- Abdominoplasty (Tummy Tuck)
This surgery is performed in an operating room under general anesthesia. You will go home after surgery and need a responsible adult to drive you home and stay with you for the first 24 hours. On the day of the procedure, wear loose-fitting clothing, and avoid any aspirin, ibuprofen, or other blood-thinning products for at least one week. Make sure you have absolutely no exposure to tobacco, marijuana, or any products (hookah, nicotine gum, or any other agents) for at least 30 days before and after surgery. Please keep in mind that second-hand exposure can be just as damaging as direct use of these products, so please avoid any exposure at all for at least 30 days before and after the procedure. Any exposure to these products can be particularly problematic for wound healing in this operation.
On the night of surgery, you will have a binder on your abdominal wall and usually two tubes; go to sleep with two pillows under your head and two pillows under your knees. Empty the drains two to three times a day; you do not need to measure the output but just discard it. When getting out of bed, it is easier to rotate so that your abdominal wall does not stretch straight for the first one to two weeks.
The day after surgery, remove the binder, and cotton, and shower. You can place the drain tubes above your shoulder, or you can place them on the side of the shower. Gently wash all areas and then dry well. When putting on the binder, put it low so that the top does not touch your breasts. It is often easier to wear a t-shirt under the binder. There are tapes (steristrips) on the incision. The longer that these stay on, the better the quality of the final scar. If they begin to fray, they can be gently trimmed with a scissors. Once they are off, you can apply an agent such as cocoa butter daily to the incision line.
Try to walk as much as possible following surgery, and to drink plenty of fluids. Walking two or three times a day, ten to twenty minutes at a time, is incredibly helpful. It is not necessary to walk rapidly or take large steps, but the activity is useful both to reduce complications and to improve healing.
The drains will be removed in the office, usually the first after one week, and the second one to two weeks afterwards. With each subsequent week, you will find your energy level rising, discomfort reduced, and well-being improved. While walking can begin shortly after surgery and can be more significant with each passing week, full activity such as strenuous sports should not resume until three months after surgery.
An abdominoplasty is the most effective technique to improve the contour of the abdominal wall.
The abdominoplasty has two main components, and a third that is frequently performed. The main component is removal of an ellipse of skin and fat from the lower abdominal wall. This skin and fat are removed and discarded; the skin above is then elevated and then pulled down. The umbilicus (belly button) is the separated from the surrounding skin and brought back out from the skin that has been pulled down. The second component of the abdominoplasty is plication of the rectus muscles. The rectus abdominus muscles are long, parallel muscles that are on the left and right sides of the abdominal wall, running up and down the entire length of the wall. During pregnancy or weight gain, they separate (diastasis recti), and in an abdominoplasty, they are sutured back together. These two maneuvers tighten the abdominal wall in both dimensions, up and down as well as side to side, and create an hour-glass appearance of the silhouette. During most abdominoplasties, there is some adipose (fat) tissue on the flanks, and I find it helpful to liposuction some of this tissue to help with contouring, performing it in most abdominoplasties.
Abdominoplasty is a significant procedure, and the recovery can take several weeks. Drains are small thin tubes that remove fluid from the surgical site, and I find that drains help recovery proceed more quickly. Sometimes this operation can be performed without drains, but many plastic surgeons find that the hassle of the use of drains is compensated by the more rapid and smoother recovery. Frequently “plication sutures” are placed between the repositioned skin and the underlying abdominal wall, and this maneuver, also known as “progressive tension sutures”, helps hold the tissue in place and reduce (or possibly eliminate) the duration of drain use. I find these techniques quite useful and am liberal in their use, but still prefer to use drains as it minimizes complications.
Recovery after abdominoplasty can take several weeks, and most patients find that two to three weeks off work is necessary. Often the abdominal wall is tightened significantly, and standing up straight is discouraged for the first week as the tissues relax. A binder or garment are sometimes used, although some plastic surgeons do not use these agents. Similarly, some plastic surgeons advocate the aggressive use of massaging, and others find that it does not significantly improve results. Regardless of the techniques used during the recovery period, time is the most critical component and usually the improvement seen from the first to the second week after surgery is profound. I do recommend that patients start walking the day after surgery and avoid prolonged periods in bed or at rest, and without question ample walking during the recovery period helps minimize complications and quickens recovery.
