How Tummy Tuck Surgery Works and What to Expect

Doctor’s Note

Welcome to Plain Talk About Plastic Surgery, a podcast that educates you about all things relating to plastic surgery procedures and operations, with down-to earth and honest information.

I’m your host, Dr. Elizabeth Kerner.  While you listen, I hope you’ll think of me as your sister, the plastic surgeon, who will tell you like it really is.

I have been in practice in Plano TX, a northern suburb of Dallas, for over 30 years.  I am an American Board of Plastic Surgery certified plastic surgeon, and have been a member of both the American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Surgery.

My practice is predominantly cosmetic surgery, doing about 80% cosmetic surgery and 20% reconstructive surgery.

I am a past president of the Texas Society of Plastic Surgeons.  I was also the first female president of the hospital medical staff at Texas Health Presbyterian Hospital Plano, where we have 1,400 doctors.

I am a member of the Texas Medical Association, and the Dallas County Medical Society. I have been on many leadership committees and boards over the years.

Each episode of Plain Talk About Plastic Surgery will focus on one area of plastic surgery in depth, discussing the anatomy, the operative technique, risks, potential complications, and most importantly, who would be a good candidate and who would not be a good candidate.

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Episode Transcript

Introduction

I’m doctor Elizabeth Kerner, and welcome to Plain Talk About Plastic Surgery, your source for all things plastic surgery.

Thank you for joining me today. We’re going to talk about abdominoplasty or, as it is more commonly known, the tummy tuck.

In this episode I’ll give you the history of the tummy tuck. I will go over my consultation when patients come in and are interested in doing something to improve their abdominal wall. And we’ll discuss risks and complications, as well as the surgical technique, and then touch your postoperative course.

Hopefully by listening to this podcast, it will answer questions that might have arisen after your consultation with me in the office.

Let’s start with definitions.

Surgical Terms & Definitions

What is an abdominoplasty? In classic terms it is a dermolipectomy of the abdominal wall. That just means taking off skin and fat. And in the olden days, say early 1900s to really about 1970, that’s all that was done. The earliest surgeons back in the 1900s would remove a large swath of skin and fat from the abdominal wall when they were trying to correct big ventral hernias, or hernias of the front of the abdominal wall.

As you can imagine, if you have a lot of skin and fat pulling down on the hernia, it’s going to be difficult to correct, or it will be difficult to maintain correction, and recurrence was really quite high. So abdominoplasty actually began with trying to correct ventral hernias by removing the very frequent, too much skin and fat, on the anterior abdominal wall that made recurrence quite likely.

The earliest case reports of these type of operations go back to the 1890s, which I find incredible. Nowadays when we do an abdominoplasty, we can control the blood vessels that are present – and there are really some pretty large blood vessels around the belly button.

I’m just going to say ‘belly button’ rather than ‘umbilicus’ because it’s easier for me. And I’ll probably say ‘tummy tuck’ rather than ‘abdominoplasty’ through this just for less words to have to speak.

The History of the Tummy Tuck

But looking back at those surgeons and what they did when all they had were hemostats, and silk ties, and they didn’t have the electrical cautery that we do, boy, my hat’s off to them that they would tackle such a large operation.

I also wondered about mortality rate and complication rate because they didn’t have drains like we have now. They didn’t have the newer suture materials and techniques and instrumentation that makes a tummy tuck a very safe operation these days. I suspect mortality was rather high and morbidity, which is the complication rate, was probably extremely high.

The type of abdominoplasty that we do now really began in the 1960s. And at this point plastic surgeons, because they were the ones mostly doing this operation, wanted to put more of a cosmetic or aesthetic stamp on this operation.

From the earlier days, the excess skin was removed straight across the middle of the abdomen around the umbilicus. And oftentimes the belly button would be completely sacrificed, or there was a vertical incision made that means a straight line that went down from the middle of your ribcage to your pubic hair, which would take out the extra skin. Of course this would solve the problem, but didn’t leave you with a very good looking abdominal wall.

At about the 1960s plastic surgeons began to combine a more aesthetic approach to the abdominal wall, coupled with better understanding of the anatomy to allow them to create a more optimal contour of the abdominal wall.

In about the mid 1960s, the muscle began to be approached because we now know that a big component of correcting the protuberant abdomen is control of the muscle. And I’ll talk about that a little bit later when I talk about the components of the abdominoplasty.

Of course liposuction coming in in the 1980s really revolutionized what can be done to the abdominal wall and spawned multiple techniques which we still have today.

