Abdominoplasty (Tummy Tuck)

abdominoplasty - tummy tuck surgery - Dr Magnusson

 

What is an abdominoplasty?

An abdominoplasty or tummy tuck is an operation on the abdomen designed to address a number of common physical changes that can occur during the course of pregnancy. These changes can be loosely related to problems of the skin (looseness or stretch marks), problems of fat and fat distribution (uneven fat distribution, loose apron, contour changes in the silhouette, volume loss in the buttocks) and changes to the muscle (muscle separation primarily associated with pregnancy and called rectus divarication). These problems are usually most severe centrally in the abdomen and an abdominoplasty is a common procedure that addresses these changes very well.

Many of these changes can also occur following significant weight gain and subsequent weight loss and are frequently greater when pregnancy is associated with weight gain and weight loss. The problem also occurs in men in the setting of significant weight loss, frequently referred to as massive weight loss (MWL). This group of patients often has more substantial concerns although the abdomen is usually still the most affected area. The difference is that the looseness goes all the way round the body rather than simply in the abdomen and consequently many of these patients will consider a circumferential body lift that addresses the abdomen, flanks, outer thigh, buttocks and lower back rather than just the abdomen.

What is an abdominoplasty?

What problems does an abdominoplasty address?

Addressing the changes to the skin, maldistribution or excessive fat and separation of the abdominal wall muscles leads to an improved contour and flattening of the abdomen. Loose and redundant skin folds are removed. Irregular contours and fullness above the umbilicus/bellybutton are evened out. The skin which is removed is also the skin which is frequently most affected by stretch marks and consequently the skin that remains is of higher quality and a better appearance. Tension in the skin also makes residual stretch marks and irregularities less visible in a similar way that lines on a bed sheet are less noticeable when the sheet is tight across the bed even though they are still present.

It is not well appreciated that there are very substantial functional improvements following abdominoplasty in addition to these aesthetic benefits. Dr Magnusson has recently contributed 77 of the total 214 patients to a prospective multi-centre study investigating these functional improvements.

Functional improvement after abdominoplasty.

The physical symptoms associated with these changes can be quite substantial. It is very common for women to develop back pain during pregnancy and for many women this is ongoing. Associated with this is a frequent struggle with the loss of “core strength” when people find it difficult to stand on one leg or to get up from lying on their back. It is also frequent to have symptoms of urinary incontinence following pregnancy.

In Dr Magnusson’s patients there was roughly a 75% improvement in back pain at six weeks and almost 90% at six months following abdominoplasty. Urinary incontinence also improved by 80% at six months.

The decrease in functional capacity following pregnancies due to a reduction in stability. There is a synergistic action of all of the trunk muscles that carry load and function through to the lumbar region. As a consequence these patients also can suffer from repetitive musculoskeletal injuries stemming from pelvic instability. At abdominoplasty the anterior rectus distance is closed and function increases. The closure of the diastases restores fashionable tension throughout the abdomen and in particular in the transversus abominis and internal oblique complex responsible for “core strength”. Abdominoplasty also works to increase intra-abdominal pressure which acts as a further stabiliser for the lumbar spine.

The method by which urinary function improves relate to increased strength of the anterior abdominal wall leading to more complete bladder emptying and improved tensioning of the lumbodorsal fascia, stabilising the lumbar spine and improving pelvic stability as the lordosis of the spine is the most important parameter controlling the distribution of the forces between fascia and muscles. With abdominoplasty the plication improves posture, repositions the pelvis with a compensatory advancement of the head and shoulders. The lordosis of the lumbar spine is restored to the pre-pregnancy condition along with stability. Retensioning of the pubis acts to lengthen the urethra and improve continence.

In this study, almost one in five of Dr Magnusson’s patients also had an abdominal hernia which was corrected at the time of surgery.

There are of course other physical symptoms associated with chronic skin irritations beneath overhanging loose skin folds. This condition, intertrigo, can be debilitating speeding to skin infections, chronic malodorous discharge and in fact if the apron is large enough can interfere with basic hygiene.

A number of Dr Magnusson’s patients undertake abdominoplasty surgery purely to address physical symptoms or hernias regardless of the aesthetic improvements.

The Surgery

What happens at an abdominoplasty operation?

Abdominoplasty is performed under general anaesthetic and most patients will stay at least one night in hospital.

