In the field of elective cosmetic plastic surgery, body contouring procedures such as abdominoplasty (tummy tuck) and liposuction often aren’t contemplated to the same exacting technical standards as more refined procedures like rhinoplasty.
Abdominoplasty is a safe operation which takes place outside of the abdominal cavity unless a hernia repair or concomitant procedure is involved.
Although the technical aspects of this operation are mostly straightforward, there are a myriad of style details and judgements that demand an individualized patient care approach. My understanding of this has been crafted by full training and board certification in General Surgery and Plastic Surgery as well as hundreds of cases over 15 years of surgical practice in northern NJ.
As an experienced body contouring surgeon, I carefully evaluate my patients preoperatively. Some of the factors that figure most prominently in my recommendations an surgical strategy include:
- Patients’ body mass index (calculated by height and weight); the length of their torso (and more specifically the distance from their breastbone to their umbilicus compared to the distance from their umbilicus to their pubis)
- The presence of any previous abdominal scars
- The thickness of the abdominal fatty layer
- The presence of a prominent fat pad above the pubis
- Their skin type and any stretch marks
- The extent and location of skin and/or fatty excess
- The presence of an umbilical or ventral hernia
- The abdominal muscle tone and abdominal wall anatomy
- The patients’ overall health condition
Whether a patient is best suited for a full tummy tuck, a limited (‘mini’) tummy tuck, liposuction or a combination of these procedures is normally clear preoperatively. The length, location and type of incision can usually be determined with input from the patient preoperatively as well.
Once we have a surgical plan in place, there are still many details to work through at the time of surgery. Once the incision is made and the abdominal wall/muscles are exposed, there are varying degrees and ways to tighten them. I contemplate carefully whether the patient is short or long waisted, curvy or blunted, and thick or thin.
Technically, I am very mindful of how good of a purchase I can take of their tissues with my sutures; the degree of their diastasis rectus (muscle separation in the middle); how I am to repair any hernia or damage from previous surgery; and the relationship and balance between abdominal wall muscle groups (rectus abdominus and obliques). My suture tightening techniques and application of any mesh (usually soft polyester) vary considerably based upon my patients’ goals and my judgement.
Once the abdominal wall is reconstructed, I must decide how to deal with any skin/fat excess. The amount removed is always predicated on good surgical judgment and takes into consideration geometry, blood supply, fatty tissue and and skin quality. Although the incision shape, length and position are mostly determined preoperatively, the end result will be heavily influenced by the skin and fatty resections.
Additionally, I always evaluate the excess pocket of fat above the pubis that is usually present in women with prior pregnancies so as to avoid a bump when the waist is flattened above. Once the excess has been removed, there are a variety of incisional closure techniques that can be applied.
I favor planning my skin resection around anchoring the top part of the skin flap DOWN to the bottom one to keep my patients’ incisions from migrating up excessively when possible. When closing the incision, it is also important to eliminate unsightly lateral skin excess (‘dog ears’) without lengthening the incision beyond what is necessary. Liposuction may be indicated in order to harmonize the surgical results and must be utilized with sound judgement so as not to compromise the operation.
Once the incision is closed in a full abdominoplasty, the belly button must be inset (an incision around the belly button is usually not necessary if a limited tummy tuck is performed). Although much has been said and written about the location and style of belly button insetting, this is an aesthetic judgement and I vary it depending upon the belly button appearance preoperatively, the thickness of the abdominal skin/fat and the length of my patients’ torso.
I usually prefer to place the umbilicus in the midline at the top of the iliac crest (hip) but this can vary depending on the length of the waist and shape of the rib cage and pelvis. Aesthetic judgement dictates the size and shape of the belly button. I am most influenced by the underlying anatomy of each patient; the length of the stalk which attaches the belly button to the abdominal wall; the thickness of the fatty layer; the presence of any hernia; the need for any mesh; and the size/shape that may be best for each patient.
I always inform my patients that we both need a little luck when it comes to how the belly button heals given the circumferential nature of the belly button incision. Even when closed as meticulously as possible, a circular incision can alter the way that the belly button heals and may require some minor modification postoperatively.
Once the surgery is completed, the vast majority of my patients return to the comfort of their own homes. Alternatively, patients may stay at the Vanguard Surgical Center or local hotel overnight with private nursing care. Regardless of discharge disposition, I believe in therapeutic nihilism after the surgery. It is important to be up and active after body contouring surgery to limit postoperative complications as well as to expedite the recovery.
I have always believed that if I have properly selected patients for surgery and then performed the right operation gently and meticulously, that there is very little my patients can do to undo their great results. Most patients can expect to return to reasonable activity by the first week and a full recovery by 2-3 weeks.
Abdominoplasty surgery is part doctor, part tailor and part artist. My thought process is a lot like a football quarterback’s in that I go through a progression with each of my decisions and maneuvers predicated on the previous and future decisions, how the operation develops and what the patient gives me at each turn. Hence, tummy tucks in my practice vary widely and are never ‘one size fits all.’