What do You Want Out of Surgery? 

When you come in to see me for a consultation for your abdominal wall, I’m going to ask you what bothers you. Is it the skin? Is it the fat? Or is it the protrusion? Most women, it’s a combination of all three. So there are three things that we can do to correct the abdominal wall.

If your skin is pretty good, meaning that you don’t have lots of loose layers, and there’s not a huge number of stretch marks, then possibly just liposuction will be all you need. And as we discussed in a previous podcast, liposuction, especially to the abdominal wall, it is a quick and easy and not particularly complicated operation to perform and to recover from. If you tell me that what really bothers you is the skin then liposuction’s not going to help that because liposuction will only tighten the skin to a small degree.

If I look at your abdominal wall and see that you have folds of skin, and the skin that you do have has lots of stretch marks, the only way to really improve that is to cut out this damaged skin. So now we’re into abdominoplasty or tummy tuck territory. If you say well, everybody asks me if I’m pregnant, or when am I due that tells me right off the bat that you have weak musculature.

Weak musculature we call diastasis recti. That just means a split or a spreading of the rectus muscles. The rectus muscles are the two muscles, they are a thin muscle that extend from the bottom of the ribcage, envelop the belly button in the middle and go down to the pubic bone. The rectus muscles themselves have a layer of fascia over top and underneath of them.

Fascia is just the white membrane like you see on a steak. If you’re going to cook a brisket you want to take that fascia off because otherwise it will curl.

Fascia is incredibly important to a tummy tuck. If you have good strong fascia, that means your abdominal wall will be flatter in most cases. If you have very thin attenuated fascia – and there’s nothing you can do to pick your fascia, unfortunately – then you’re probably going to have a weaker abdominal wall.

Diastasis and Pregnancy

Let’s talk about what happens when you develop a diastasis. For most of us when we’re younger, and we haven’t had children and we’re not obese, the two rectus muscles touch in the middle. It’s like a little sandwich.

So you’ve got fascia as the bread and the rectus muscle is the meat inside, and down the middle there’s a little intention, but you haven’t cut completely through the sandwich in the middle. And then the belly button sort of sticks up like you put a little canapes. I can’t think of what the name of those things are, but the little things that have paper on the end of them. A little stick, you know, and that’s sticking up in the middle.

When you have a pregnancy and the pregnant uterus, the gravid uterus pushes out, the muscles have to stretch to accommodate that because obviously the uterus has to go somewhere. Below the belly button there’s only fascia on the top of the rectus muscle. So of course it gives more there than it does up above the belly button.

That’s why most women when they’re pregnant have much more fullness below down towards the pelvic area. But if you stretch enough, or if your fascia is weak, you’ll begin to stretch the upper musculature as well. And then the muscle begins to spread.

So what I see in the operating room is muscle on one side and then a little valley between the muscle on the opposite side. There’s fascia there, but because there’s no muscle in between it, it doesn’t have the strength and that means when you stand up, your abdominal wall is going to bulge out.

So a big part of abdominoplasty is correcting the diastasis. Occasionally when I operate, I will find someone who doesn’t have a diastasis. I remember a patient who came in, she was really quite fit and she came in to talk about maybe doing an abdominoplasty. She had had five children, all vaginally.

And I figured when I looked at her abdominal wall, she was going to be just as poochy and stretched out as could be, and she was not. She did not have any evidence of any diastasis.

That is incredibly unusual and I would say that she probably won the fashion lottery and all we did on her was a little bit of liposuction just to tidy up the abdominal wall and complement the fitness that she had already created through her exercising.

Now, I got a little bit of a digression there, I’m quite sorry. We’ll go back to the consultation.

Modern Abdominoplasty Surgery

So my next step will be to talk to you about what we do in an abdominoplasty. I will run through that because it’s quite straightforward, and of course I’ve shown you the pictures in the book, and hopefully you’ll recall what we were talking about.

An abdominoplasty incision is going to be low. If you have a C-section scar it’s going to be below that. Normally it’s going to be right at the junction of the pubic hair and your abdominal skin. And it’s a long scar. It does usually go hip to hip.

Nobody wants a hip to hip scar and I would love not to create a hip to hip scar because it means less sewing for me. But if you have skin that’s loose, and we sew up just in the center part, it’s going to leave a flop of skin or a fold of skin out towards your hip bones, and that won’t go away. And I can tell you that from personal experience, because I have that from my C-section 27 years ago, and it’s not gone away.

