How an Abdominoplasty is Done Mountain View

This is what is involved in a tummy tuck.

If the patient has extra thickness of fat of the abdomen and waist or flanks, the tummy tuck starts with infiltration of all these tissue layers with tumescent salt solution followed by treatment with power-assisted or vaser ultrasonic liposuction.

The lower incision has been planned so that it cannot rise up out of the bikini line. This is done by having the patient pull the lower abdomen up, while in the standing position, while wearing a bikini type garment. By doing this all the skin below the incision is placed on stretch and it cannot then go any higher when the incision is closed. This maneuver also rejuvenates the front of the thighs and pubic area. Failure to do this is what leads to the commonly observed malposition of abdominoplasty scars, visible above the low bikini line or asymmetrical. The outlines of the bikini are then marked and the thighs are serially flexed to ensure that the lateral incision lies precisely within the flexion crease of the thigh, where the bikini also goes. The incision is then precisely marked as a gentle curve within this marked boundary.

I do not consider a patient with excess fat of the abdomen or waist to have had a proper tummy tuck without treating all these areas. At the end of the procedure I want the patient to have a sculpted, natural look. I try to bring out the underlying shape of the waist and hips.

All tummy tucks are individualized, but all include careful elevation of the upper abdominal flap in a way that preserves the maximum blood supply to the skin that must join the lower incision. This is usually referred to as a tunnel from belly button to lower tip of breast bone. Undermining is limited to just the width needed to bring the rectus muscle together. Some doctors undermine all the way up to the rib margin and lose this blood supply. This takes less time and makes it easier to bring the flap down for closure without having to use other techniques such as discontinuous undermining and more flexing of the table to relieve tension; but wide undermining compromises blood supply and increases risk of skin and/or fat necrosis in the lower abdomen.

I have been so impressed with Exparel, long-acting bupivicaine anesthetic, that I now use this instead of a pain pump, thus eliminating any catheters or drains after the procedure. The Exparel is injected at this stage underneath the muscle fascia, under the skin of the flap and the incision, and if liposuction has been done on the waist and flanks, under the liposuctioned area. This greatly reduces the need for narcotic pain medication post-op, and patients usually wake up with little if any pain.

The next step is a multiple-layer closure of the rectus muscle in the midline. This is done along the entire length of the rectus, above and below the belly button. I prefer multiple figure-of-eight permanent braided nylon suture, followed by a double row of slowly dissolving Quill sutures. I take care to go all the way up, and all the way down to the pubic bone to avoid unsightly bulges in the upper and/or lower abdomen. The area around the umbilicus is further tightened with a permanent prolene suture.

I next trim the flap to precisely fit the lower incision without dog ears. I use the Lockwood flap marker to ensure that no extra skin is left behind.

If there is any excess fat remaining after elevating the upper flap, it is carefully trimmed at the appropriate level from below. The margins of the flap, particularly laterally, are carefully tapered and trimmed to fit nicely with the thinner skin of the anterior thigh and hip below the incision.

The elevated abdominal skin is re-connected to the abdominal wall with multiple interrupted vicryl sutures above the belly button and special Quill quilting sutures below the belly button. Quill sutures are a recent technological innovation having a needle on both ends and barbs of suture material pointing backward toward the center, that allow the skin to be progressively snugged up, top to bottom, without needing individual sutures or knots. The entire open space of flap elevation is closed off. No drains are required when this is done.

I then determine the umbilical location using the Lockwood marker, with the flap temporarily closed with atraumatic clamps to set the tension properly before measuring where to place the belly button. I always place the umbilicus at a distance from the pubic incision that is normal, depending on patient height and pre-existing height of their belly button. Nothing is more unattractive than a high incision and a low belly button relative to the incision.

The belly button recipient site is designed as a 2 cm vertical oval and the skin removed. The fat below is removed so the belly button has a natural shallow depression to fit into. Closure is done in layers with deep interrupted dermal sutures and half-buried nylon skin sutures with the knots on the umbilical side. No sutures go over and over through the skin, so there is no chance of getting stitch mark scars. These sutures can be left in for two weeks to get good healing and tensile strength, without any stitch mars.

The incision closure is done to last a lifetime and minimize the chance of any unfavorable scarring. My goal is to have such a secure closure that the scar will heal as a fine pencil line after the redness fades. There are two separate suture layers. The deepest layer is closed with strong, slowly-dissolving Quill sutures. The Quill sutures are placed in the deeper level of the flap called the superficial fascial layer; this layer has a network of fibrous tissue that can hold securely under tension. The superficial closure is closed with a dermal layer of fine early-dissolving Quill sutures to get precise skin approximation. Care is taken to bring the edges together as evenly as possible to get a fine line scar. Finally, to stabilize and seal the incision, I place an external layer of Prineo dermabond tape with polymer adhesive. This tape remains for three weeks, splinting the incision and helping to relieve tension as well. The skin edges have been brought together without any tension creating the most favorable conditions for a hairline, flat scar.

As you can see, the tummy tuck described above is a technical and refined operation. It requires adequate time to achieve the goal that patients want: a youthful, slim figure, a fine-line scar, invisible in a bikini, and a pleasing belly button.