Introduction
Nowadays, there is so much attention paid to a nice and youthful appearance including our body shape more than ever before. The discrepancy among the consumer society, shops full of seductive food, advanced automotive transport, decreased physical effort in work and the necessity or possibility of physical exercise – this all contributes to the increasing proportion of overweight or obese people. It is alarming that citizens of the Czech Republic are statistically among the nations with the highest number of people of excess weight. The small percentage of people who have a strong will and follow a balanced diet and exercise regularly, try to keep a good body figure. However, there are some people who are sportsmen and exercise daily, but still have some body parts with stubborn fat they cannot lose (or they can but with difficulties). These parts include external thigs in the hip joint areas, and certainly female’s underbelly. There are some people who have localized fat deposits in the abdominal area combined with feeble stomach muscles. Women after delivery experience damage to the muscle structure in the stomach area by extending the direct abdominal muscles (diastasis) in combination with some of the stomach ruptures (most often rupture of the navel). In this case any hopes for a “flat tummy” without surgery are very difficult, if not impossible, to achieve. What is more, the situation can become even more complicated – if, after pregnancy, along with the lax abdominal wall the skin starts to sag and combine with striae. Having your own children is definitely worth it, no question about it. But there is nothing wrong with thinking about what can be done to improve it. Another group of patients considering stomach contouring are those who have lost a large amount of weight (20 kg and more). After significant weight loss, the skin fails to shrink back and starts to sag. Many people are then left with heavy “apron” of skin around the abdomen and skin rash might occur under this “apron” as a result of prolonged skin-on-skin contact. Abdominoplasty is plastic surgery procedure designed to reshape your abdomen so that it is more flat and firm. It is not, however, weight loss surgery. On the other hand, firming the muscles in the abdominal wall in combination with a balanced diet and exercise after surgery is likely to produce weight loss within a few months following surgery (5-10kg). Tummy tuck is a procedure that will remove excess skin folds and fatty tissues from the abdomen and tighten the muscles in the abdominal wall, giving your body a flatter and tighter abdomen and also a slimmer waist. In the event that there is only a thick fatty layer without sagging skin and underlying tissue, liposuction alone is a more suitable procedure (fat removal surgery performed with cannulaes – see the liposuction chapter). In other cases where large excess fat and sagging skin occur together, liposuction can be performed in combination with other abdominal plastic surgery. At the consultation, your plastic surgeon will advise you on the most appropriate procedure for you.
Am I a suitable candidate for tummy tuck?
Your consultation will determine this. You will be asked about your medical history including details about any previous abdominal surgery or childbirth. Women planning pregnancy should wait until after delivery. If you smoke, you will be asked to stop (or at least significantly reduce) smoking for a minimum of 14 days before surgery. Smoking seriously constricts blood vessels and therefore decreases blood flow to the specific area resulting in worse healing. Aspirin and some other anti-inflammatory drugs and medications may cause increased bleeding, so these should be avoided 2-4 weeks before surgery. Furthermore, you will be given a special diet you should follow for two days prior to surgery. This diet leads to evacuation of the digestive tract so that the stomach and bowels are not burdened with digestion. Within the medical inspection, a physical examination will decide whether you are a suitable candidate for a tummy tuck procedure and what type will be the best for you. It should not be performed to correct obesity. Patients with 95-100 kg and more will be disappointed. Abdominoplasty is absolutely inadvisable for such obese patients. For two reasons. Firstly, they will not be satisfied from the cosmetic point of view, because the upper torso and buttocks will still keep a considerable fatty layer in the skin folds which will contrast with a tighter and smaller abdomen. Secondly, obesity is associated with an increased risk of complicated wound healing, but there is also much more serious risk – life-threatening complications. In order to avoid this situation and disappointment after surgery, and to minimise the necessity for a secondary (corective) procedure, the best candidates are men and women who are within a few kilograms of their ideal weight. As mentioned earlier, there are several variations in the abdominoplasty technique. The choice will depend on your skin quality and degree of sagging, the laxity of your muscles and the amount and distribution of fat. If you had any previous abdominal surgery, the scars may also be taken into account. Very rarely can the technique and scar extent be inspired by the patient’s wish and if it happens, it usually affects the surgery outcome. The final decision can only be made after a consultation and after a thorough examination. However, generally speaking, if you have loose muscles and excess skin in both the upper and lower abdominal regions with only moderate fat deposits, you will most probably need a full abdominoplasty. If you have loose skin mainly in the lower abdominal region but still retain good skin and muscle tone above the navel with only little or no excessive fat, then a “mini tummy tuck” may be applied. Alternatively, if there is only moderate excess fat in the upper abdominal area, then a combination of liposuction and “mini tummy tuck” can be used to get a better result. But we should say that the term “mini” is improper in this situation as the scar the surgery leaves is about 25 cm in length and surely cannot be considered “miniature”. In most cases, another scar around the navel must be present. At your consultation, always remember to be open and honest with your expectations. We will also be frank with you and together we will work on choosing surgery that is the most suitable for you and which will fulfil or come as close to your expectations as possible. Another thing to keep in mind is, as we mention with other procedures, that the best candidates are people mentally stable with realistic expectations, willing to listen and follow the postoperative recommendations including regular exercise and strengthening the abdominal wall.
