The abdominoplasty commonly referred to as a “tummy tuck,” is a procedure to reduce the excess skin and fat around the abdomen and strengthen the abdominal wall musculature. The goal of this procedure is to develop an aesthetically pleasing abdomen and can incorporate direct excisional techniques as well as liposuction. With the rise in bariatric surgery, the abdominoplasty has become a significant resource to help these patients with an excess abdominal tissue after their weight loss.[rx]

Anatomy and Physiology

The fat in the trunk is separated into distinct regions. It is divided by Scarpa’s fascia into superficial and deep layers. The blood supply of the skin and fat of this area is supplied by perforating branches of the superior and inferior epigastric vessels. There are anchoring fascial areas, such as the anterior superior iliac spine (ASIS) and the umbilicus, which provide structural support for the abdominal skin. The inguinal and mons pubis zones of adherence are the most important because they maintain the structural integrity after abdominoplasty.

Indications

The reasons for undergoing abdominoplasty are numerous, including (1) men and women desiring aesthetic improvement of the abdomen, (2) women with significant skin and abdominal wall laxity following multiple pregnancies, or (3) bariatric patients who have excessive skin and/or pannus following significant weight loss. When selecting patients appropriate for surgery, it is vital to obtain a thorough history. Wound healing is of vital importance, and patients require good nutritional status, as well as optimal overall medical health. Bariatric patients present the plastic surgeon with specific challenges. The laxity of the skin after significant weight loss, as well as the potentially massive size of the skin apron, may require further dissection and may require additional adjunct procedures to lift the thigh, back, arm and flank areas to maintain overall symmetry of the body. Patients with lower BMI tend to have superior results, and patients with diabetes mellitus (DM) may be more prone to complications[rx]. Patients with little to no fat and no abdominal wall laxity are optimal candidates for liposuction alone. Patients with minimal to moderate subcutaneous fat and minimal to moderate abdominal wall laxity which is located primarily in the infra-umbilical region are candidates for the “mini-abdominoplasty.” Patients with excessive skin laxity, fat, and abdominal wall weakness are ideal candidates for full abdominoplasties[rx].

Contraindications

Patients with poor health including advanced cardiopulmonary disease, cirrhosis, and uncontrolled diabetes are poor candidates for this procedure. Smoking is severely detrimental to the abdominoplasty, as the procedure requires an adequate blood supply. Many plastic surgeons consider current smoking a contraindication to the surgery. [rx]

Equipment

No special equipment is needed for this procedure. If liposuction is to be added to the procedure, liposuction equipment should be available. Closed-suction should be readily available.

Personnel

Besides the surgeon, an assistant should be available to assist in retraction and can aid in closing the many layers associated with abdominoplasty.

Preparation

A patient’s medical health should be optimized before surgery. Appropriate medical clearances should be obtained well in advance to identify any underlying illnesses that would preclude the patient from the procedure and should be tailored to each patient’s medical history. Appropriate antibiotics should be given in the preoperative period to reduce skin flora contamination of the wound.

Technique

The incision is extensive and is typically made from ASIS to ASIS through the natural suprapubic crease. This positions the final scar low enough on the trunk to be hidden in the bikini line. A flap between the fascia and fat is then created superiorly to the costal margin, following it until the xiphoid process is reached. The umbilicus is circumferentially dissected from the flap, leaving it attached to the abdomen by the umbilical stalk and fat. Special care is needed to leave enough of a fat pad circumferentially around the umbilicus to avoid ischemia and necrosis, as the plexus surrounding the umbilical stalk contains its blood supply. Once the flap is raised, the patient is flexed in the bed to re-drape the flap and determine its final position at the previous incision, and the excess skin is then marked. The fascia of the rectus muscle is then plicated with long-lasting absorbable suture such as polydioxanone (PDS) suture to reinforce the abdominal wall. Some surgeons prefer permanent sutures such as nylon or Prolene, though reports of local reactions and extrusion do exist.[rx] After careful measurement, the marked excess skin and fat are excised and the superior flap is reapproximated to the lower incision in multiple suture layers to strengthen the closure and avoid tension on the skin layer, optimizing healing of the final scar. The umbilicus is then transplanted into the flap, and many techniques have been described for successful omphaloplasty with the choice left to the discretion of the individual surgeon and patient scenario[rx].

