Procedures - Tummy Tuck

The words tummy tuck mean that we are removing skin and fat and tightening your abdominal muscles. However tummy tucks come in a variety of forms. The following is the terminology that may be used. These words symbolize the different combinations that are possible with your skin, fat and muscle. (What procedure is best suited for you will depend on your anatomy.)

Mini tummy tuck.

If, for example, your fat deposits are limited to the area below the navel, you may require a less complex procedure called a partial abdominoplasty, also known as a mini-tummy tuck, which is usually performed on an outpatient basis. This procedure usually leaves the belly button in its current place and removes the fat below the navel, tightening the muscles but only from the navel to the pubis.

This frequently is performed with liposuction to obtain the best results.

Full tummy tuck.

In the full tummy tuck procedure, we create a new belly button and tighten the muscles from the lower chest area to the pubis. The scar is usually from hip to hip. Liposuction is usually performed at the same time to create a nice contour. Although this is up to the individual surgeon. In our practice liposuction is routinely performed.

Extended tummy tuck.

An extended tummy tuck is usually for obese patients that have a great deal of excess fat and have overhanging skin that extends to the back. In order to leave a nice contour, our scar needs to be extended beyond the hip area and extend more towards the back. Again in this case we tighten the muscle and create a new belly button. Liposuction is usually performed at the same time to create a nice contour. Although this is up to the individual surgeon. In our practice liposuction is routinely performed.

Circumferential tummy tuck.

A circumferential tummy tuck is usually for someone who has lost a great deal of weight and fat (usually after gastric bypass surgery) and now has loose overhanging skin all around the body. In order to create a nice contour we need to extend the scar all around the waist line. This allows us to lift the outer thigh and buttock creating a smoother nicer look. Also the muscle is tightened and the new belly button is created.

In any case, your surgeon should work with you to recommend the procedure that is right for you and will come closest to producing the desired body contour.

Who is a candidate for an abdominoplasty.

In today's society that is very health and beauty conscious, our bodies are a focus of attention and sensuality. Through the years our bodies start to change. Our eating habits, activity levels, and physiologic changes take a toll on our bodies shape and form. We begin to loose the abdominal wall tone and develop excess fat and even skin laxity problems. This Muscular laxity and extra fat will sometimes respond to exercise, however, contour problems may persist even with a program of routine sit-ups and regular exercise. Diets and working out may tone your muscles and help you lose weight, but they will not tighten your loose skin, nor will they tighten your loose inner girdle. When the skin is badly stretched and abdominal muscles separate at the midline, plastic surgery of the abdomen can accomplish many things that you cannot accomplish on your own.

As the ASPS ( American Society of Plastic Surgeon's) has stated, an Abdominoplasty or tummy tuck is the surgical procedure by which we can restore the youthful body shape, and improve you're contour by removing excess skin and fat and tightening the muscles of the abdomen wall. A tummy tuck gives you a flat stomach by tightening your inner girdle.

The best candidates for Abdominoplasty are men or women who are in relatively good health but are bothered by a large fat deposit or loose abdominal skin that won't respond to diet or exercise. The surgery is particularly helpful to women who, through multiple pregnancies, have stretched their abdominal muscles and skin beyond the point where they cannot return to normal. Loss of skin elasticity in older patients, which frequently occurs with slight obesity, can also be improved. Women who plan future pregnancies can still have a tummy tuck, however if the reason for the tummy tuck is stretch marks then you may wish to wait, since stretch marks may return after pregnancies.

Abdominoplasty is a cosmetic procedure. Sometimes it is scheduled in conjunction with gynecological surgeries such as bladder re-suspension or hysterectomy. This minimizes the patient's expenditures for the operating facility and anesthesia, and requires only one recovery period instead of two.

There are various types of procedures to contour your body. What procedure is best for you will depend on your particular anatomy and your surgeon's preference.

What is the best procedure for you?

In determining what is the best procedure for you, three Key components will need to be evaluated: Skin, fat and muscle. Lets discuss each one separately:

1. In terms of adiposity (fat), we need to evaluate two things:

1. The amount of fat that is present, but more importantly
2. We need to evaluate exactly where the fat is located.

Is it intra-abdominal or extra-abdominal? Let me explain the difference, since this issue is key in understanding our treatment options.