The most frequent type of abdominoplasty is a full or radical abdominoplasty. there are other types of abdominoplasty including a mini abdominoplasty, corset trunk-plasty and fleur-de-lys abdominoplasty which are less frequently performed, are indicated in certain circumstances and have different types of scars.

At operation local anaesthetic with adrenaline is infiltrated into the area to be treated. This means that less pain is felt during the operation and there is less pain immediately after the operation as well as a reduction in bleeding during surgery and bruising afterwards.

Liposuction of varying amounts is performed next. Liposuction is performed to remove fat directly under the skin that is removed so that the normal lymphatics and nerves can be preserved as much as possible to reduce the recovery time and likelihood of some complications such as seroma. The distribution of liposuction varies from one patient to the next according to the individualised operative plan and the specific patient goals. the liposuction can be just under the skin that is removed, include the flank/love handles or incorporate removal of fat all through the abdomen, waist and back to sculpt the whole body.

Following liposuction, the abdominoplasty is performed.

An incision is initially made around the umbilicus and for a full abdominoplasty, the umbilicus stays where it is and everything else moves around it. The remaining skin and fat is lifted up off the abdominal muscles from the incision in the bikini line up towards the ribs in the centre exposing the muscles that have been separated. In the recent study the average separation of the muscles that was repaired at surgery was 5.2 cm. These muscles are repaired with permanent stitches so that the separation does not develop again. This is the most important functional step of the procedure and is performed regardless of which type of abdominoplasty is undertaken.

Following the repair of the muscle separation the bed is placed into a semi seated position and the skin is pulled down over the thighs and the excess is removed.

The skin is held back on the muscles by progressive tension sutures which obliterates the space underneath the skin reducing the risk of problems in the recovery.

A small incision is made above the umbilicus and it is returned to the surface of the skin in it’s usual position.

A drain is usually required. The skin around the umbilicus and along the wound in the bikini line are repaired with stitches that are placed under the skin and dissolve without requiring removal.

Dressings that are waterproof are placed over the incisions and a compression garment is fitted in the operating room that will be worn night and day for six weeks apart from shower time. Normal showering is resumed once the drain is removed which may be the next day but is commonly three or four days.

Surgical options and additional procedures.

Although the problems that are being addressed within abdominoplasty are generally in the middle of the abdomen, the larger the amount of loose skin that is going to be removed then this will mean a longer scar. After removal of the central excess, the side elements of the scar are essentially a pleat to make everything sit flat. The larger the gap the longer the pleat and therefore the longer the scar. If this skin is in very good condition and the problem relates primarily to fat volume and muscle separation that may be possible to perform a mini-abdominoplasty. During this operation and incision is made which may be not much longer than a cesarean scar, there is no separate incision around the umbilicus but the muscle is still repaired and liposuction can still be undertaken to help contour the body even when the skin is of good quality. When there is a significant excessive skin and especially when there are significant stretch marks, a minimum dominant class to you will not achieve the same outcome as a full abdominoplasty because there won’t be an ability to remove as much of the damage skin and to address looseness or an apron.

Operations such as a fluer-de-lys abdominoplasty or corset trunk-plasty are for specific circumstances. They usually performed following massive weight loss and especially in the presence of pre-existing mid-line abdominal scarring. These procedures can help develop side to side tension as well as up-and-down tension which is also a problem following MWL. While most patients with massive weight loss will consider a circumferential lower body lift which has a much more concealed scar, some may consider these procedures instead. The more visible scars are a significant reason why these are less common procedures.

Circumferential trunk liposuction is performed frequently with abdominoplasty surgery in about half of the Dr Magnusson’s patients In this procedure all of the fat beneath the skin to be removed is taken away with liposuction preserving the lymphatics and superficial nerves. Additional liposuction is then performed above the umbilicus to reduce the thickness of the fat layer under the skin in this area so that it matches better the thickness of the skin and fat in the groin. Further liposuction is also performed with the patients on their side in the love handles, into the lumbar region of the back and also the lower chest in the bra roll. This allows for the removal of significant quantities of fat which can be returned into the buttocks as fat grafting commonly referred to as a Brazilian Butt Lift (BBL), or it can be discarded.

