Tummy Tuck (Abdominoplasty): making your middle match the rest of you

Tummy Tuck and Liposuction
Located in Raleigh, North Carolina serving patients in Raleigh, Cary and Durham

A tummy tuck almost always has a very powerful effect on an individual’s self image and sense of well-being. This surgery will often put a patient back into clothes that they haven’t been able to wear (or haven’t been comfortable wearing) for years.

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Many moms that I see for tummy tucks are very fit and in good physical condition, but despite efforts to ‘slim down’ through diet and exercise, the middle third of their body just doesn’t match their more slender upper and lower thirds. As with all aesthetic surgeries, I attempt to restore a sense of harmony and balance to a patients figure when I perform an abdominoplasty.

A tummy tuck is designed to accomplish two things:

1. Remove excess abdominal skin and fat
2. Tighten and flatten the abdominal wall muscles

The surgery is performed through a ‘bikini-line incision’ which, for a full tummy tuck, may extend from hipbone to hipbone. For patients that need only a ‘mini-tummy tuck’, the incision is usually somewhat smaller, extending just beyond the limits of the average C-section scar. The suprapubic incisions used for this operation are designed so that the resulting surgical scar is hidden by underwear or a bathing suit.

A full abdominoplasty requires the surgical creation of a new belly button. Creating the new belly button, which is called an umbilicoplasty, is a part of tummy tuck surgery that requires a great deal of attention and finesse on the part of the surgeon. My goal is to create a new belly button that, as much as possible, resembles a ‘natural’ belly button. Natural belly buttons do NOT look like a perfect circle, and circular umbilicoplasty scars are a tummy tuck dead giveaway.

The technique I use for umbilicoplasty is designed to create a slightly ‘hooded’ appearance to the upper half of the belly button, an appearance that is generally considered fit and athletic. Not all patients have the goal of wearing a two-piece swimsuit, but many do, and I want these patients to be able to do so without feeling self-conscious about the appearance of their new belly button.

Tummy tucks and liposuction

In almost all cases I combine liposuction of the hips and abdomen with a tummy tuck, in order to provide the best possible postoperative abdominal contour. Liposuction must be performed carefully and cautiously when combined with an abdominoplasty, however, as aggressive removal of fat can compromise the ultimate surgical result, and can in fact lead to significant complications such as lower abdominal skin necrosis.

Following a conventional tummy tuck, the normal blood supply to the abdominal skin has been interrupted and the skin now relies on circulation that passes anteriorly and inferiorly from the lateral chest and abdomen. For this reason, it is very important to limit and even avoid liposuction of the back and waist at the time a tummy tuck is performed.

I quite frequently combine liposuction of other areas, especially the thighs, knees, lower legs and upper arms with abdominoplasty surgery. Many patients who carry excess weight in the ‘middle third’ of their body also carry it in their thighs, and circumferential liposuction of the thighs, in appropriate patients, produces a dramatic enhancement of the abdominoplasty result.

The ‘full’ tummy tuck

Many women, after one or more pregnancies, will have changes in both the abdominal soft tissues (skin and fat) and the abdominal wall. This usually consists of loose, flaccid skin with (but sometimes without) stretchmarks, and outward bulging of the abdominal wall, especially below the belly button. These changes occur in response to both mechanical expansion of the abdomen by the growing baby and to pregnancy hormones that circulate in high levels only during gestation.

For most patients with these post-pregnancy changes, no amount of diet or exercise will significantly improve the abdominal appearance. Most of these patients require a full tummy tuck, as described above. A full tummy tuck involves removal of most or all of the skin and fat between the pubic area and the existing belly button, tightening of the rectus abdominis (‘6-pack’) muscles from the bottom of the sternum to the pubic bone, and creation of a new belly button. Some abdominal and hip liposuction is usually performed as well.

A few patients have severe post-pregnancy skin and soft tissue excess that cannot be adequately corrected by means of a horizontal, suprapubic incision alone. In select patients, a vertical midline incision can be added to allow removal of skin excess in a horizontal as well as vertical direction. A great advantage of adding this incision is the ability to draw the waist inward as the tummy tuck is closed. This procedure is sometimes referred to as an ‘anchor’ or ‘inverted-T abdominoplasty’, as the resulting scar has that configuration. The technique is performed for patients in whom the resulting improvement in the overall abdominal profile outweighs the ‘downside’ of a midline surgical scar.

