Abdominoplasty (Tummy Tuck)

Article Author:
John-Paul Regan
Article Editor:
Jesse Casaubon
Updated:
8/14/2018 5:08:13 PM
PubMed Link:
Abdominoplasty (Tummy Tuck)

Introduction

The abdominal trunk is an area of special interest to plastic surgeons as it presents a large area of opportunity for body contouring. The trunk is a gross description of the area between the inferior aspect of the breasts and the beginning of the pelvis. The abdominoplasty, commonly referred to as a "tummy tuck," is a procedure to reduce the excessive skin and fat around the abdomen and strengthen the abdominal wall musculature. This procedure results in an aesthetically pleasing abdomen. 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.[1]

Anatomy

The fat in the trunk is separated into distinct regions. It is divided by Scarpa 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 ASIS and umbilicus, which provide structural support for the abdominal skin. The inguinal and mons pubis zones of adherence are the most important zones because they hold the structural integrity after the abdominoplasty.

Indications

The decision to have abdominoplasty is far-ranging, 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 pannus following significant weight loss. When selecting patients appropriate for surgery, it is vital to ascertain a thorough history. Wound healing is of vital importance, and patients require good nutritional health. Bariatric patients present the Plastic Surgeon with a more challenging issue. The laxity of their skin, as well as the massive size of their skin apron, may require further dissection and may need further procedures to lift the thigh, back, arm and flank areas. It has been noted that the better the BMI of the patient, the better the results. 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 infraumbilical region are candidates for the "mini-abdominoplasty." Patients with excessive skin laxity, fat, and abdominal wall weakness are ideal candidates for full abdominoplasties. 

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. [2]

Equipment

No special equipment is needed for this procedure. There are proponents for different types of sutures, such as barbed sutures, but these are used at the surgeon's discretion. 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 for retraction and can aid in closing the many layers associated with the procedure. 

Preparation

A patient's medical health should be optimized before surgery. Appropriate clearances should be obtained, when necessary, well in advance to identify any underlying illnesses that would preclude the patient from the procedure. 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. It is performed low enough on the trunk to hide the resulting scar in the bikini line. A flap between the fascia and fat is then created superiorly to the costal margin, angling 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 to the umbilicus. Once the flap is created, the patient is flexed in the bed to bring down the flap and determine its final position at the previous incision. At this point, the fascia of the rectus muscle is plicated to reinforce the abdominal wall. After careful calculation, the specimen is excised and the superior flap is reapproximated to the lower incision in multiple suture layers to prevent the flap from opening; then, the umbilicus is transplanted into the flap. Many different techniques have been described for the omphaloplasty. Surgeon preference seems to dominate which technique is used to transplant the umbilicus into the flap. 

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, which is essentially an abdominoplasty without the muscle plication, can be of better benefit in patients who have had extreme weight loss. The blood flow to the abdomen is better maintained in this procedure since it does not need to be extended to the xiphoid process. This ensures sufficient blood flow after significant weight loss and excessively flaccid skin aprons. A "mini-abdominoplasty" is ideal for patients who are not overweight and present with infraumbilical abdominal wall laxity and minimal skin and fat excess. These are typically women at a healthy weight who have had one or two children and have maintained good skin laxity. 

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 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 anecdotal benefits to preventing infection and other complications such as seroma and hematoma formation.

Complications

Seromas and hematomas are common complications postoperatively. If left untreated, these can result in necrosis of the flap from lack of blood supply or infections which can destroy the flap and be life-threatening. Placement of closed-suction drainage systems can help decrease the incidence of accumulation of these fluids. 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 an adequate blood supply. Superficial wound complications remain the most common complications for this patient population. Infection and wound dehiscence can result when excessive tightness is caused by the closure. Patients are usually placed in the "Semi-Fowler" position to prevent these complications, but their rate of occurrence remains regardless of ideal positioning. [3][4]

Clinical Significance

When done well, the majority of patients remain satisfied with the abdominal tummy tuck procedure. However, it is vital to educate patients on changes in lifestyle to prevent reaccumulation of fat around the waist area. This means participating in regular physical exercise, eating a healthy diet, discontinuing smoking, and refraining from excess alcohol.

Enhancing Healthcare Team Outcomes

Abdominoplasty is a major procedure and can be associated with many serious complications of which one of them is wound infection, which can prolong admission, worsen the cosmesis and lead to an increase in healthcare costs. Thus it is imperative to identify the risk factors and perform a thorough assessment of the patient prior to any surgery. [5] A team approach is an ideal way to limit the complications of this procedure. Prior to surgery, the patient should have the following done:

  • Evaluated by the pulmonary and cardiologist to optimize lung and heart function
  • Be taught by the nurse to use the incentive spirometer
  • Be consulted by the pharmacist for post-op pain management, antiemetics and use of blood thinners
  • Seen by the anesthesiologist to ensure that the patient is fit for general anesthesia

Evidence-based Approach

An interprofessional team that provides a holistic and integrated approach to postoperative care can help achieve the best possible outcomes. If a surgical wound infection occurs, the role of the laboratory and diagnostic laboratory cannot be undermined. If the patient is to be discharged home with a drain, consultation should be made with a social worker and community nurses who can monitor the patient and make referrals as needed. Finally, one major complication that is associated with high morbidity is deep vein thrombosis, and hence the physical therapist must be consulted for early ambulation.

Collaboration shared decision making, and communication are key elements for a good outcome. The interprofessional care provided to the patient must use an integrated care pathway combined with an evidence-based approach to planning and evaluation of all joint activities.[6] The earlier signs and symptoms of a complication are identified, the better is the prognosis and outcome.[3] (Level C)



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