What does the surgery involve?
You must understand that in the full abdominoplasty there is an “anchor” incision made, running through the middle abdomen from the rib cage around the belly button and down to underbelly and then another, long incision made within the “bikini line” just above the pubic hair, going from hip to hip. The skin and a layer of fat is then lifted off the the muscle from the lower horizontal incision up to the rib margin. The exposed muscles are then sutured or tightened as necessary using dissolvable stitches. By stitching the muscles together, a firmer abdominal wall and a narrower waist is created.
If a hernia is present, a qualified surgeon will assist, performing the hernia repair.
The lifted layer of skin and fat is then stretched down towards the initial incision and any redundant tissue is removed. These incision are subsequently sutured, but not before a new hole for the navel is made. Drainage tubes are usually put under the skin in order to evacuate any extra fluid that may collect in the first 24 hours after surgery. The tubes are removed when the fluid formation has stopped (usually 24-48hr).
What type of anaesthetic is used?
Abdominoplasty is practically always performed under general anaesthesia. With respect to the length of narcosis, scar extent, surgical areas and possible suture of abdominal wall muscles, usually two days of hospitalization are recommended. With less extensive abdominal techniques, sometimes only one-day stay is sufficient.
How long does the surgery?
It depends on the technique used and whether the procedure is accompanied by any other surgery such as liposuction. Tummy tuck usually takes 1,5-3 hours.
What happens after the operation?
As soon as you wake up, you will notice a compression elastic garment around your waist and abdomen. This garment will help compress the surgical area and reduce the postoperative swelling and bruising. You will also observe one or two drain tubes that collect any accumulated fluid after surgery. These are usually removed within 24-48 hours following the operation. You will experience some pressure and soreness in the abdominal area and you will also notice that your knees are raised, supported by a special part of the bed so that the tension in your abdominal muscles and sutured sites is reduced. For the same reason, you will be advised to walk with a forward lean for several days following surgery. All incisions apart from the one around the navel are sutured with dissolvable stitches, so you do not need to worry about the suture removal. Immediately after the operation you will receive infusion solutions, analgesics, anti-thrombosis medications and antibiotics. You will be also asked to exercise your legs and perform breathing exercises. You should expect that for the first 48 hours after surgery before your bowel passage is fully recovered, we will not serve solid food.
Is it painful?
Soreness and discomfort are subjective sensations, but it is true that abdominoplasty surgery is one of the most painful procedures. This will be most noticeable when you start standing or walking in the first few days after surgery. In order to minimise the pain, analgesics will be administered to you during your stay and you will also receive painkillers for using at home. This all is already included in the price for surgery. You will need to take painkillers for about 3-4 days, but no more than a week. It is usually not the surgical wounds that cause pain, but the sutured abdominal wall muscles. If in very rare cases the muscles do not require suture, then even the postoperative pain is mild!
What should I expect after tummy tuck surgery?
