Tummy tuck
Tummy Tuck
Dermolipectomies Abdominoplasty
Introduction
We live in an age when a significant number of women do not give themselves to motherhood, fearing bodily consequences.
They are willing to give birth to children, however they sacrifice only a part of their lives for motherhood. Moreover, after birth-giving they try to get rid of the bodily consequences which they wear as traces of pregnancy and of the following period. The number of women whose appearance shows a regression of a degree that they might as well deny the fact of birth-giving, is small. Most of them, despite their youth, have to take notice of significant changes even after no extreme weight fluctuation. The deformities of the abdomen and the breasts are especially apparent and long-lasting.
Thus it is not accidental that the various diets, skin regenerating and refreshing cures, the offers of fitness clubs, which promise participatants to regain their youthful shape, are popular. Those who are fortunate with their bodies and are sufficiently persistent, sometimes achieve some kind of result with one of the methods mentioned above. Others (and this is the majority), being dissatisfied with or even before such experimentation turn to solutions provided by plastic surgery.
The candidates of abdominoplasty are naturally female, more rarely male, patients who request an operation because of abdominal adiposity that developed due to obesity, or people who require corrections of the deformities that were caused by post-dieting weight loss. In these cases deformities of the tissues affected are similar to the consequences of pregnancy, thus they are discussed together, emphasizing that there is a great variety of the abdominal constituents participating in the deformity that forms the basis of the complaint, and in the degree of the complaints.
Definition of Abdominoplasty
Abdominoplasty is the functional and aesthetic operation of acquired abdominal deformities. The intervention also affects the skin, fat and muscular pallium.
The indication of the operation is the changing tissue form that plays the main role in the development of the deformity, but as a result of the intervention our activity covers other constituents as well. The primary aim of the operation may be functional (rectus diastasis, sagging abdomen causing intertrigo), in other cases the demand for treating the abnormality is aesthetic.
Lately there have been more well-informed patients, moreover, associate specialists requested for a joint performance of abdominal interventions (ovariectomia, hysterectomia) and abdominoplasty.
Abdominal Deformities caused by Pregnancy (Weight Gain-Loss)
- • A. Striae, stretching-sagging, attenuation of the abdominal wall skin, in certain cases express atrophy (mainly around the umbilicus). Scars that developed previously due to birth giving.
- • B. Regional fat deposits of the abdominal area. General obesity. Indenture and fat deficiency of the periumbilical region.
- • C. Stretching of the abdominal wall muscle-tendon pallium. Rectus diastasis. Herniae.
- • A. We often wonder that the skin, following its stretching caused by pregnancy, is able to retain almost no traces of it even after multiple birth-giving. This is the more remarkable since the skin area between the rib arch and the fold of the groin has to stretch 2-2.5 times the normal size during a normal pregnancy.
This process of stretching is not identical with the stretching performed by artificial tissue expansion, since pregnancy does not attenuate the skin. In this case due to the metabolic activity caused by the pregnancy hormones, new epithelium, collagen and flexible fibers develop, as well as new blood-vessels, nerves and lymphatic vessels. Its main difference from weight gain-loss is its ability to develop new tissues.
The pace and degree of skin shriveling after birth-giving are determined by constitutional factors, age and lifestyle conditions following pregnancy (eating, regular exercises), but do not guarantee the avoidance of consequences. Thus there are a lot of cases when despite the young age and fit, active lifestyle even one pregnancy may leave its permanent traces on the skin.
The size, number and position of the striae may vary. Sometimes there are only a few slightly visible lines. In other cases the skin is covered with 2-
These are linear athropic scars which develop due to the tightening skin. Histologically, first edema and perivascular infiltration are visible. In the case of older scars the epidermis grows thin and the collagen-eosinophil fasciculi are perpendicular to the direction of the tightening. Their colour is first livid-red, later pearl white and yellowish. (Knowing and seeing the cross-section of the striae during operations, one can hardly understand the justification of masks and various treatments, which (according to TV commercials) promise their disappearance after a sufficient number of repetition.)
