Abdominoplasty–What you need to know
An experienced plastic surgeon’s viewpoint by
Dwight V. Galloway M.D.
Abdominoplasty, popularly known as tummy tuck, has become one of our most commonly requested and preformed surgeries. It is the central feature in the “mommy make overs” which helps correct the most visible changes to your body associated with child bearing. This means that a huge percentage of the female population are candidates, something that has always been a problem but only in the last 30 years has become well known.
The 2 major problems that need correcting are the stretched and excess skin and fat on the abdomen – and the stretched muscle and midline tissue that give a lower abdominal ”pooch”, as well as low back pain. A mini abdominoplasty does not move the belly button and in plastic surgeon’s thinking is what is really “a tummy tuck”. The skin above the umbilicus must be fairly smooth and a less severe overall problem apparent for this to be the best solution. It takes only about an hour to perform and can be done as an outpatient. My estimate is that about 10 to 15 percent of women would need only the mini, though in the past I did a much greater percentage than that. The part of the stretched midline tissue, actually called a “rectus diastalsis” that is causing the low back pain can be repaired through this much more limited operation.
The full abdominoplasty removes all the skin and fat from the top of the pubis to just above the umbilicus and goes from mid lateral to mid lateral on each side. For weight loss cases this incision goes well around the back and in extensive cases a “total body lift” goes all the way around, like a belt. The upper skin and fat from the umbilicus to the breast bone and ribs is opened up to allow this tissue to stretch down to the pubis. The umbilicus is left attached to the midline where it is originally and a small hole cut through the skin to allow it to be brought up to the surface. This dissection gives superb visibility and access to the muscles and midline tissue to easily repair the ”rectus diastasis” and cure your low back pain and allow you to again to do sit ups. Liposuction is usually done on the flanks to help narrow the waistline but is probably dangerous to do in the upper abdomen as the blood supply to the lower midline skin and fat comes through that area. (It is safe to do liposuction for a mini abdominoplasty.) Of major significance on this operation is the danger of nicotine, usually from smoking, either just before or after the surgery and even a history of smoking years before can increase the incidence of skin death and a huge open wound for 2 to 3 months. If you continue to smoke or are around smoke from someone else the skin can die. The full abdominoplasty is by far the most common operation I do today that is so severely affected by any source of nicotine.
The initial abdominoplasties were usually done for obesity and/or weight loss with the abdominal skin hanging down on the thigh. This is still done today and some obesity surgeons do their own cases, with my blessing since these are very big cases with low insurance payments. The insurance companies will not cover the routine abdominoplasties as they call it “cosmetic” and completely deny the association with the low back pain relief that routinely happens when the muscles separation is repaired.
Drains and suction catheters after surgery are routinely used by many plastic surgeons. Only about a third of us do not. I have not used them in over 40 years and have used what are now known as “quilting stitches” or “tension stitches” during that time, 20 years before they had a name. It is a well published and l know as fact that seromas and hematomas are essentially eliminated by this method, though they are very common i.e. 30%, with the drains system. It takes some extra time and work to place the sutures but we have become very efficient in their placement and can do a complete full abdominoplasty with rectus diastasis repair in about 2 hours. The drains are usually the patient’s major complaint after operation.
The position of the resultant scars has changed over the past 30 years. Initially in the 1950s the Bikini bathing suit was very low but went across the hips and we tried to place the scar where it could be covered by the suit. Then in the early 1980s the one piece bathing suit and exercise and running garment left the hips exposed and these scars stuck out and were unacceptable and we placed our incisions much higher and more confined to the abdomen. Now we are back to the low suits with very narrow bands so we are back to 1970 but placing the central incision thru the pubis. These scars are usually not thin hairlines and require coverage by clothes or possibly a tattoo. The lower central skin is numb after the operation and usually the nerves grow back and sensation returns over a one-year period.