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Introduction

Desire for an abdominoplasty to improve the appearance of the abdominal wall is a common concern. Anomalies of the abdominal wall can result from many varied experiences. Weight fluctuations throughout life can lead to excess skin that will not go away with diet or exercise. Pregnancy can lead to not only excess skin but also a weakness of the abdominal wall that results in a protruding abdomen, also recalcitrant to exercise. Prior abdominal surgery can result in scars and contour irregularities that can only be corrected with surgery. Endogenous and exogenous hormones and medications can also have an effect on our body contours that may be permanent and only corrected with body contouring surgery. Finally our own genetics and age related changes can result in excess skin and fat that requires more than diet and exercise to correct.

Evaluation

A history of any medical conditions, particularly heart, lung, liver, or rheumatologic conditions need to be discussed in the initial evaluation. A history of smoking is a significant risk factor for wound healing. Current recommendations are that patient stop smoking for a minimum of 4-8 weeks prior and after surgery. The use of nicotine patches is not an adequate measure in the perioperative period.

The physical exam focuses on evaluation of the entire abdomen, umbilicus, mons pubis, flanks and back rolls. Any prior surgeries and the resulting scars need to be considered when planning an abdominoplasty procedure. If an incision appears to interrupt the blood supply to the abdominal wall, then a variation of the surgery needs to be performed to ensure proper wound healing. The use of liposuction with an abdominoplasty helps address fullness noted in the mons pubis, hips and flanks, and dorsal back rolls.

The skin quality needs to be assessed as part of the exam. The presence of striae indicate a loss of elasticity of the skin and may affect the way the surgery is performed. Excess skin is the main indication for an abdominoplasty procedure and the amount of excess needs to be qualified to choose the right procedure for the patient. Patients who have abundance of adipose tissue but do not require skin or muscle treatment, i.e., have a good skin tone and reasonable potential for the skin to contract after removal of substantial volume, may be better candidates for liposuction alone as opposed to an abdominoplasty procedure.

The quality of the musculofascial layer is also important to evaluate for any weaknesses. More commonly, patients exhibit a weakness of this fascia termed rectus diastasis. This leads to a bulging abdomen that can only be fixed by plicating the fascia and restoring the rectus muscles to their original position. More severe defects of the fascia consist of hernias, particularly umbilical hernias and ventral hernias. These may need to be ruled out and if present, will be corrected at the time of the abdominoplasty.

The innervation of the abdominal wall is provided by lateral branches of intercostal nerves. These branches remain intact after the procedure so numbness in the anterior abdominal wall after surgery will improve and sensation should return to normal. Other nerves in the abdominal wall like the lateral femoral cutaneous nerve and the ilioinguinal and iliohypogastric nerves are susceptible to injury during closure so particular attention needs to be directed at these.

The presence of intraperitoneal fat or fat inside the abdominal cavity deep to the fascia cannot be treated with an abdominoplasty procedure. This fat is only reducible through diet and exercise. If fullness due to intraperitoneal fat is excessive, this may preclude undergoing a successful abdominoplasty.

Preoperative preparation

Once the decision to pursue an abdominoplasty is made, blood work is obtained and possibly a medical clearance from your primary care doctor is obtained to ensure you are at optimal health for the surgery. In some patients the use of anticoagulants is recommended due to their having a high risk of blood clots develop in the lower extremities after the surgery.

Day of Surgery

The day of surgery, markings are made on the patient’s body with the patient’s choice of swimwear or underwear. Incisions are placed immediately above the pubic region with a horizontal lateral extension, so that it would be hidden beneath current attire.

The surgery is typically performed under general anesthesia with a board certified anesthesiologist. When you wake up from the procedure, you will have an abdominal binder with dressings and should be comfortable. You may be admitted overnight or go home after the surgery. The pain medicine prescribed to you by Dr. Thomassen will keep you comfortable during the early postoperative period.

Mini-Abdominoplasty

This procedure is indicated when there is minimal extra fat and skin in the lower abdomen only, and only fascial weakness in the lower abdomen below the umbilicus. It removes an elliptical area of skin in the lower abdomen that may be affected by prior scars or striae and does not address the upper abdomen. The incision line is not as long as a standard abdominoplasty incision. Liposuction is added to improve the overall result.

The umbilicus is not relocated with this procedure. The fascia below the umbilicus is plicated so any bulging in the lower abdomen is corrected. In some cases the umbilicus can be “floated” by cutting the stalk and reattaching it lower on the abdominal wall. Indications for this are limited.

This procedure is not indicated for most patients since most patients would benefit for more skin removal and plication of the entire length of the abdominal wall fascia.

Full Abdominoplasty

First described by Pitanguy and Callia in 1967, this is the procedure most commonly performed in patients desiring improvement of their abdomen and torso. It involves a low anterior curvilinear incision extending from one anterior superior iliac spine (ASIS) to the other, umbilical translocation and full fascial plication. The umbilical stalk is kept attached and the umbilicus is brought out through a new incision in the abdominal wall skin. Sometimes, plication of the external oblique aponeurosis is added for improved contouring of the waist.

Liposuction has been proven safe to undergo along with this extensive dissection and is typically added to improve the overall contour of the result. It can reduce the thickness of the upper abdominal area. Liposuction and wedge reduction (both vertical and horizontal) are the most common techniques used to treat the mons pubis and excess volume in this area.

Sometimes an abdominoplasty can be combined with a hysterectomy or other gynecological procedures for patients interested in avoiding two recovery periods. Studies have proven the safety of these procedures.

Fleur de Lis Abdominoplasty

In this variation, the horizontal elliptical excision of lower abdominal wall skin is performed as well as a vertical elliptical excision in the midline. This results in a vertical scar that extends from the xyphoid to the pubis, and then a second horizontal scar extending from each hip. This procedure is indicated in patients who have lost significant weight and have excessive skin in the midline. It aids in contouring the waist for a more feminine outline; however the additional vertical scar needs to be considered carefully.

Complications

Because conventional abdominoplasty procedures involve significant undermining, there is increased potential for complications, such as skin necrosis, infection, wound dehiscence, seroma, and hematoma. In addition, plastic surgery procedures are associated with a high incidence of adverse effects when performed in patients who smoke. These complications are related to the release of nicotine and carbon monoxide during smoking, which decrease blood flow and oxygen delivery and induces thrombogenesis. One recent study of 132 patients who underwent abdominoplasty reported a complication rate of 48% in smokers.

Patients should be advised to discontinue smoking four to eight weeks before the surgical procedure and for an additional four weeks after surgery. Serum levels of nicotine have been shown to return to normal when patients abstain from smoking for eight weeks. In addition, studies of patients who underwent flap reconstruction showed that complications were decreased significantly when smoking was discontinued a minimum of four weeks before surgery.

Some patients are at high risk for developing a clot in the lower extremity deep vein system during or after the surgery. The use of graded compression stockings worn preoperatively and 7 days postoperatively, intermittent pneumatic compression devices placed before surgery and until discharge, strict intraoperative and perioperative warming, and ambulation within the first hour of the operation are important to reduce this risk. High-risk patients are treated with an anticoagulant after surgery to help reduce this risk.

Seroma is a fluid collection that can occur under the skin flap. Postoperative seroma in abdominoplasty is the most common complication in this type of surgical procedure and is avoided with the use of drains, quilting sutures, and compression garments.

 

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