The sagging, stretched skin on the abdominal wall (as well as on other parts of the body) is most frequently detectable on women who regain or even lose weight before pregnancy. The degree with which the skin participates in the abdominal deformity can be judged with the so-called "pinch test" (cf. ‘Examination methods’). Extreme looseness is mentioned as "prune belly" in the literature. (cf. picture B.)
Post-pregnancy longitudinal scars after caesareal section are often hypertrophic, and frequently stuck to their root. Even in the case of minimal adiposity they deform the abdominal region by dividing it into two (causing an incisure in the middle). The deformity becomes disturbing mainly when the patient is leaning forward or sitting. The transversal scar of caesareal section (Pfannenstiel-incision) causes more rare aesthetic problems.
Among scars that remained after earlier procedures and are not associated with pregnancy, the median scars above the navel do not hinder the possibility to perform abdominoplasty, although they may cause blood-supply consequences.
B. Most women connect their obesity or fat deposition with their pregnancy. Actually, most of them cannot regain their original weight, or if they can, fat deposits often remain, especially on the region that is under the umbilicus.
According to estimations, in modern Western societies 75% of the population have problems with their weight during their lives. 50% is permanently overweight. Central European countries, including Hungary as well, surpass the West in this respect. Experts explain this with several socio-cultural factors (eating habits, inactive lifestyle, odd prices etc.) Thus, it is not surprising if most candidates of abdominoplasty are more or less overweight. Moreover, many of them believe the operation to be a weight-reductive intervention.
Whether the patient is overweight or not can be determined with a glance during the first examination. Calculations have to be made for his/her classification, as it is indicated among the examination methods.
As opposed to the fat-deposit on the abdominal region (central distribution or "apple-shaped" obesity), peripheral obesity (where the fat deposits appear on the limbs and the hips) means a larger risk factor from the point-of-view of metabolic complications.
Surgical incisions in abdominoplasty
In 1967 Pitanguy published his work on abdominal lipectomy, which is considered to be a milestone. By 1975 he had already reported about 539 cases. His basic principles include: an inconspicuous extending on the lower abdomen to the fold of the groin, subcutaneous undermining extended to the rib arch, umbilicoplastica in transversal direction, strengthening the musculoaponeurotic layer, post-operative compression and simultaneous mammaplasty. His results with minimal complications, were convincing.
In 1972 Regnault reported on the so-called W-dermolipectomy technique. With an incision in the pubic hair and extending it in the mons pubis region, as well as placing the wound tension to the lowest point of the W, he achieved that the scar will not migrate towards the cranial even in a long run, thus he can avoid the ugly suprapubic scars. He emphasized that the identical lengths of the upper and lower wound edges are very important, and that it is useful to slip the upper wound edge into a medial direction in order to avoid "dog ear" edges.
In 1973 Grazer reported on 44 abdominal dermolipectomies, in which with his incision he managed to keep the scar line within the bikini line.
In 1978 Planas with the "vest over pants" technique makes the first incision in the level of the umbilicus giving it a curve so that its lateral end meets the planned transversal incision line. After undermining the part of the abdominal wall that is above the umbilicus, he fixes and pulls the lower position of the incision like "vest over pants".
The "Belt-lipectomy" according to Gonzalez-Ulloa
In 1940 Somalo was the first to extend the transversal incision to the hip region in cases of abdominal dermolipectomy. The method was popularized by Gonzalez-Ulloa (1959, 1960) as the "belt lipectomy" to treat extreme fat deposits of the trunk region (cf. figure "Belt lipectomy").
In 1975 Regnault published the "fleurs de lis" method in which the retained parts are not undermined, with a similar aim.
The introduction of liposuction in 1980s brought significant changes in the field of dermolipectomy as well. This technique, which was popularized by Illouz (1983), Kesserling and Meyer (1978) gained the right in contouring the abdominal region both on its own and in combination..
As it is well-known, the median scars above the umbilicus have already terminated the colateral blood-supply that runs to the opposite side. During the operation their unwounded excision is endeavoured and an inverted T scar is promised from the outset (cf. figure 146). The subcostal scar-line that is parallel to the rib curve necessitates a larger care (cf. figure 147).