It is also common to combine abdominoplasty procedures with breast surgery which is commonly referred to as a mummy-makeover. The nature of the breast surgery is quite diverse and clan include any form of breast surgery but most frequently breast implants/augmentation, breast lift/mastopexy, breast reduction or an augmentation mastopexy which is a combination of implants and a breast lift.

The Ideal Candidate

Who is a good candidate for abdominoplasty surgery?

Abdominoplasty surgery delivers a substantial outcome but is also is a significant operation with an early recovery period associated with reduced activities, a reduced ability to perform normal household chores and no driving.

The ideal candidate for abdominoplasty surgery:

  • Has good general health with a positive attitude and realistic goals.
  • Is close to or in the normal body weight range and has achieved their goal weight if weight loss is required and has remained stable at this weight for some time.
  • If the patient is a woman, she has completed her family and waited at least 12 months firstly to be sure and secondly because there are significant changes to the body that occur during this period of time.
  • The chemicals in cigarettes reduce the blood flow in the skin and have the ability to impact wound healing. While many of the associated goals of this surgery are for an improved appearance of the abdomen, wound healing problems would be a substantial concern. This surgery is not performed by Dr Magnusson on current smokers. Every patient who smokes would be required to stop smoking for at least six weeks prior to surgery and remain off cigarettes for at least 4 weeks following surgery.
  • The best outcomes from any procedure involve three aspects: selection of the correct proceeded to reach the goal, are technically well performed and safe procedure, diligently following the post-operative management plan. Deviation from this path at any step may alter the outcome and importantly that also includes not following the post-operative instructions.

Preparation

The consultation.

When you attend your consultation with Dr Magnusson you will initially be seen by a nurse who will check your medical history, your current medications, any allergies you may have and clinical photographs for your record will be taken. These images are a private and confidential part of your medical record and are not shared in any way without your consent and prior approval. Clinical photographs greatly assist the consultation process as we can look at photographs of the body from angles that you would not normally see to help explain relevant points of the examination and treatment decisions that may be considered.

Information that is important includes past surgical procedures, medications, allergies and adverse reactions to medications.

You will be seen in a lengthy consultation with Dr Magnusson. He will want to determine your goals, expectations and motivating factors.

Your body mass index will be assessed as there is a differential rate of risk and different outcomes associated with different levels of body weight and different body shapes. Dr Magnusson will have a frank discussion about your weight and your goals in this regard.

This surgery has many forms and in some patients additional procedures are indicated.

An examination will be performed that will include:

  1. The assessment of skin elasticity and the distribution of stretch marks if any are present
  2. Fat distribution and volume all the way around the body
  3. Buttock fat content and shape
  4. The separation of muscles in your abdomen and whether or not there are any hernias present.
  5. The presence of any additional problems such as an apron which may be troubled by skin irritations.
  6. Dr Magnusson will then spend time educating you about the various elements of the surgery and what they are designed to do and how this could relate to you specifically.

Commonly there is more than one option to consider. The natural tendency is to choose the smaller and simpler option. A most important aspect in choosing a procedure is to have a clear goal and by understanding how the various elements of the procedure interact to lead to outcomes it will become clear which procedure or combination is going to get you closest to that goal.

Choosing an alternative procedure which won’t logically take you to your goal may be performed well, you may recover flawlessly and yet not be completely satisfied. If your goal and the surgical procedure do not align it is time to pause and realign your decision-making to avoid this.

Dr Magnusson will expertly guide you along this path.

Realistic expectations.

There are many factors that impact surgical outcomes and while good outcomes can be achieved in many different body shapes and sizes, it is important for the patient to appreciate which category they fit into and therefore what type of outcome they will individually achieve.

Patients present with different body shapes. There are curvy figures, apples, pears, those with central visceral fat depositions as well as different shapes according to body weight. In patients of each different type a procedure can be performed well with a good recovery and yet the results will still all differ.

There are also patients who actively engage their abdominal core muscles and stand straight and tall with a relatively flat stomach despite muscle separation. There are others who don’t engage these muscles nearly as actively. Although the muscles are repaired in all patients this does not mean those muscles will be activated. With two patients of identical body shape size and BMI, a patient who engages their muscles will always have a flatter stomach following surgery although both have the ability to hold their stomach flat and this is not under the control of a surgeon.