Following the operation you will experience considerable swelling and sometimes even bruising in the abdominal area. This condition will be even more noticebale if the tummy tuck surgery is combined with liposuction. The bruising usually lasts about 3 weeks. Most of the swelling will have subsided by this time, nevertheless minor swelling might be present for up to three months after surgery. Soon after surgery you will definitely notice that your abdomen is very firm to touch, especially along the edges of the incision sites. This happens as a result of the normal healing process. It usually takes three months to resolve, but you can facilitate the process by pressure massages and wearing elastic garment, we recommend to wear it for 6-8 weeks after surgery. You should expect reduced skin sensation in the abdominal region. This is a result of surgical damage to the skin nerve branches in the area. The sensation is usually regained within a few months.
What are the scars like?
As explained before, abdominoplasty produces extensive scars. These usually extend from hip to hip – above the pubic region in a horizontal line. Sometimes it may be necessary to add another incision – a vertical one below and above the belly button and therefore the anchor-like scar is left. Although surgeons try to suture the incisions as neatly as possible, it is almost impossible to predict any scars ultimate appearance. In fact very seldom can the abdominoplasty scars be described as hairline. Still, you should understand that because of the normal healing process the scars are red, raised and lumpy in the first few weeks following surgery, but they settle, get softer and fade over time. In any case, the scars are permanent!
What could go wrong?
When a tummy tuck procedure is performed by a qualified plastic surgeon, the risks are usually small. Nevertheless, specific complications can and do occur. Like any other surgery, abdominoplasty carries the risk of infection. This can be minimised by careful surgical technique and preventative administration of antibiotics during and after surgery. However, you should know that despite these precautions mild infection is occasionally reported, usually around the incision sites. This infection of local wound clearance or additional antibiotic therapy subsides within 2 weeks. There is the risk of blood clots (embolism); its occurence is however rare. It is due to the preventative administration of medications reducing blood clotting properly and due to the early verticalization of the patient – we urge the patient to start moving as soon after the surgery as possible. You also should expect swelling, as mentioned earlier. Mild swelling will be quickly reabsorbed by the body. Very rarely, increased bleednig is present that can lead to more significant swelling and the formation of haematoma (a blood collection under the skin). Should this happen, surgical drainage to remove this would be necessary. Another possible complication is a collection of fluid called a “seroma” under skin-fatty layer – in the place where the skin was lifted off the muscle. This fluid has clear, yellow, amber colour. This complication appears as a swelling in the lower abdominal area and a lot of patients describe this as a movement of this fluid under the skin. It usually occurs about 10 days after surgery. The treatment will depend on the amount of fluid present. If the amount is small and is not causing any physical problems, only a pressure garment is applied and the body reabsorbs the fluid, usually within a month. However, if seroma occurs in a considerable amount and causes pain or discomfort, the primary treatment is to evacuate the fluid with a needle. After that, the swelling and unpleasant feelings rapidly disappear. It is usually necessary to repeat this procedure a couple of times, and every time the abdomen must be bandaged so that the cavity does not fill quickly again. With the anchor incision, it is important to emphasise a quite frequent complication. It is a defect where the vertical and horizontal incision meet. This occurs as a result of a worse blood supply to the lower fat layer. The skin usually takes 7-10 days to heal, but the lower fat tissue has worse healing qualities – the fat dissolves and this amount of fat dissolves the scar and the defect develops. These can be quite small, but sometimes also rather big in size. Then you should expect prolonged healing (in weeks), more frequent rebandages, wearing elastic garment for a longer time and longer after-care according to instructions.
How long before I get back to normal?
Abdominoplasty is a serious operation and you should respect it accordingly. You are likely to wait a couple of weeks before you feel yourself again. Also keep in mind that the time individuals take to heal significantly varies. To get an idea – although most patients are able to return to light work duties by 10-14 days, others need to take further 1-2 weeks to recuperate. Walking is appropriate in the first 3-4 weeks since it improves blood circulation and helps reduce the swelling and the risk of developing blood clots. Heavy lifting and any strenous activity is prohibited in the first 6 weeks after tummy tuck surgery. If you feel soreness or pressure while doing an activity, stop doing it!
Summary
Abdominoplasty has always been a popular cosmetic surgery procedure. It is a brilliant solution to situations where people worry about excess skin and fat around the abdominal area and weakened muscles. Provided you are prepared for permanent scars and lengthy recovery period, it is advisable to undergo this procedure. Tummy tuck surgery will increase your self-confidence and allow you to put on clothes that you used to wear but are no longer well-fitting. The results are usually long lasting, if you follow a balanced diet and exercise reasonably.