In case the skin that lies medially of the incision is undermined during the operation, the blood-supply of a roughly triangular area that extends to the middle line becomes insecure. The more the caudal end of the subcostal incision approaches the future transversal surgical wound, the larger is the risk of necrosis in this region.
Conclusion: apparent, disturbing deformities of the skin: striae, sagging and scars can be the primary indications of abdominoplasty. In most cases deformities can be removed only partially. Post-operative scars are fundamentally affected by previous scars.
The surgical plan is determined by the degree of the patient's adiposity.
If there is a definite local fat deposit in the abdominal region, liposuction is a more adequate solution.
If central fat accumulation is of such degree that the abdomen level does not sink under the chest level when the patient lies on his/her back, then the muscle-tendon sutures that tighten the abdominal wall are not recommended, taking the stretching force of the intraabdominal deposed fat into consideration, which may result in the intersection of the suture.
If the fat deposit of the abdominal region results in a sagging abdomen, i.e. the skin filled with deposed fat above the abdominal stria like above a natural skin fold, sags on the pubic area and thus becomes the source of hygienic problems (sweating, intertrigo), this alone may justify the operation. In this case the least possible undermining is attempted: skin resection in a laurel leaf shape has the least consequences.
B.5. Due to obesity pneumonia, wound infection, the disjunction of the wound, post-operative pains in the vertebrae and thromboembolia are of higher possibility. Thromboembolia was the last in our enumeration, although it is the most feared consequence, since it may also be the source of pulmonary embolism. The inclination to venous thrombosis is partly due to the changed metabolic condition: increased haemostatic activity (like eg. fibriogen, VII. factor) and partly the mechanic consequences of obesity are venous stasis and edema of the lower extremities, which the post-operative tension increases in the abdominal cavity and the position of the lower extremities spoil further. Other risk factors (smoking, anamnesy, expectedly long operation time) may explain the anticoagulant profilaxis beside the elastic gauze.
B.
Conclusion: it can be said that among the abdominal wall constituents the condition of the adipose tissue decisively affects the abdominal deformity that constitutes the surgical indication. Thus, the specific thickness and position of the adipose tissue have to be carefully analysed when making the surgical plan, since these determine the eligible technique. In a lot of cases the result of the operation can be best evaluated on the formal changes of the adipose tissue.
Standard abdominoplasty
Preparation
The patient who regains his/her pre-determined weight, is admitted in an examined condition, if s/he has no low extremity varicositas that would risk the surgical event. During his/her admission it is examined whether s/he has pyoderma or intertrigo on the abdominal wall skin.
The operation is performed with general or epidural anaesthesia, pre-medication happens accordingly. If necessary, thrombosis-profilaxis is started the day before the operation. The pubic hair is shaved off at the time of pre-medication with an electronic razor if possible, or with a unipersonal razor. The abstersion of the umbilicus, especially in the case of bowl-shaped navels, must be given special attention. It is a severe risk factor in the infection of the surgical area.
The covering of the lower extremities with an elastic bandage from the toes to the thigh twist, may be reasonable until the time of the patient's mobilisation (cf. early complications).
Marking
The remaining surgical scar has to be planned to be ideally covered by the underclothes and the swimming-suit. Recently high cut swimming suits have been favoured, thus is be taken into consideration when determining the area of dermolipectomy.
The longitudinal middle line of the abdominal region and the expectable borders of resection are marked in standing position. In our institute it is carried out by drawing the upper wound edge line in the level of the umbilicus (Planas's 'vest over pants' technique), by judging the curve of convexity, the degree of the lateral extension and its meeting place with the lower wound edge with the help of the "pinch test" in a convex arch towards the crania.
According to our experience, in cases of minimal and moderate excess of fat, incisions end under and in front of the frontal-upper coxal spine. The end of the excisions of larger excesses exceed the line of the coxal spine and may reach the lateral line of the trunk.
The plan that was carried out with the patient's standing position is controlled in the patient's lying position with the legs being pulled against the abdomen: by pushing the supra-umbilical region in the caudal direction and by rimming the skin of the pubic area in the caudal direction, we ascertain whether the degree of the planned resection complies with the excess.