Additional elements such as massive weight loss, lead to other concerns such as horizontal laxity around the body in addition to vertical laxity in the front of the body. There are also frequently concerns in other areas such as the breast, arms, thighs and even the face. These additional areas may need to be addressed at the same time or at subsequent procedures.

Preparation for surgery and the hospital.

Abdominoplasty surgery is performed by Dr Magnusson at fully accredited hospitals under a full general anaesthetic with fully qualified and experienced anaesthetists.

The vast majority of patients remain at least one night in hospital and if the surgery is more complex such as a mummy makeover or body lift procedure it is not uncommon to stay two nights or less commonly longer.

You will be contacted by the hospital prior to admission who will go through your medical history to ensure there is nothing additional that is required in preparation for your anaesthetic.

You will be admitted to the hospital a couple of hours prior to your surgery and these details will be checked again to ensure that the right person has the right operation.

Dr Magnusson will see you before the anaesthetic and lines will be drawn onto your skin while you are awake in a combination of standing and lying positions to plan the operative procedure. You will have an opportunity to ask questions at this point however it is not good for complex questions because at this point most patients are more focused on the immediacy of the surgery rather than the answers to these questions.

You will be well cared for.

After you are asleep, a catheter is inserted into your bladder, the skin is prepared and the procedure is undertaken as outlined above.

You will wake up in the recovery room, the bed will be bent into a semi-sitting position and you will have your compression garment on.

After about 45 minutes you’ll be taken to the ward and attending family will be able to see you there.

At the end of the day’s operating Dr Magnusson will see you before he leaves the hospital and you will be seen on each day you remain at the hospital.

Many patients with an abdominoplasty do have a drain and you will be taught how to read this and remaining contact with the clinic so that you are aware when it requires removal. For local patients on the Gold Coast or in Toowoomba it will be conveniently removed in clinic. For patients from a more remote or distant location these can frequently be removed with guidance by a GP or nurse. We will assist with instructions in this regard if required on an individual basis.

Dr Magnusson will need to see you on a number of occasions over the next 12 months. Your post-operative visits will be two weeks, two months, six months and 12 months following surgery. If there are concerns or problems arising along the way you will be seen as required at other times.

Recovery

Preparing for the return home.

When you return home from hospital you will have a reduced ability to perform your normal activities and especially your normal household duties.

For those with children arrangements will be necessary to ensure that they are adequately cared for during this time.

Meals: prepare with simple meals that are easy to reheat and healthy snacks with lots of available water.

Accessibility: think of those things that you will need to wake toiletries, medications, tissues/wet wipes, phone/charges/computer/TV remotes. These items should be readily available at hip height so that they don’t require bending or reaching.

Written instructions: keep information about your medications, their timing and your post-operative recovery instructions handy for regular reference as required. Consider a medication organiser so that regular medications can be taken at the right time of the day.

Written instructions: keep information about your medications, their timing and your post-operative recovery instructions handy for regular reference as required. Consider a medication organiser so that regular medications can be taken at the right time of the day.

Recovery.

There are various stages of the recovery from surgery and especially from a significant procedure such as an abdominoplasty.

Immediately after the surgery is common to feel a little dizzy, discomfort and a bit disorientated in association with the medications from your anaesthetic and for managing pain.

The various stages include managing discomfort and the activities of daily living, managing more general household responsibilities, returning to activities including driving and exercise and finally the full maturation of the outcome and scar. These aspects all occur at different speeds.

You will remain in hospital until you are able to manage your discomfort and perform all the necessary routine activities of daily living with the level of support that you will have available at home. This will be after one or two nights in hospital for most patients.

While in hospital you will be taught how to manage your drains and remain in contact with the clinic so that you will know when the drain is ready for removal.

You will be commenced on a medication called clexane and taught how to administer it at home. Clexane thins your blood and is administered by injection once a day. Abdominoplasty surgery does increase the intra-abdominal pressure and reduces blood flow from the legs and theoretically increases your chance of clots. This medication helps reduce the risk of clots during the initial early stage of your recovery during which your mobility is most affected and therefore this risk is Increased. This is a very effective precaution and is continued for a total of 10 days for most patients unless there is additional risk.

In the short term when you get home there will be no driving, no significant exertion and you will feel a little bent over when you try to stand and your abdomen will feel tight. In bed most patients require some extra pillows under their knees to keep them in a slightly bent position for comfort. After about one week most people are standing and lying flat.

