The Tummy Tuck
Written by Dr. Cross
The tummy tuck, or abdominoplasty, is one of the most powerfully corrective procedures in plastic surgery.
Before and after demonstrating the amount of flattening of the abdomen that can be achieved with a tummy tuck procedure. *Results May Vary
Patients come to the office, often reporting years of frustration after having children. They have been left with skin excess and poor quality skin that won’t tighten despite either successful or unsuccessful attempts at weight loss. Many describe a fullness to their belly that does not improve with sit ups and core strengthening. This fullness often presents with a ridge that patients can feel running down the center of their abdomen, called Diastasis Recti. Other patients are plagued with years of worsening skin looseness and fat deposits that occur with age or fluctuations in weight. The common theme is that these issues cannot be corrected at home with diet or exercise. They can, however, be corrected with a customized approach to address the areas of anatomy in need of improvement.
A successful result after a tummy tuck procedure requires a few key steps. The first is customization of the plan. This involves understanding a patient’s goals and examining their anatomy. There are many different ways of performing a tummy tuck. Having the correct plan going in to the procedure, helps to insure that the final result will achieve the patient’s goals. Second, what the patient sees in the mirror, and what can be seen by others must look a natural as possible. This includes making sure that the belly button looks youthful and not like it has ever undergone a procedure. The incision that is used to remove extra skin should be low, and well hidden under any pair of underpants, bathing suit bottom, or low cut pair of pants. Finally, the recovery should be as short and as manageable as possible.
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Skin is comprised of many different cells and molecules. Two of the most important molecules that determine skin quality and firmness are collagen and elastin fibers. These fibers course through the second layer of the skin, called the dermis. The amount of collagen present in the skin, in part, determines the thickness of the skin, and the quality and amount of elastin fibers are responsible for the skin’s ability to tighten. Pregnancy or other forms of weight gain put stress on the collagen and elastin fibers, causing them to thin, weaken, and break. Some breaks are severe enough to cause areas of relative absence of collagen. These “superthinned” dermal regions with intact overlying epidermis are known as “stretch marks”.
Changes to the skin are often not reversible, even when the stress of pregnancy or weight gain is removed. The skin is left with poor quality collagen that has been spread over a larger surface area, creating less healthy, thin, and excessive skin. These changes can, however, be corrected by removing the unhealthy or loose skin. Additionally, any stretch mark at the level of the belly button or below can be removed, and any stretch mark above the belly button can be lowered so that it is not as visible.
Under the skin, the muscles of the belly experience the same stresses. The tissue that hold muscles in place is called fascia. Fascia is stronger than skin, but it too will stretch in an irreversible way during pregnancy or weight gain. When the fascia between the rectus muscles (also known as the “six pack” muscles) is widened, a ridge, or separation (diastasis recti) can be felt between the muscles.
Because the muscles are no longer running next to each other on either side of the center line of the belly, they function less effectively. This leads to the appearance of a bulge to the belly, even though the muscles may be very strong. Since proper positioning of the rectus muscles helps to balance the pull from the muscles of the back, core strength is often significantly affected by diastasis recti.
After pregnancy or fluctuations in weight, pockets of fatty tissue can collect that are metabolically less active than other areas. This makes them extremely resistant to diet and exercise.
Finally, thinning of the fascia can lead to the presence of hernias, or bulges through the fascia. This can occur in many regions throughout the abdomen, but most commonly occurs in the belly button region. Some patients notice a significant fullness in the belly button region, others just notice that their belly button looks like an “outy”.
Like the skin above, none of the changes that occur to the fat, fascia or muscles can be improved by diet and exercise alone. By tightening the fascia, repositioning the muscles, and repair hernias simultaneously, a youthful belly can be achieved.
Before and after showing correction of loose skin, stretch marks, massive diastasis recti and a hernia just above the belly button. *Results May Vary
Excess skin is addressed by removal of the skin. For many, this is all that is necessary, and is known as a “skin only” or “modified” tummy tuck. This technique can be used to tighten loose skin, and will remove all poor quality skin as well as stretch marks that are located below the belly button. The skin is lifted up and pulled tight. Excess skin is tailor tacked and removed through an incision that runs horizontally and below the underpant or bikini line. In fact, Dr. Cross allows patients to wear their favorite style underpant or bikini bottom on the day of the procedure so that he can insure that the resultant incision is placed within the region covered by the garment. The key to a faint, discreet scar is avoiding tension on the closure. For this reason, Dr. Cross performs a closure technique known as eversion. It removes tension from the skin edge to reduce scar widening and thickening.
In the after picture compared to the before picture, the belly button looks natural and the incision is hidden discreetly so that, even in low cut underpants, it is not visible in any way. *Results May Vary
When muscle widening, muscle looseness, or diastasis recti is present, this is addressed with repositioning of the muscles. During this procedure, the muscles are not cut. Muscle repositioning is performed by tightening the fascia that surrounds the muscles. At this time, hernias are repaired bulges are reduced.
When fatty pockets are present, these are sculpted with liposuction and can be combined with both a skin only procedure or with skin removal and muscle tightening.
Dr. Cross is now performing many of his tummy tucks using a “no drain” technique. Drains are small, clear tubes, approximately the diameter of IV tubing that connect to bulbs that look like clear avocados. Traditionally, drains are used to remove fluid that would otherwise collect under the skin during healing. Buildup of the fluid can prevent appropriate healing. In appropriate patients, Dr. Cross uses an internal suturing technique that allows him to eliminate the space where fluid can accumulate, making drains unnecessary.
The No Drain Tummy Tuck
Though drains are often used to help minimize swelling over the first few day of the procedure, Dr. Cross is often able to use a technique that eliminates the need for drains. This is achieved by using special sutures and suturing techniques under the skin to allow rapid healing without the need for drains. This can be particularly helpful for people with young children who have to get back to their daily activities more quickly and who can’t afford to be slowed down by the presence of drains.
Upon completion of the procedure, patients are placed in a compressive garment. They are encouraged to walk actively each day. Exercise may often be resumed within two weeks.
The recovery time for a tummy tuck is largely determined by the type of procedure that is performed. For a “skin only” procedure, the recovery is limited by the skin tightness that the patient feels after the procedure. Traditionally, patients are told by their surgeon that they have to walk with a significant bend at the waist after the procedure. The skin loosens over time, but this often takes a week or more. Dr. Cross is now completing the procedure in a way that allows patients to walk almost completely upright immediately after the procedure. Patients wake up after the procedure wearing a garment that is very similar to a medical version of spanks. The garment is removed after 2 days, at which point the patient can shower and wash over their body. All sutures are dissolvable, and incisions have a water tight glue placed on them at the end of the procedure. There is often a moderate degree of discomfort along the incision for up to a week, but most patients are able to take very little pain medicine and are back to most of their normal activities, including driving, within a few days. Exercising can begin 2 weeks after the procedure.
If muscle tightening is performed, there is more discomfort in the belly region. In many cases, however, Dr. Cross treats the muscle with a numbing medicine that lasts 3 days. This numbing has decreased discomfort by over 50% in his patients. Patients will take a few more days to heal compared to the skin only technique, but light exercising can begin around 3 weeks after the procedure.