One of the rewarding and challenging things about medicine is that things are always changing, and mostly for the better. Anyone who has had a surgical career for more than 10 or 15 years is now doing things which we learned after we completed our training. Sometimes we are doing an entirely different operation and sometimes we are improving on operation we have been doing for many years. Certainly this applies to tummy tucks from my perspective.
Tummy Tucks Over Time
Tummy Tucks or abdominoplasties have always been one of my favorite and most consistent operations. The operation is one designed to work on the skin of the abdominal wall, the fat layer beneath the skin, and the abdominal muscles (mostly in women who have had pregnancies). Over the years I have made several changes to how I perform this operation. And although I have always liked my tummy tuck results, I am even happier with them now as a result of these changes. So, let’s look at the changes in my tummy tucks over time.
It’s all about the scar
The appearance of the scar from a tummy tuck is a concern for all women who are considering this operation. And there are two components to the scar: its appearance, and its placement. Scar appearance is not something that we can totally control. Things like skin type, sun exposure, and a patient’s genetic predisposition to scarring are the things we can’t change. But we have found that the use of silicone strips that compress the scars during the healing process can be very beneficial. We now use them on everyone and they have really helped the appearance of these scars.
The position of the scar is something that I have a lot more control over. And my main objective is to try and place the scar in a position where it will be covered by a bathing suit bottom. To help with this, I ask my tummy tuck patients to bring a bathing suit bottom to the surgery center the day of surgery so that I can mark my scar to be covered by the bathing suit. But no string bikinis, please!
One of the things that is interesting about this, is that people in this country like different bathing suit styles than people in Brazil, for example. So what works in Rio in terms of scar placement, may not work in Knoxville.
Liposuction makes it better
The biggest single change that I have made to my tummy tucks has been the addition of liposuction to a traditional abdominoplasty: the Lipoabdominoplasty. This idea was developed by some very talented plastic surgeons in Brazil. I had the pleasure of hearing Dr. Saldanha discuss this technique about 7 or 8 years ago in a meeting. What he said made so much sense to me that I began using this technique in almost all of my patients immediately. And the results are better.
For many years it was thought that liposuction performed on the abdominal skin at the time of a tummy tuck could be dangerous: it could interfere with the circulation to the skin and cause severe healing problems. But by adapting the operative technique we are now able to use liposuction with the tummy tucks, and this has made all the difference in the world. Not only are the outcomes better, but some studies have shown lower complication rates with the lipoabdominoplasty compared with the standard abdominoplasty.
Increasingly plastic surgeons have been focused on the safety of all operations, particularly elective ones. And one of the things we have been paying particularly close attention to is the prevention of deep venous thrombosis (DVT). This is when blood clots can form in the veins of your legs while you are asleep, under anesthesia, and immobile. The same thing can happen to people when they sit on a plane for a long time, like flying across the ocean. Or to truck drivers who sit for extended periods of time.
There are some simple measures we employ in all patients to prevent this complication. Such as pneumatic compression hose which sequentially squeeze the leg to promote venous blood flow. Additionally, however, I evaluate all patients who are undergoing a tummy tuck on a scale (the Caprini DVR Risk Assessment) which quantifies the risk of this happening depending upon many different factors.
Once the risk level reaches a certain point, I may elect for a patient to administer to themselves a low level of blood thinner for ten days after surgery. Twenty years ago, no one was doing this at all. But now it is pretty common place. While the blood thinner is something of a nuisance, it does not significantly elevate the risk of bleeding after surgery, and it can help prevent a potentially dangerous complication.
The reason drains are used with a tummy tuck is that there is a space created beneath the skin. The body will fill this space with fluid (serum) and the drains are used to remove this fluid. The concerns about not using drains are that you can get a collection of fluid , or a seroma, under the skin that will have to be addressed by aspirating the fluid with a needle and syringe. (Occasionally this would happen after a drain was removed in the patients who had drains.)
I will confess to being a little slower than some to catch on to this, but I have almost totally eliminated the use of drains in my tummy tucks. Again, this requires some modifications of the technique, but — if one is willing to make these modifications – the drains aren’t necessary. I suspect that the majority of Knoxville surgeons are still using drains for this procedure. But I have seen less seromas by modifying the way I do the operation without drains, than I was seeing in patients when I was using drains.
While the tummy tuck is great at improving the contour of your front, it doesn’t do anything for the back, namely the hip rolls, the love handles, the muffin top. Once the tummy is looking great, some women can still have issues with the muffin top hanging around the back. For this, in the right patients, we can add the excision of the love handles to the tummy tuck which we have termed “the muffinator.” And, you don’t have to be Arnold Schwarzenneger to do this!
This means that the scar will go around onto the back, frequently about two thirds to three quarters of the way around the torso. But this does not really extend the recovery process and can make a big difference to the outcome. (There are some people who only need liposuction of the love handles without skin excision, and this can be done as well.)
It’s always nice when you can make a good thing better. Certainly I have seen this with my tummy tucks. Most of the changes have not been radical redesigns of the surgery, but have just improved the results of this operation. No doubt there will be other changes to this and other operations as time goes on. My challenge is to not only to keep up with changes, but to understand which ones really make a difference and then to be open to incorporating them into what I do.
David B. Reath, MDTummy Tuck
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