Special Considerations

The abdominoplasty can be catered to each patient’s body habitus by altering the procedure slightly. The use of liposuction can aid in the removal of excess fat in the lateral flanks and upper thighs to help smooth the contours of the abdominoplasty. A panniculectomy (essentially an abdominoplasty without the rectus muscle plication) can be of significant benefit in patients who have had extreme weight loss. The blood flow to the abdomen is better maintained in this procedure since it is not necessary to extend dissection to the xiphoid process. This ensures sufficient blood flow after significant weight loss and excessively flaccid skin aprons. A “mini-abdominoplasty” (wherein minimal skin and fat are excised but the rectus muscle is plicated and re-enforced) is ideal for patients who are not overweight and present with infra-umbilical abdominal wall laxity and minimal skin and fat excess. These patients are classically women at a healthy weight who have had one or two children but have maintained good skin laxity[rx].

Postoperatively, it is important that the patient remains in a flexed (Semi-Fowler) position for 2 weeks. This positioning helps avoid excessive straining on the incision and reduce the risk of hypertrophic scar formation. A belt lipectomy can be considered in patients with significant flank, buttock, and thigh fat. This is a circumferential lipectomy which can add the benefits of a thigh and buttock lift to the abdominoplasty. Closed suction drains and oral antibiotics are used at the discretion of the surgeon but have shown only anecdotal benefits in preventing infection and other complications such as seroma and hematoma formation[rx].

LATERAL TENSION ABDOMINOPLASTY

In his publication in Plastic and Reconstructive Surgery in 1995, an article worth reading for any student of Plastic Surgery, he asserted that abdominoplasty was not a two dimension issue but a three dimensional procedure.

Dr. Lockwood’s operation, the lateral tension abdominoplasty, was not just a variation on the old theme but a new concept in the pathophysiology of the abdominal laxity and its management.

His assertions were

In the post partum abdomen the excess of skin is not just vertical, but circumferential.

• The lax skin tends to move medially and caudally when in an examining position (standing) which had given rise to the concept of central abdominal excess as being only in the mid line in the classic abdominoplasty.
• Muscle correction is an integral part of creating a flat abdomen.
• A continuous dissection in the subcutaneous tissue is not necessary to mobilize tissue for excision.
• Discontinuous dissection is done to mobilize tissue
• Use of liposuction to contour the torso, tissues are left behind, not excised.

With these assumptions he devised the surgery that was different from the classic in terms of the placement of scar, the extent and nature of dissection, the direction of the tension and pull and the recognition of the tension bearing layer he called the superficial facial system (the SFS).

The evolution of this thought process was to meet the demands of people who were not only looking for a relief of a burden of weight but seeking an aesthetically attractive abdomen as an end result [Drawing 1].

Aesthetic Units of the abdomen

Complications

Seromas and hematomas are relatively common postoperative complications, occurring in up to 1/3 of cases[rx]. If left untreated, these can result in necrosis of the flap from lack of blood supply or infections which can destroy the flap and are potentially life-threatening. Placement of closed-suction drainage systems can help decrease the incidence of accumulation of these fluids anecdotally, though high-quality data are not available to demonstrate efficacy[rx]. Vascular compromise to the umbilicus is an important complication to avoid. Careful dissection of the umbilical stalk is directed at maintaining enough fat around the umbilicus to preserve adequate blood supply. Superficial wound complications remain the most common complications for this patient population. Infection and wound dehiscence can result when excessive tension is borne by the closure, particularly the subdermal and skin layers. Patients are usually placed in the “Semi-Fowler” position to minimize these complications, but even with ideal positioning the rate remains significant. [rx][rx]