous (TRAM) flap reconstruction may be performed at the time of mastectomy or as a later, separate procedure. Good candidates for the surgery include women who have had or will have a large portion of breast tissue removed and also have excess skin and fat in the lower abdominal region. Women who are not in good health, are obese, have had a previous abdominoplasty, or wish to have additional children are not considered good candidates for TRAM flap reconstruction.

The procedure is usually performed in three separate steps. The first step is the TRAM flap surgery. In a procedure similar to traditional abdominoplasty, excess skin and fat is removed from the lower abdomen, then stitched into place to create a breast. The construction of a nipple takes place several months later to enable to the tissue to heal adequately. Finally, once the new breast has healed and softened, tattooing may be performed to add color to the constructed nipple.

Costs

Because abdominoplasty is considered to be an elective cosmetic procedure, most insurance policies will not cover the procedure, unless it is being performed for medical reasons (for example, if an abdominal hernia is the cause of the protruding abdomen).

A number of fees must be taken into consideration when calculating the total cost of the procedure. Typically, fees include those paid to the surgeon, the anesthesiologist, and the facility where the surgery is performed. If liposuction or breast surgery is to be performed, additional costs may be incurred. The average cost of abdominoplasty is $6,500, but may range from $5,000–9,000, depending on the surgeon and the complexity of the procedure.

Diagnosis/Preparation

There are a number of steps that the patient and plastic surgeon must take before an abdominoplasty may be performed. The surgeon will generally schedule an initial consultation, during which a physical examination will be performed. The surgeon will assess a number of factors that may impact the success of the surgery. These include:

• the patient's general health
• the size and shape of the abdomen and torso
• the location of abdominal fat deposits
• the patient's skin elasticity
• what medications the patient may be taking

It is important that the patient come prepared to ask questions of the surgeon during the initial consultation. The surgeon will describe the procedure, where it will be performed, associated risks, the method of anesthesia and pain relief, any additional procedures that may be performed, and post-surgical care. The patient may also meet with a staff member to discuss how much the procedure will cost and what options for payment are available.

The patient will also receive instructions on how to prepare for abdominoplasty. Certain medications should be avoided for several weeks before and after the surgery; for example, medications containing aspirin may interfere with the blood's ability to clot. Because tobacco can interfere with blood circulation and wound healing, smokers are recommended to quit for several weeks before and after the procedure. A medicated antibacterial soap may be prescribed prior to surgery to decrease levels of bacteria on the skin around the incision site.

Aftercare

The patient may remain in the hospital or surgical facility overnight, or return home the day of surgery after spending several hours recovering from the procedure and anesthesia. Before leaving the facility, the patient will receive the following instructions on post-surgical care:

• For the first several days after surgery, it is recommended that the patient remain flexed at the hips (i.e., avoid straightening the torso) to prevent unnecessary tension on the surgical site.
• Walking as soon as possible after the procedure is recommended to improve recovery time and prevent blood clots in the legs.
• Mild exercise that does not cause pain to the surgical site is recommended to improve muscle tone and decrease swelling.
• The patient should not shower until any drains are removed from the surgical site; sponge baths are permitted.
• Work may be resumed in two to four weeks, depending on the level of physical activity required.

Surgical drains will be removed within one week after abdominoplasty, and stitches from one to two weeks after surgery. Swelling, bruising, and pain in the abdominal area are to be expected and may last from two to six weeks. Recovery will be faster, however, in the patient who is in good health with relatively strong abdominal muscles. The incisions will remain a noticeable red or pink for several months, but will begin to fade by nine months to a year after the procedure. Because of their location, scars should be easily hidden under clothing, including bathing suits.

Risks

There are a number of complications that may arise during or after abdominoplasty. Complications are more often seen among patients who smoke, are overweight, are unfit, have diabetes or other health problems, or have scarring from previous abdominal surgery. Risks inherent to the use of general anesthesia include nausea, vomiting, sore throat, fatigue, headache, and muscle soreness;

In an abdominoplasty, or tummy tuck, an incision is made in the abdomen (usually from hip bone to hip bone). Excess skin and fat is removed (B). The muscles may be tightened (C). The navel will be placed into the proper position (D), and the major incision closed beneath it. (

Illustration by GGS Inc.

)

Risks associated with the procedure include:

• bleeding
• wound infection
• delayed wound healing
• skin or fat necrosis (death)
• hematoma (collection of blood in a tissue)
• seroma (collection of serum in a tissue)
• blood clots
• pulmonary embolism (a blood clot that travels to the lungs)
• numbness to the abdominal region or thighs (due to damage to nerves during surgery)

Normal results

In most cases, abdominoplasty is successful in providing a trimmer abdominal contour in patients with excess skin and fat and weak abdominal muscles. A number of factors will influence how long the optimal results of abdominoplasty will last, including age, skin elasticity, and physical fitness. Generally, however, good results will be long-lasting if the patient remains in good health, maintains a stable weight, and exercises regularly. One study surveying patient satisfaction following abdominoplasty indicated that 95% felt their symptoms (excess skin and fat) were improved, 86% were satisfied with the results of the surgery, and 86% would recommend the procedure to a friend.

