To Tailor the Tummy, Tailor the "Tuck"

Posted Friday, September 14, 2007 to PROCEDURES > Body

Posted by The Original Anti-Aging & Cosmetic Surgery Magazine

New York plastic surgeon Philip M Godfrey MD explains different techniques for a flatter abdomen.

Tummy Tuck" is an expression that has long been used to describe the plastic surgical recontouring of the abdomen. This terminology leaves many with the impression that there is but one procedure employed to improve abdominal shape, and indeed, such was the case during the early years of body contouring surgery (late 1950's to late 1970's). However, the advent of new technologies, together with an improved understanding of the tissue changes brought by age, weight change and pregnancy, have enabled today's surgeons to "tailor" the remedy to the individual patient. Choosing correctly from among the several procedures now available is important if results are to be optimized and risks and scarring kept to a minimum.

To develop a proper treatment plan the surgeon must evaluate each of the major tissues of the anterior trunk.

Skin elasticity is assessed, and any redundancy, striae ("stretch marks") and scars noted.

The fatty contribution to abdominal contour is judged by palpating the thickness of the fat and exploring the uniformity of its distribution over the underlying muscles.

The muscles are themselves examined as the physician's palpating hand feels for abnormalities of muscle position and alignment, as well as for frank hernias.

"While modest fatty excess can exist in anyone at any age, pregnancy and large weight swings are by far the most common causes of damage to the skin and muscle." When skin has been stretched enough to become loose or even pendulous ("hangy"), direct removal of the excess will usually be needed. If abdominal protuberance ("pot belly") has resulted from the thinning and separation of muscles, direct plication of the membrane (called "fascia") surrounding the muscles will be needed to narrow the waist and flatten that "tummy bulge."

The specific concerns of the patient are coupled with the physical findings to generate a surgical plan. Simplest among such plans are those for patients with youthful skin and undamaged muscles for whom fatty excess is the sole problem. Suction lipectomy, performed through small incisions will produce excellent results at minimal risk and with short recovery time. In these cases, fat is approached through tiny skin punctures (-3-4mm) placed in the belly button, the pubic hairline and occasionally the flanks. After the fat is infused with a dilute local anesthetic solution, small metal straw-like tubes known as canullae are used to vacuum fat from areas of excess. Post-operative discomfort is generally mild and patients are asked to wear a compression garment and avoid strenuous exercise for 2 weeks.

Patients with muscular damage but minimal skin problem can be offered a musculo-fascial repair performed through incisions in the belly button and the pubic hairline. Using fiberoptic or endoscopic instrumentation, the surgeon can visualize and repair the deeper anatomy through modest incisions that lead to only small scars. These maneuvers can be combined with liposuction where indicated by fatty excess. Postoperative care and recovery very much mimic those following liposuction alone. However, patients are asked to avoid strenuous abdominal exercise and heavy lifting for up to 3 months to protect the muscular repair.

Individuals with damaged, loose skin will ordinarily require some skin removal as part of any total solution. If skin excess is modest and confined to the area below the belly button, removal can be accomplished via a relatively short incision. However, for many patients, skin laxity goes above the umbilicus, requiring the surgeon to loosen and redrape the skin of the entire abdomen. Although this "full abdominoplasty" will result in a lengthy scar at the groin level, it empowers the surgeon to deal aggressively with all three component tissues of the abdomen. This can lead to some of the most dramatic contour changes seen after "tummy tuck" surgery.

Recovery after full abdominoplasty is longer than with lesser operations. Patients can expect several weeks of tightness and moderate soreness, and will often need 3 to 4 weeks to achieve return to pre-operative energy levels. Workouts not emphasizing the abdomen can begin 4 weeks post-operatively while abdominal muscle exercises should wait at least 3 months.

Further "Tailoring" of Surgical Solutions

Although a thorough analysis of the physical findings is critical to the treatment planning process, it may not be essential in every case to plan surgical remedy for every problem identified. Indeed, there are many instances in which patients can have their major concerns addressed through smaller, less risky operations if they are prepared to accept the limitations of those procedures in dealing with every aspect of the deformity. A common example is that of the patient who has liposuction alone and is willing to forego the further improvement that could be achieved with musculo-fascial repair. Clearly, tailoring the "tummy tuck" to the anatomy as well as to the needs and expectations of the patient will yield the best outcomes.

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