At about one week you are well in control. You can return to driving, you know what will bring on the pain and therefore you avoid it and the medications are becoming far less necessary to remain comfortable. A relatively moderate discomfort during the day can be ignored when you are busy or thinking the other things that may become more noticeable when you are trying to clear your mind for sleep. Consequently many patients will still take a stronger pain tablet at night.

Patients with a sedentary job need to be back at work may be able to go back on light duties if they are no longer requiring strong painkillers and especially if they are able to have shortened hours. Most patients will prefer to wait until two weeks if their circumstances permit. If the level of exertion at work can’t be controlled than six weeks off work will be required in uncommon circumstances.

By three weeks you are performing gentle exercise such as walking quietly without hand weights. You are in control of all aspects of your recovery and many patients are completely off painkillers. At this stage you will be performing most of your normal activities they will just be a little more slow and deliberate than usual because you will still be avoiding significant exertion and not moving quite as freely as usual to avoid exacerbating any discomfort.

At six weeks you are liberated! You can return to all activities even exertion at the gymnasium however it will take a while to build back up to normal speed. He will have both good days when you do a bit more and bad days when you feel the results of those activities. For those with significant back pain prior to surgery there will have been about a 75% improvement and about an 80% improvement in bladder function for those with symptoms of urinary stress incontinence.

At six weeks your scar will appear as a relatively fine pink line. From this point it will actually become pinker and reach its most obvious point for most patients between three and five months.

At about three months most patients feel that they are not reminded daily about the surgery. They are back to their normal activities and for those who are normally quite active and familiar with their own capabilities will comment that they are notably stronger and they were prior to surgery after the repair of the muscles. The post-operative swelling in the lower part of the abdomen and associated with areas of liposuction will have largely stabilised and resolved. There will be further improvements particularly in areas of liposuction over the next 12 months but these won’t be occurring at a appreciable rate from day-to-day.

At six months patients with back pain will have had an average 90% improvement and this tends to be maintained. The scar will have usually peaked in terms of its visibility and already be improving but the full improvement of the scar is slow and takes 18 to 24 months.

Is there any Medicare and health fund assistance with abdominoplasty surgery?

At the end of 2015 the federal government limited the accessibility of item numbers for abdominoplasty surgery to post-weight loss patients.

This may then mean individual patients receive assistance with the costs of the hospital admission and medical expenses relating to the surgery if they meet the government requirements. These item numbers are subject to change without notice and are meant as a guide.

The item number for abdominoplasty is 30177 and the requirements that need to be met are:

Lipectomy, excision of skin and subcutaneous tissue associated with redundant abdominal skin and fat that is a direct consequence of significant weight loss, in conjunction with a radical abdominoplasty (Pitanguy type or similar), with or without repair of musculoaponeurotic layer and transposition of umbilicus if:

  • (a) there is intertrigo or another skin condition that risks loss of skin integrity and has failed 3 months of conventional (or non surgical) treatment; and
  • (b) the redundant skin and fat interferes with the activities of daily living; and
  • (c) the weight has been stable for at least 6 months following significant weight loss prior to the lipectomy

Similar restrictions apply for body lift but with a different item number 30179:

Circumferential lipectomy, as an independent procedure, to correct circumferential excess of redundant skin and fat that is a direct consequence of significant weight loss, with or without a radical abdominoplasty (Pitanguy type or similar) if:

  • (a) the circumferential excess of redundant skin and fat is complicated by intertrigo or another skin condition that risks loss of skin integrity and has failed 3 months of conventional (or non surgical) treatment; and
  • (b) the circumferential excess of redundant skin and fat interferes with the activities of daily living; and
  • (c) the weight has been stable for at least 6 months following significant weight loss prior to the lipectomy

Following your consultation you should understand and have answers to the following questions:

  • Are you a good candidate for this surgery?
  • What type of procedure am I going to need to achieve my goal?
  • Are your goals realistic and achievable?
  • The length, quality, duration and location of scarring.
  • The important aspects of your recovery.
  • The timing of your return to work and other activities.
  • The risks of surgery and the likelihood of complications and what is required to manage them.
  • What it is required of you to achieve the best outcome from surgery both in preparation for the procedure and the recovery from surgery.

Dr Magnusson

Dr Mark Magnusson

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