Intra-abdominal fat is composed of two types:

1. The first is that fat which is surrounding the internal organs.
2. The second is the Omentum. The Omentum is like a large fat blanket that is found in the abdomen and covers all the organs, its function is to protect internal organs from infections. This is why it is called the guardian or protector of the abdomen.

The combination of these two internal fat structures when in excess can increase the intra-abdominal pressure stretching the abdominal muscles. This in turn is what creates the large distended belly. Men and women will have different anatomic problems. In men usually the fat is intra-abdominal, and men that have large bellies usually have this kind of fat.

• Extrabdominal fat it the fat that is found outside the abdominal cavity, in other words, it is the fat that is between the muscle and the skin. It is the fat that you pinch whenever you grab your belly and say I am to fat, (The Kellogg's pinch and inch test). This is the fat that is removed during a tummy tuck or liposuction.

The difference between these two becomes crucial since the treatment options are completely different. If the fat is extra-abdominal /superficial/ (the kind you can pinch) then this can be removed with either a tummy tuck or with liposuction. Which to perform will depend on your goals, desires and skin quality.

If the fat is intra-abdominal then the treatment is weight loss and exercise. This fat we cannot remove neither with liposuction nor with a tummy tuck. As a matter of fact if a tummy tuck is performed, the big belly will more than likely return in a few months. The omentum could be removed but this is extremely aggressive surgery and not usually performed.

2. In terms of skin we need to evaluate two things:

• The quality of the abdominal skin, and the
• Amount of excess skin present

The quality of the skin is one of the factors that will help determine whether liposuction or a tummy tuck is right for you. The quality of the skin will depend on if you have any cellulite, stretch marks or looseness to the skin. If any of these are present, you have lost some of the skin elasticity and the ability of the skin to reshape and re-drape. In these cases something needs to be done with the skin, like removal. Many patients have the tummy tuck to remove stretch marks; this is a consequence of extreme weight fluctuation or pregnancy. If the stretch marks are below the belly button then usually we are able to remove almost all the them. However, if they are above the belly button, then the rule of thumb is that we will not be able to completely eliminate all the stretch marks. The exception would be if you have a great deal of excess skin and the marks are minimally above the belly button.

The amount of excess or overhanging skin will determine the length of the scar. If you have a pendulous skin, obviously the scar will need to extend as far back as needed in order to avoid the 'dog ear deformity', This is excess skin that hangs on the side of the belly and hangs over like ears. On the other hand, if you have good skin with good elasticity, then perhaps a limited scar, mini-tummy tuck or even just liposuction can be performed. Click here to read about mini-tummy tucks.

3. Finally we need to evaluate the looseness of the abdominal muscles (called diastasis). The looseness of the muscle can be located either only below the belly button area (most common) or, it can be the entire abdomen (from xyphoid to pubis). This differentiation is the key when deciding on your options. If your abdominal bulge is located below the belly button, and it is due to weak muscle, then, we only need to tighten the muscle from the belly button on down (a mini-tummy tuck may be an excellent choice). If however, the looseness is in the entire abdomen, then a more formal procedure is required and will require the entire muscle to be tightened (most likely it will involve a full tummy tuck).

In evaluating someone that comes in with a large abdomen we have to differentiate if the problem is excess fat, loose abdominal muscle or both. This becomes important because the treatment options are different. If for example we determine that your large abdomen is from the extra-abdominal fat and the stomach muscle is in good shape, then one option for you would be liposuction alone and no need for the large scar. This of course, will also depend on the quality of your skin; if your skin has many stretch marks, cellulite, or is very loose and overhangs then the tummy tuck is needed to remove the bad skin. If on the other hand, we determine that your muscle are loose, then, the only way to improve your body contour will be by tightening the muscle. This is done by a surgical tummy tuck. No matter how much liposuction is done to remove the fat, the muscle will remain stretched and you will never have a flat abdomen.

The best procedure for you will depend on these three components (skin, fat and muscle) that will be looked at when evaluating your particular case. Lets look at some examples as to how these three will interact.

• On examination we find that your muscles are in good shape, yet you do have some excess fat. You skin quality is excellent and by this I mean there is no cellulite, wrinkling, stretch marks or looseness to the skin, then liposuction alone may be the best option.
• Lets get a little fancy, lets say your skin is good, and you do have some excess fat, but now you also have a slight pooch below the belly button. In this case we could do liposuction, but if only liposuction is done you would still have a lower abdominal bulge since the problem is your muscle. Therefore in order to have a flatter stomach we could do a small incision in the pubic area, and this way we can tighten the muscle from the belly button on down.