The Surgical Procedure
In the first phase of the operation no raising or table bulge is applied. In our institute the operation is started with an incision made in the umbilicar fold. The umbilicar pedicle is dissected, and is left connected to its root. After this, in the level with the previous incision, a transversal incision is made in accordance with the marking by leaving a small "skin area" beside the umbilicus in connection with the cranial wound edge (cf. figure) and by catching them with a tool the use of hooks and catches are avoided. Dissection is made in the level of the musculus obliquus abdominis externus fascia until the rib arches, until the epigastrium, the perforants are electro-coagulated.
The operating table is put in "pen-knife" position, and by pulling the undermined dermal fat flap in the cranial direction with the help of tools, the size of the excess is determined. (If justified, our drawn plan is corrected.)
The transversal skin incision of the caudal convex arc is performed, then the dermal fat between the incisions is removed by detaching it from its root. The supplier blood-vessels are electro-coagulated, the larger or the recurring bleedings are stitched under.
Post-Operative Treatment
In the first 5 hours of the post-operative period a sandbag is placed on the surgical area. The tension of the abdominal area is reduced by supporting the poples. At the same time, the awokening patient is asked to move his/her lower extremities.
Next morning the operated person is woken up and encouraged for self-subsistence as soon as possible, to help his/her mobilisation. The patient is a given laxative with a crystalloid medication, if it has no result for two days, then on the third post-operative day a cone is attempted. If necessary, on the 4th day defecation is solved by enema.
The strip of the lower extremities is removed in the case of patients who achieve the amount of movement that is necessary for self-subsistence. The drain is removed as soon as possible. However, we should take into account that there is a connection between the development of post-operative seroma and the early removal of suction treatment, thus in the case of the drained saines which exceeds a daily amount of 50ml, the drainage is maintained. Usually the drain is removed on the third-fifth post-operative day. At the same time, hospitalisation may also be terminated.
The removal of the suture is carried out discontinuously. The knotty suture of the umbilicus is removed after a week, except the hooked suture. Two weeks after the operation the remaining suture of the umbilicus is also removed, one end of the continuous suture is cross-cut. This latter is pulled out after 3 weeks.
The elastic belly-belt must be worn 24 hours a day until the removal of the sutures, after this only during the day, altogether for 6 weeks. (If the patient wants to wear it on, s/he is not rejected.)
Concerning exercises, the patient's individual activity decisively affects what s/he attempts to do and when. Usually 6 weeks after the surgery, s/he can do everything s/he did before, which also includes sports. The only exceptions are the exercises which are aimed at strengthening the abdominal muscles. These can be started only 3 months after the operation, and even then only gradual stressing is recommended.
Other surgical solutions
Since abdominal deformities vary, their classification is reasonable only if the choice of the surgical technique depends on it. Among the different classifications Matarasso's (1989) seems to be the most appropriate one, since it meets the former demand and is not too complicated.
The classification of abdominal deformities:
- • 1st type: Minimal skin looseness without any anomaly of the muscle-tendon pallium. There is excess fat on the infraumbilical region. It is detectable on young women who have not been pregnant yet. The eligible method is liposuction.
- • 2nd type: Minimal excess skin and muscle-tendon pallium looseness on the lower abdominal region, with any degree of excess fat. Rarely detectable anomaly. The eligible method: miniabdominoplasty.
- • 3rd type: Moderate excess skin and muscle-tendon pallium looseness on the whole abdomen, with any degree of excess fat. The eligible method is midiabdominoplasty.
- • 4th type: Express skin excess and muscle-tendon pallium sagging on the whole abdomen, with any degree of excess fat. It is usually detectable on middle-aged women with multiple pregnancies. Eligible method: standard abdominoplasty.
Conclusion
On the basis of the above facts, it can be seen that abdominoplasty requires due foresight and appropriate experise so that the patients can leave satisfied with appropriate surgical results. (The above facts are demonstrated with some photos taken before and after abdominoplasty, cf. pictures L, M, N, O, P in colour appendix.)
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