Morbidity and mortality rates

The overall rate of complications associated with abdominoplasty is approximately 32%. This percentage, however, is higher among patients who are overweight; one study placed the complication rate among obese patients at 80%. Rates are also higher among patients who smoke or are diabetic. The rate of major complications requiring hospitalization has been reported at 1.4%.

Alternatives

Before seeking abdominoplasty, an individual will want to be sure that loose and excess abdominal skin and fat cannot be decreased through a regimen of diet and exercise. Abdominoplasty should not be viewed as an alternative to weight loss. In fact, some doctors would suggest that a patient be no more than 15% over his or her ideal body weight in order to undergo the procedure.

Liposuction is a surgical alternative to abdominoplasty. There are several advantages to liposuction. It is less expensive (an average of $2,000 per body area treated compared to $6,500 for abdominoplasty). It also is associated with a faster recovery, a need for less anesthesia, a smaller rate of complications, and significantly smaller incisions. What liposuction cannot do is remove excess skin. Liposuction is a good choice for patients with localized deposits of fat, while abdominoplasty is a better choice for patients with excess abdominal skin and fat.

Resources

periodicals

Hensel, J. M., J. A. Lehman, M. P. Tantri, M. G. Parker, D. S. Wagner, and N. S. Topham. "An Outcomes Analysis and Satisfaction Surgery of 199 Consecutive Abdominoplasties." Annals of Plastic Surgery, 46, no. 4 (April 1, 2001): 357–63.

Vastine, V. L., et al. "Wound Complications of Abdominoplasty in Obese Patients." Annals of Plastic Surgery, 41, no. 1 (January 1, 1999): 34–9.

organizations

American Academy of Cosmetic Surgery. 737 N. Michigan Ave., Suite 820, Chicago, IL 60611. (312) 981-6760. http://www.cosmeticsurgery.org .

American Board of Plastic Surgery, Inc. 7 Penn Center, Suite 400, 1635 Market St., Philadelphia, PA 19103-2204. (215) 587-9322. http://www.abplsurg.org .

American Society of Plastic Surgeons. 444 E. Algonquin Rd., Arlington Heights, IL 60005. (888) 4-PLASTIC. http://www.plasticsurgery.org .

other

"2001 Statistics." American Society of Plastic Surgeons, 2003 [cited April 8, 2003]. http://www.plasticsurgery.org/public_education/2001statistics.cfm .

"Abdominoplasty." American Society of Plastic Surgeons, 2003 [cited April 8, 2003]. http://www.plasticsurgery.org/public_education/procedures/Abdominoplasty.cfm .

Gallagher, Susan. "Panniculectomy: Implications for Care." Perspectives in Nursing, 2003 [cited April 8, 2003]. http://www.perspectivesinnursing.org/v3n3/panniculectomy.html .

"Training Requirements." American Board of Plastic Surgery, July 2002 [cited April 8, 2003]. http://www.abplsurg.org/training_requirements.html .

"Tummy Tuck." The American Society for Aesthetic Plastic Surgery, 2000 [cited April 8, 2003]. http://www.surgery.org/q1 .

Zenn, Michael R. "Breast Reconstruction: TRAM, Unipedicled." eMedicine, December 13, 2001 [cited April 8, 2003]. http://www.emedicine.com/plastic/topic141.htm .

Stephanie Dionne Sherk

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Abdominoplasty is usually performed by a plastic surgeon, a medical doctor who has completed specialized training in the repair or reconstruction of physical defects or the cosmetic enhancement of the human body. In order for a plastic surgeon to be considered board certified by the American Board of Plastic Surgery, he or she must meet a set of strict criteria (including a minimum of five years of training in general surgery and plastic surgery) and pass a series of examinations. The procedure may be performed in a hospital operating room or a specialized outpatient surgical facility.

QUESTIONS TO ASK THE DOCTOR

• How long have you been practicing plastic surgery?
• Are you certified by the American Board of Plastic Surgeons?
• How many abdominoplasties have you performed, and how often?
• What is your rate of complications?
• How extensive will the post-surgical scars be?
• What method of anesthesia will be used?
• What are the costs associated with this procedure?
• Will my insurance pay for part or all of the surgery?
• Do you provide revision surgery (i.e., if I experience suboptimal results)?