• Lets say the skin was good condition and you had some fat, but the muscle looseness was now in the entire abdomen. Then, we have several options: you could do a full tummy tuck, or, you could perform liposuction and at the same time perform a limited incision above the pubic area so that we can then tighten the muscle all the way down.



• If the skin is poor quality and your stomach muscles are in good shape, then some sort of skin excision would be required. This will obviously require a scar. The length of the scar will depend on how loose your skin is, and how extensive your stretch marks are. Sometimes there is minimal looseness and it is limited to the lower part of the abdomen, (below the belly button). In these cases we can just excise the portion that is loose, leaving the belly button intact. The drawback would be that the belly button would be stretched downward giving it a longer appearance. If the muscles were loose and it was also limited to below the belly button, then we could also tighten the muscle from the belly button down to the pubis. Avoiding a formal tummy tuck. this is called a mini-tummy tuck. If the stretch marks and skin looseness was more extensive or the excision of the lower part of the skin was so large that it would distort the umbilicus, then the only option is a formal tummy tuck.



• If you have poor skin, a prominent abdomen, along with excess fat, then a full Abdominoplasty will be needed.
• In cases of extreme weight loss, (most commonly seen after gastric bypass surgery). There is a tremendous amount of loose skin through the body. It is in these cases that a circumferential tummy tuck/lower body lift is needed.

Now that you have an understanding of our decision making process, the next step is to determine where the surgery will be performed. You must remember that different Plastic surgeons will have different philosophies on this issue.

Where your surgery will be performed.

The operation can be performed as an outpatient in an office based surgical center, an ambulatory surgical center or in a hospital base setting. However, in some patients it may require hospitalization for several days.

Safety is our primary concern, therefore, in our practice we have strict guidelines in selecting those patients that can be done in our surgical center and those that will require a hospital setting. The criteria that we use has two primary issues:

1. Your overall medical condition
2. Your Body mass index

Body Mass index is a number that is determined by your height and your current weight and it is compared to the weight that you should be at. This number allows us to assess how much over your ideal body weight you may be and consequently, assess your risk factor for many medical conditions that overweight patients can develop.

• If you are in good health and your Body Mass index is below 31, then the operation can be safely performed in our surgical center as an outpatient basis. However,
• If you are over 30% of your ideal Body weight or your Body Mass index is greater than 31, then it needs to be done in the hospital. The reason is because you will require at least one or two night stay - over in a hospital.

To see where you fall and see what your Body Mass index is please click here.

Types of Anesthesia.

Most commonly this operation is performed under general anesthesia, although it could be performed under local with IV sedation.

Preparing for your surgery.

Every plastic surgeon has his/her own ritual and guidelines, in our practice we have found it helpful to perform the following things:

1. Prior to surgery there are certain medicines you want to avoid, such as, Vitamin E, aspirin or aspirin products. These may increase the chances of bleeding during surgery. After your consultation with Dr. Mendieta you will receive an extensive list of other medication to avoid.

2. Smoking causes spasms of the blood vessels and also creates poor oxygenation to the tissues. These increases the chances of complications especially skin necrosis. Therefore, if you smoke, plan to quit at least two to three weeks before your surgery and don't resume for at least two weeks after your surgery.

3. We usually recommend a body garment after the surgery, which is to be worn for about 4 weeks. This helps in reducing swelling.

4. Starting a mild exercise program before the surgery may be helpful especially if you are overweight. This does not have to be elaborate, it can be just walking around the block several times.

5. After your surgery, we recommend a recliner chair that you can sleep on. This is because your stomach muscle will be tightened; sleeping at a 45 degree angle may alleviate some of the discomfort. These recliner chairs can be rented from some medical supply companies. It they are not available, you can place several pillows under your head and some under your knees to keep them flexed at 45 degrees.

6. The most dreaded complication is a pulmonary embolism, which is a blood clot in the lower legs. We can try and prevent them with the use of antiembolic stockings during surgery. After surgery it may be helpful to use thigh high Ted-hose. These are special surgical stockings that compress the lower legs. These can also be purchased at any medical supply store or pharmacy. We also recommend early ambulation after your surgery. It is important that you move the lower legs as much as possible to avoid the formation of clots.