The nature of the tummy tuck surgery that will best suit each patient is determined during the consultation and is based on the physical examination. For all patients, I draw the proposed incisions on their body with a skin marker (it washes off easily) so that it is clear what the nature of the resulting surgical scars will be. I also outline liposuction areas if that is part of the surgical plan.

The ‘Mini’ tummy tuck

In some women, the abdominal skin will contract after delivery and maintain a great deal of its natural tone. Abdominal bulging may be confined to the area below the belly button. In these patients, a mini-tummy tuck may be adequate, which involves a shorter suprapubic incision, no surgical alteration of the belly button, and a quicker recovery time.

In a mini-abdominoplasty, the rectus abdominis muscles may be tightened below the belly button only, if the abdominal “bulge” is confined to that area. If abdominal wall laxity extends above the belly button, it is possible to tighten the muscles all the way up to the level of the sternum (ribcage). To do this, the umbilical stalk is divided at its base, and then reinserted at its original location once the muscle-tightening sutures have been placed. The patient still keeps their ‘original’ belly button.

A mini-tummy tuck generally does not alter the blood supply of the abdominal skin as much as a full tummy tuck, and therefore more aggressive liposuction of the waist and back may be performed in many cases.

‘Reverse Upper’ abdominoplasty

Not infrequently I see patients in whom there is as much skin laxity in the upper abdomen as there is in the lower abdomen. In fact, some patients after pregnancy will have fairly ‘toned’ lower abdominal skin, but very lax and redundant upper abdominal skin. In these situations, the removal of skin in a vertically downward direction ( a conventional tummy tuck) is not adequate to correct the upper abdominal skin laxity. Such patients are often very good candidates for what I refer to as a ‘reverse upper’ abdominoplasty.

This surgical technique involves removing excess abdominal skin vertically upwards using incisions hidden in the inframammary folds underneath the breasts. In general, this operation is best reserved for patients with fairly full or at least slightly droopy breasts, which serve to nicely conceal the inframammary folds. An important part of this procedure is the placement of permanent lifting sutures that elevate the lower skin edge, following removal of excess skin, to the upper skin edge in the inframammary fold. These permanent sutures ensure that the resulting surgical scar remains hidden within the inframammary fold.

A great advantage of this procedure is that the patient’s original belly button is preserved, and thus there are absolutely no surgical scars that are visible when wearing a two-piece swimsuit or typical underwear (bra and panties). Additionally, because this procedure generally requires less skin undermining and thus less interruption of the normal blood supply of abdominal skin, more thorough liposuction of the waist and back can be performed at the same time.

Many patients having this surgery, therefore, undergo a reverse upper abdominoplasty combined with a lower ‘mini’ abdominoplasty, tightening of the entire length of the rectus abdominis muscles, and liposuction of the circumferential trunk – and keep the belly button with which they were born. I usually refer to this operation as ‘reverse upper / modified lower abdominoplasty’.

The ‘Internal Corset’ – a procedure to narrow the waist

The permanent sutures that are used to flatten and tighten the abdominal wall are typically placed in the midline. The rectus abdominis muscles, prior to pregnancy, are lined up immediately side-by-side. Expansion of the abdominal wall during pregnancy allows the muscles to stretch apart, leaving a weak layer of fascia (connective tissue) spanning the gap between the two muscles – the medical term for which is diastasis. The midline tightening sutures correct the diastasis and bring the rectus muscles back into a ‘side-by-side’ configuration, flattening the abdominal wall in the process.

Although this midline tightening dramatically enhances the abdominal profile, it often does adequately address the fact that pregnancy can also wreak havoc on the waist, turning what was formerly an ‘hourglass’ figure into something that is more cylindrical in shape. For several years now I have been using permanent ‘internal corset’ sutures, placed laterally in the abdominal wall, that draw the waist inward and restore some of the hourglass effect of abdominal concavity at the waistline in frontal view. The addition of these sutures to midline tightening, and in some cases in place of midline tightening, has allowed me to achieve even more impressive postoperative results.