So we create a longer scar so we can get rid of the extra folds of skin out towards the hip. So an abdominoplasty is done by making this long scar, then lifting up the skin and fat on top of the muscles, right on top of the fascia, until we get to the belly button. Then on the outside of the skin I’ll cut around the belly button and leave the belly button on its stalk. The belly button has a little stalk, usually one to two centimeters, and it just lives exactly where it lives.

Frequently, the belly button is not in the midline and I will try and pull it back over. If it’s way off of the midline, it won’t stretch too far unless you’ve had a big weight loss.

If you think about it, when you gain a lot of weight, the belly button does eventually lengthen and stretch so it can continue to extend out to the front of the abdomen. So if you’ve got a pretty big abdomen, you may have a long stock on the belly button. And in those cases, we’ll have to shorten it so that it doesn’t look like worm underneath your skin when we’re all finished.

And then once the belly button has been separated out, I continue to lift up the skin and the fat until we get up to the ribcage.

Important things in this area are the blood vessels that come out from under the ribs because these blood vessels course down through the skin and provide good blood supply.

If you think about it, when we lift up the whole flap, that’s the skin and the fat of the abdominal wall. I’m cutting all the blood vessels that go from the muscle up to the skin. Those are called perforators, and they look like little trees that just come straight up, and when I see them, I put a little clip on them, or if they’re small, I just cauterize them. Around the belly button, there’s usually two pretty large ones that will have clips.

So one of the considerations when you’re doing a tummy tuck is to make sure that when you’re all finished, that the blood supply going along the ribs can get all the way down to the cut end of the skin and keep everything healthy.

There are zones in the abdominal wall and many plastic surgeons will do modifications of a traditional liposuction to capture as many of the blood vessels to keep the edge of the skin healthy.

Keeping the edge of the skin healthy is the number one safety concern with the procedure. If you cut too many blood vessels or there’s too much swelling, and the blood supply can’t come down through the skin and get to the edge where you’ve cut off and sewn in above the pubic hair, then that skin is going to die, and that’s a big complication. It can be corrected but it’s a lot of work and of course, a lot of emotional anxiety for the patient and also for the plastic surgeon.

If you smoke, I won’t do your operation because of those concerns, because I already know the micro vasculature of the little blood vessels in the skin are not good and I can’t do as much as I want because of concerns of blood supply. Also, if you’ve had an old gallbladder incision where it goes underneath of your ribcage on the right side – a big long scar – that’s going to cut off blood supply down to the edge, and things become a little touchy.

Now if your gallbladder was about 30 years ago, it probably doesn’t matter. But I’m going to tell you, I’m going to be very conservative in that area to try and maintain all the blood vessels.

I do see lots of ads for plastic surgeons and I see lots of articles in my journals, where people go to extreme lengths to try and maintain all the blood vessels. I don’t think that’s quite practical. When you need to pull the skin down, if you have all those blood vessels still staying in there, they tether the skin and you can’t pull and take off as much as you want.

Most of this, as you’re beginning to gather, is going to be judgment based on the plastic surgeon’s experience with previous abdominoplasties.

Back to the operation. Now the skin is all lifted up, then I inspect the muscles and see how far they’re spread apart. In almost every case, I’m going to put sutures in the top of the muscle. This is called glycation and it brings the muscles back together in the midline.

I do a non-absorbable suture because I personally feel that if you put an absorbable suture in once it dissolves, there’s no particular reason for the muscles to stay together. And these muscles are strong, you think about what you do just even in exercising and with sit ups and planks and burpees, they have to be able to withstand the stress trying to pull them back apart.

So I put two layers of a big non-absorbable suture. These layers go from the bottom of the ribcage to the belly button and then we leave a little hole for the belly button to poke out and then another two layers from the bottom of the belly button down to the pubic bone.

Fat, Liposuction & Drains

My next step then is to look at the fat that’s on the abdominal wall, and I’m going to liposuction almost everybody. You know some patients are so thin they don’t need to be liposuctioned. But I’m normally going to liposuction along the waist area, the front part of the hips, and the pubic bone. Liposuction along the lower ribcage or in the skin above the belly button will be determined on how hard I have to pull down to get the skin off.

We just talked about blood supply and this completely relates to making sure that there’s good blood supply to the edges of the skin right where I’m going to cut off. If I don’t have to pull very hard, I’m going to liposuction a lot. If I have to pull quite hard and you’re thin and I’m worried about blood supply, I’m probably not going to do much liposuction above the belly button.