Some patients get decreased blood flow to the lower, central part of the abdominal wall, the area below the umbilicus (belly button) just above the incision line. Some degree of decreased blood flow is quite common, particularly when the abdominal wall has been pulled tight and liposuction performed. Usually this area heals without difficulty, although in some patients the area with decreased blood flow can slough and a small opening appear. With each day, the blood flow to this area improves, and the wound improves and heals. While this situation can be frustrating, it often has no effect on the final aesthetic result and resolves by itself.
The most concerning complication following abdominoplasty is a blood clot in the legs (DVT/PE), which we believe is a combination of tightening of the abdominal wall, and a period of immobilization. Some patients have a predisposition to blood clots, so if you have had a blood clot in yourself or in a family member, or have had abnormal bleeding, please let your surgeon know so that additional measures can be performed. The single best way to minimize the chance of a problem with blood clots is to walk early and frequently. Some patients can be placed on blood thinners (especially if they or family members have had blood clots), although blood thinners will raise the risk of bleeding after surgery. If you have any shortness of breath or any concerns following surgery, notify your surgeon immediately.
This surgery is usually performed at in an operating room under general anesthesia. You will go home after surgery and need a responsible adult to drive you home and stay with you for the first 24 hours. On the day of the procedure, wear loose-fitting clothing, and avoid any aspirin, ibuprofen, or other blood-thinning products for at least one week. Make sure you have absolutely no exposure to tobacco, marijuana, or any products (hookah, nicotine gum, or any other agents) for at least 30 days before and after surgery. Please keep in mind that second-hand exposure can be just as damaging as direct use of these products, so please avoid any exposure at all for at least 30 days before and after the procedure.
The access sites are usually loosely closed, or sometimes left open, to allow fluid to egress. It is helpful to place a towel above your sheets to collect any fluid that might egress for the first and second nights. The day after surgery, you can shower and wear loose-fitting clothing to minimize rubbing and tenderness.
Beginning the second day after surgery, it is helpful to gently massage the areas daily with an agent such as cocoa butter or shea butter, ideally for the first two to three months. While this is not mandatory, it does help the tissue heal in a supple and soft manner. In addition, if you wish to wear a garment, you can do so but make sure to remove it at least once a day. Some plastic surgeons find that garments are incredibly helpful in achieving the desired result and reducing recovery time; other plastic surgeons have found equivalent results with and without garments, with concern about skin pinching and the cost of the garments. I personally find that there is variation from one patient to the next and have found patients to do quite well both with and without garments.
Liposuction is one of the most common plastic surgery procedures because of its effectiveness, minimal scar burden, and rapid recovery; it is also one of the more understated challenging procedures. A small cannula is placed through a series of sub-centimenter incisions to remove fat under the skin; the small cannula minimizes damage to nerves and blood vessels, and the fat is suctioned through the sides of the cannula. Often the paths are crossed to achieve a more even result. Probably just as important, the cannula often scrapes the underside of the skin and irritates it, and deep skin inflammation can result in contraction of the skin over the subsequent three to six months, an often-desirable secondary effect.
The challenge of liposuction is removing the appropriate amount of fat. In areas such as the flank, abdominal wall, back, and neck, often a significant amount of fat can be removed that results in profound improvement with enough fat left behind to allow ample sliding of the skin against the underlying muscle and fascia. In other areas, most often the thighs but even in the abdominal wall, removing enough fat to achieve an improvement, but avoiding contour irregularities and ridges can be quite challenging. Sometimes the results look superb at the time of the operation, only for contour irregularities to develop as the tissue heals and remodels. In areas such as the upper arm and neck, occasionally the fat can be reduced, but the remnant skin does not sufficient contract—or does not contract at all—and there is loose skin, replacing one concern with a second. While several technologies attempt to tighten skin without surgery, the results on most of these have been disappointing, and I have not seen any that consistently gives significant results without added complications or scarring.
For most liposuction cases, general anesthesia is necessary due to the discomfort. For small areas such as the neck or small spot points on the body, liposuction can be performed in the office under local anesthetic. However, it is difficult to anesthetize larger areas in an awake patient, and general anesthesia is needed for most cases.