Improvement of flaccid skin and C-section scars

I have been encountering more and more patients who through exercise, good fortune, and quite probably the right genes maintain a flat abdominal wall after pregnancy, but who have some excess skin below the belly button. This situation is actually quite common in patients who are very fit and athletic, and it can often be improved dramatically in an office procedure that involves removal of redundant skin only.

I also see a fair number of patients who are content with the overall appearance of their anterior abdomen, but who are not that happy with their C-section scar. C-section scar revision is also frequently performed as an office procedure, and minor lateral extension of the C-section scar can allow some tightening of the lower abdominal skin to be performed in those patients who desire it.

Abdominoplasty for Men

Men are also candidates for tummy tucks, especially those who have experienced significant weight loss, and as a result have excess abdominal skin and laxity of the abdominal wall which generally cannot be corrected with exercise alone. In male abdominoplasty, it is sometimes possible to achieve the desired post-operative appearance by means of fairly aggressive liposuction of the anterior abdomen and circumferential trunk, combined with removal of redundant lower abdominal skin via a suprapubic incision. In many cases, this does not require enough skin excision to warrant the creation of a new belly button, and thus surgical scars are avoided in that area.

Other male patients with significant anterior abdominal skin excess will require significant skin excision and the requisite umbilicoplasty. Midline tightening of the rectus muscles is performed to flatten the abdominal profile. As male patients are more likely than females to have significant intra-abdominal fat storage, it is especially important for male patients to be at an ideal (and stable) weight when undergoing tummy tuck surgery. Excessive intra-abdominal fat storage can significantly limit the potential enhancement of the abdominal profile.

Note about Drainless Tummy Tucks

There are two means for performing drainless tummy tucks. The overall concept is that you do something which secures the abdominoplasty skin flap to the underlying abdominal wall, closing down the potential space in which a seroma can collect. Seroma fluid will still be present to some extent postoperatively; however, it is usually not possible for a large seroma to form as the abdominal skin is secured to the abdominal wall.

One means of securing the skin flap to the abdominal wall is by placement of “quilting sutures”, which are running sutures that secure the abdominal skin flap to the abdominal wall and which are placed during the closure procedure. This can work well for patients with thicker layers of subcutaneous fat, as there is more subcutaneous fat for the sutures to grab and it is therefore less likely that visible indentations will be present in the abdominal skin when this procedure is completed.

Another way of accomplishing drainless abdominoplasty is by the use of an internal adhesive product, which essentially glues the abdominal skin flap to the abdominal wall. This is an ideal approach for thinner patients, who tend to produce less seroma fluid and who are more likely to have obvious indentations in the skin from quilting sutures. Unfortunately, the product that we have been using on our thinner abdominoplasty patients called TissuGlu has been recently discontinued as the company could not get FDA approval for additional indications for their product and is no longer producing it.

So at this time our only option is quilting sutures, which I only use for patients with thicker abdominoplasty skin flaps (thick layer of subcutaneous fat which helps conceals the quilting sutures). In some instances of quilting suture placement, I still place one drain in the suprapubic area in patients who I think are likely to produce a lot of tissue fluid postop.

For thinner patients, I still use drains. However, the thinner the skin flap, the less fluid production there will be, and thinner patients therefore tend to need their drains for a much shorter period of time.

One other issue to consider regarding postop drains is this: patients are not permitted to exercise for two weeks following abdominoplasty, and intimacy is not really practical for the first two weeks given the fairly significant recovery involving the entire anterior trunk. While the drains are perhaps a little bit cumbersome to manage for the week or two (or rarely three) that they are generally in place, I don’t think that they are that much of an imposition given the fact that patients are not exercising or having intercourse.

I am hopeful that a new internal adhesive will come on the market in the near future. We had great success with TissuGlu in our thinner patients, and those patients certainly did appreciate not having to manage drains for the first one to two weeks postop.

For more information about cosmetic plastic surgery for body contouring or if you would like to schedule a body contouring surgery consultation, please contact the Raleigh, North Carolina office of Dr. Michael Law today!