7. Since your abdomen will be tightened, deep breathing will be extremely important to avoid respiratory complications (Pneumonia). We will often recommend an 'incentive spirometry'. This is a device that helps you exercise your lungs and your diaphragm since it encourages deep breathing. This can be purchased at any pharmacy.

8. After the surgery coughing may be uncomfortable. We have found it helpful to place a pillow over the stomach area and apply gently pressure before coughing. This takes away some of the tension placed on the abdomen and suture line when you cough.

9. Whether your surgery is done as an outpatient or inpatient basis, you should arrange for someone to drive you home after your surgery and to help you out for three or four days after your surgery and/or after you leave the hospital, if needed.

10. If you are very overweight and a great deal of liposuction is being performed, sometimes it is best to donate your own blood before surgery, in case a blood transfusion is needed after the surgery.

Your surgery.

The operation that is most appropriate for your particular case will be determined by the methods described above. A complete abdominoplasty usually takes two to three hours, depending on the extent of work required. Partial abdominoplasty may take an hour or two.

An incision just above the pubic area is used to remove excess skin and fat from the middle and lower abdomen.

The length of the incision will depend on your particular skin and muscle anatomy. In a traditional abdominoplasty, the incision extends from hip to hip.

The abdominal skin is lifted in order to reveal the underlying fascia and abdominal muscle. In elevating the skin, the umbilicus has to be preserved, this is done by making a second incision around the belly button so that it can be freed from the surrounding tissues. The umbilicus will be repositioned in the same place later.

Once the skin is elevated, the abdominal muscle is tightened from the xyphoid (solar plexus) to the pubis. Suturing the muscle close together tightens the inner girdle and narrows the waistline.

The skin flap is then stretched down and the extra skin and fat is removed. The skin flap is now ready to be closed, but prior to closing a small incision is made in the skin flap and the umbilicus is brought out through the abdominal skin and repositioned. Drains may be placed in order to collect the fluid that forms inside the body after a tummy tuck. (These will be removed in about 5-7 days.) The skin flap is then closed, completing the abdominoplasty. Liposuction can be combined at the same time, as the tummy tuck, but this will depend on your surgeon's philosophy. For more information please click here.

With a partial abdominoplasty, the incision is much shorter and the navel may or may not be moved the skin is separated only between the incision line and the navel. This skin flap is stretched down, the excess is removed, and the flap is stitched back into place.

Recovery period.

Depending on the extent of the surgery, you may be released within a few hours or you may have to remain hospitalized for two to three days. In terms of discomfort, the first three days are the hardest in your recovery period. The discomfort is easily controlled with medications and ice packs.

In the first three days you may notice some difficulties in breathing since your muscle have been tightened. It is important for you to concentrate on deep breathing and really expanding the chest area in order to avoid respiratory problems. This will take some conscious effort on your part.

Coughing is a normal response after surgery; it will help tremendously if you place a pillow against your belly in order to help with the discomfort.

At first you may not be able to walk straight, but you should focus on improving your posture and make an effort to straighten out. The quicker you can do this, the faster you will recuperate. You will require someone to help you get around for 5-6 days.

Returning to work will depend on how well you recuperate; the majority of patients are back by 10-14 days. Some patients have healed incredible well and have returned after one week. When you first return to work, you will tire easily and it will take about a full month before you are back to your old self. Starting an exercise program can be done after one month.

At first you will notice a great change in your shape, but your old clothes will not fit since you are still swollen. We will want you to wear a special garment for about 4-6 weeks and this will help in keeping the swelling down. I know you may be anxious to show off your new body and wear your new clothes. However, tight clothes or constricting underwear are discouraged since this may cut off the circulation and or create marks on your body. It will take one month before your clothes start to fit properly, and about 2 months before you have to change wardrobe.

You will have drains placed after your surgery since your body will produce fluid that needs to be removed. These drains will be removed at about 5-7 days when the drainage amount decreases.

Sutures will be removed in about 7- 10 days. The abdominal scars, while they'll never disappear completely, will not show under most clothing, even under bathing suits. The scars may actually appear to worsen during the first three to six months as they heal, but this is normal. It will take about a year before your scars flatten out and lighten in color.

Your new look.

