This article by Dr. Cuzalina appeared in the publication Surge in Summer 2009

Everyone would love to have a flat tummy, preferably without surgery, yet this may be the only choice for many. The number of tummy tucks performed in the U.S. has dramatically increased over the last several years. A few reasons for this big increase is more acceptance in the general public for cosmetic procedures and a larger number of patients having bariatric procedures with massive weight loss and hanging skin. Also, the rise in advertising new, minimally invasive, “lunchtime laser this” or “laser that” have all contributed to more tummy tucks for better or worse.

Granted, the development of the lipo-abdominoplasty or “modified Avelar type” tummy tuck has been a wonderful new technique for the appropriate patient. However, there is no such thing as a minimally invasive abdominoplasty. Just because a surgery can be performed under local anesthesia does not make it “minimally invasive.”  A rush to abandon traditional techniques is not wise simply because a new procedure sounds great. For abdominal rejuvenation, traditional abdominoplasty should still occupy a major portion of one’s surgical gamut.

Figure 1. 35 year old female before and one month after a full lipo-abdominoplasty in order to both excise skin from pubis to above the umbilicus, as well as debulk the upper abdominal fat with liposuction and very limited or no undermining.

Diagnosis & Treatment Planning

Determining who is best treated with a traditional abdominoplasty is based on an evaluation of tissue from xiphoid to pubis. Deciding whether there is skin laxity that would not shrink well with liposuction alone is a basic initial assessment.

Abdominal skin laxity isolated below the umbilicus can typically be treated with a mini abdominoplasty. This classic patient is the well-built female after a C-section with limited hanging skin over her existing scar. Any rectus diastasis must be noted and, if severe, considered for repair. Significant skin laxity both above and below the umbilicus typically is best treated with a full abdominoplasty whether it be via traditional or via lipoabdominoplasty (Modified Avelar) in order to tighten the skin of the entire abdomen (Fig. 1).

Advantages of a Traditional Full Abdominoplasty over a Full Lipoabdominoplasty:

1. More skin volume and striae can be excised
2. Lower resulting scar
3. Maximum access for hernia and rectus diastasis repair

Advantages of the Lipoabdominoplasty vs. Traditional Abdominoplasty:

1. Theoretically better blood supply from limited undermining  (ex. safer for the patient who has an upper right open cholecystectomy scar)
2. Ability to safely liposuction upper abdominal fat simultaneously

The “grey area” of diagnostic dilemmas can be challenging.  For instance, an abdomen with minimal rectus diastasis and only slight skin laxity immediately above the umbilicus can occasionally be treated with a mini tummy tuck with an umbilical float if the existing umbilicus is somewhat high relative to the anterior iliac crest. This occasionally develops following childbirth or after a patient has had abdominal liposuction where the resulting internal fibrosis during healing leads to an abnormally high appearing umbilicus with a shortened distance between the ribs and belly button. Floating the umbilicus down 1-2 cm can be helpful for an isolated few patients but carries risk of having an odd-looking low belly button in the wrong patient. Additionally, an umbilical float burns a bridge if a full tummy becomes necessary in the future since the stalk has been amputated from below and would likely result in umbilical necrosis from future periumbilical incisions.

Traditional Tummy Tuck Technique

The planned incision is marked from “hip bone to hip bone” below any lower abdominal existing scars or an average of 2 cm inferior to the existing pubic hair line.

The periumbilical incision is marked for the ideal desired depth and shape along with a vertical mark along the entire midline from xiphoid to pubis. Optional marking of the costal margins and estimated skin excision can be performed. Additional marks vertically in a parasagittal manner may be helpful for closure without “dogear” formation.

Liposuction, if performed at all, is limited to areas lateral to the horizontal incision, low waist and pubis following tumescent infiltration. No liposuction should be performed in any other abdominal areas during a traditional abdominoplasty to avoid flap perfusion compromise. Thinning the lateral incision of fat can help prevent dog-ear formation along with careful medial advancement of the flap on closure.

Dissection is performed over the rectus sheath up to the xiphoid process. Next, the patient is flexed at approximately 30° and the amount of skin marked for excision. After excision of the lower skin-fat flap, excess deep fat of the upper abdomen can be carefully excised with scissors down to scarpa’s fascia.

Extreme caution must be taken with this technique to avoid over thinning of the flap. Midline rectus plication using permanent suture such as Nurolon or Prolene is per formed and drain placement prior to final layer closure. Scarpa’s fascia can be plicated down to rectus fascia in the pubic area to avoid “riding up” of the incision line. A number of methods can be used to determine the location for the umbilicus. It is important is to use your midline mark to avoid lateral displacement and carefully mark the height above the pubis to prevent torsion on the stalk.

“Ideal” Cosmetic Abdominal Surgery Treatment Protocols

• Liposuction Only: Lipohypertrophy with good skin and muscle tone
• Mini Abdominoplasty with Liposuction: Lipohypertrophy with skin laxity limited to the lower abdomen below the umbilicus and hopefully minimal rectus diastasis
• Mini Abdominoplasty with Umbilical Float: Minor skin laxity that extends 1-2 cm above the umbilicus which appears unusually high (above iliac crests)
• Full Lipoabdominoplasty (Modified Avelar): Skin laxity above and below the umbilicus with moderate to heavy upper abdominal fat and limited rectus diastasis
• Full Traditional Abdominoplasty: Severe skin laxity above and below the umbilicus with or without rectus diastasis and limited excess upper abdominal lipohypertrophy (Figure 2)
• Endoscopic Abdominoplasty: Great skin tone with moderate rectus diastasis and lipohypertrophy (rarely indicated and a “super” mini tuck may be just as well)

Figure 2. 40 year old before and 3 months after a full traditional abdominoplasty

Pearls for Great Tummy Tuck Results

1. Use extreme caution when combining liposuction (especially aggressive liposuction) with any abdominal flap to avoid potential ischemia.
2. Avoid smokers and patients with heavy intra-abdominal fat or “barrel” chest.
3. Do not hesitate to use a full abdominoplasty for a male patient with extreme skin laxity. Men tend to heal often better than women after abdominoplasty.
4. Verify umbilicus position using several methods: palpation from below, midline marks, hip bone level, 7-10 cm above pubis or incision line and distance from umbilicus to incision 1/3 that of umbilicus to xiphoid.

Conclusion

A traditional abdominoplasty is ideal for patients with significant skin laxity above and below the umbilicus along with severe rectus diastasis in relatively thin, multiparous women or post massive weight loss patients (Figure 4).

Using more conservative techniques for this class of patient may create problems that are difficult to correct. Minimally invasive laser or liposuction techniques are simply not indicated for major belly laxity. There are plenty of good techniques; the challenge is selecting the one that best suits each individual patient. Keep the classic tummy tuck in your repertoire.

Figure 4. 48 year old before and 3 months aftera full "traditional" abdominoplasty required to tighten severely loose skin above and below the umbilicus as well as repair rectus diastasis from xiphoid to pubis.

Tags: abdominoplasty, Liposuction, post-bariatric, tummy tuck

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