During the first few weeks you will notice a big difference in your body contour, but it will not be reflected on the scale. Do not get impatient or frustrated, since, your old clothes may fit tight, this is because you are swollen. After about two weeks the swelling begins to decrease and you will see your clothes fitting nicer. It is not until a month that you will see a real change and it will take about 2-3 months to see the final results. You must remember that the best results are obtained when you maintain a healthy eating diet and start a regular exercise program. If you're realistic in your expectations and are willing to accept the lengthy, permanent abdominal scar. Abdominoplasty may be an excellent option for you.

All abdominoplasty surgeries carry some risk.

Risk is inherent in anything we do, surgery is no exception. Although the risk can be minimized when performed by a plastic surgeon that is trained in body contouring, it does have its risks.

• Infection: Although it is common to develop some localized area of redness from the sutures, it is rare to develop a full-blown infection. If it does occur it can be treated with antibiotics and sometimes may require drainage if an abscess or localized infected fluid develops. These infections can usually be controlled with oral antibiotics on an outpatient basis, rarely does it require hospitalization.
• Hematoma: this is a collection of blood from a persistent point of bleeding. This is very rare, but if it occurs it will require a re-operation to control the bleeding. This should not be confused with the normal postoperative fluid that will drain after your operation. It is common to leave drains in after the surgery to collect any fluid the body may produce, this fluid often appears bloody and may persist with this red color for several days, it will then turn a clear color, this is very common and is usually not a hematoma.
• Bad scaring: This is perhaps the most common problem; the operation will leave a long scar that is visible. Although we do everything possible to leave you with the most inconspicuous of scars, every person heals differently. Some scars you can barely notice, others can be very thick and dark. It is up to your own healing process as to the type of scar you will develop. There are some things we can try to do to improve the appearance, like silicone patches, external pressure with silicone or tape, vitamin E, scar guard, and even steroid injections if thick scars develop.
• Seroma: After your surgery drains will usually be left in place, this is to collect the fluid that your body produces. At first this fluid is red in color and as days goes by it turns to a yellow color. The production of this fluid usually subsides after about 6-9 days and the drains can be removed. In very rare cases the body continuous producing this fluid after the drains are discontinued. Since there is no way to get the fluid out it can accumulate and your body swells. If this happens you may need to have another drain placed. This usually solves the problem, however in a very small percentage of patients this problem may persist requiring other forms of treatment, like sclerosis or a re-operation this problem is very rare.
• Pulmonary Embolism: this is a very rare complication. This develops from a blood clot that is in the lower legs that travels to the lungs. This is the most dreaded of complications since it can be quite serious. We take great precautions to try and avoid this problem by placing special compression devices in the lower legs that keep the blood flowing, not allowing the blood clot to form. This device is used during surgery, but after surgery we need you to move around or at least move your legs to encourage circulation of the lower extremities. This is the type of surgery where you don't want to just lay in bed for days, as a matter of fact we need you to ambulate as quickly as possible.
• Fat Embolism: this is a phenomenon that is not well understood and as a matter of fact some feel it may not exist. The theory is that fat somehow gets into the blood stream and goes to the lungs blocking the exchange of air creating a low oxygen state. The treatment is supportive care with oxygen and perhaps steroids. This complication is also very rare.
• Necrosis of the skin: this happen when not enough blood reaches the tissues so that circulation is not enough, causing tissue death or necrosis. This is uncommon but it does occur more frequently in smokers, diabetics, and obese patients and in patients that have had previous abdominal surgery (Gallbladder surgery). When this occurs the body has an amazing way of healing, and it will eventually heal, but it may take 2-3 months. During that time you will need to have frequent wound care. This time will be nascence to you but the wound will eventually heal. The scar may require a scar revision after several months, but the final results are usually pretty good. It is for this reason that patients should avoid smoking before surgery, since it occurs most commonly in smokers. For more info please click here.
• Sensation changes in the skin: it is normal to have sensation changes after your surgery and may take several months to return to normal. In some very rare cases these changes can be permanent.
• Lower abdominal bulging: the purpose of the tummy tuck is to leave the abdomen flat and remove any loose excess skin. In some patients there is an intrinsic weakness to the lower abdominal muscles and no matter what is done (i.e. mesh repair or restoring of the muscle) this area will always have some weakness and will bulge again.
• Recurrence of abdominal bulging: in a small amount of patient the entire abdomen can bulge again, this is usually due to an intrinsic muscular problem. On rare occasions it could be because the sutures came loose. For more info click here.
• Need for blood transfusion: this is very rare, it is more common when the abdominoplasty is combined with liposuction or when a circumferential tummy tuck is being performed.