I think this is one point that distinguishes me from a lot of surgeons. Many surgeons just liposuction everything and don’t worry about it, but I’m a little conservative. I haven’t had any skin loss before, and I would prefer not to have to deal with that complication with any of my patients.

Once the liposuction is done I’ll put numbing medicine along the muscle repair which will help you after surgery. And then we’ll sit you up, we just move the bed to be a semi-sitting position, and we’ll pull that skin down and cut off the extra skin and then it gets sewn up in layers.

There will be two drains, one on each side that go underneath of the skin between the muscle and the lower fatty layer to collect blood and serum.

There are some surgeons that do what are called quilting sutures inside, or progressive tension sutures, where they suture the bottom of the fat to the muscle beginning at the ribcage all the way down so that they don’t have to use drains.

I know that it works just great for them and I can’t seem to make it work just great for me. I always get little dimples. It takes a long time for the dimples to go away. I like to put drains in, that way I know the fluid’s gone. When you see how much fluid comes out, you’ll kind of go “Oh yeah, that’s probably a good idea”.

I also recognize that the drains are very infuriating. They’re just aggravating. You want them out as soon as you can, but they’re going to be in there for probably seven to nine days. The more active you are, the more you’re going to drain, this is just friction. The more liposuction I do, probably the longer it’s going to drain. The more fat on the abdominal wall, the longer it’s going to drain.

So the drains go in and then we’ve cut the skin off, and then when I’m in the process of cutting the skin off, I just make a little mark where the belly button lives and then we’ll cut a circle of skin and fat out on top of it and pop the belly button in and sew it’s so it gets a new opening. So you keep your same old belly button, you just get a new opening for it.

I tend to make either a circular or preferably a vertical oval belly button. I don’t like the italicized “I” belly button that lots of people do, or the sort of tulip looking belly button. I don’t like any of those. But I’m open if you have particular belly button shape that you would like to try and achieve. I will certainly work to do that.

Then surgery is now concluded. We’re going to put a girdle on you and you’re going to wear that girdle for the better part of six weeks. We start with a surgical girdle that has the crotch out and zippers on the side, as it’s easy to get on and off. And then once your drains are out you can go to a commercial one.

Restrictions After Tummy Tuck Surgery

Restrictions after surgery: You will be semi-sitting for probably a week to 10 days. Each day you can get a little straighter, and hopefully by the end of two weeks you’re reasonably straight. And by the end of three to four weeks, your shoulders, your back and your posture is back good.

What can you not do after an abdominoplasty?

You can’t do a backbend. If you think about everything I’ve done with pulling the skin down, and suturing the muscle, if you start doing back bends or the bow in yoga, you’re going to really pull everything out. Frankly, I can’t imagine that you would be able to do that after a full abdominoplasty. But that is one restriction. So if in your life, if you really like to do back bends, this is not an operation for you.

Other consequences of this operation are a longer scar. Scars usually do well but that’s something to consider. And there’s usually some numbness above the scar that will be permanent.

We’ve begun a new program called ERAS, which is Extended Recovery After Surgery. And it’s just a means of giving you different medications that will help to control your pain after surgery so hopefully you won’t need to take as many narcotics.

Narcotics in and of themselves are not bad but they do create problems with constipation, and of course, everybody knows about opioid dependence. Most of my patients are happy to get off of narcotics as soon as they can, so that they have a clearer brain and feel like they’re functioning more normally. The ERAS protocol is a little bit cumbersome because it’s taking lots of medications, one here and one here and one here, but we have it all written out and hopefully it will not be too hard for you to understand.

Risks & Complications of Abdominoplasty

I thought I would go over risks and complications right now. You will see when you look at the consultation form that we give you that there’s quite a list of risks and complications. I don’t want anyone to be scared about them, but this is a major operation and of course, things can happen. So that’s why we give you this list so that you know if any of these complications or consequences happen, how we would take care of them.

Big surgical risks would be bleeding or infection. Infection is quite uncommon but could be taken care of with oral antibiotics. Bleeding is also very uncommon but if it did occur would mean going back to the operating room.

I do like to put little clips on the blood vessels, so I don’t see much bleeding. But if a clip came off and you bled it would be very obvious; you’d have swelling under the skin, which creates a great deal of pain and of course, a lot of blood would come out in the drain.

That situation would require return to the operating room because blood vessels are large enough that we would have to be concerned about your life. But I’ve only had a handful of these – I think four in 32 years – so not much of a problem with that.

The things that I really deal with are the scar. Of course not everybody’s scar does great. Some people don’t scar well. Some people scar very well. If you have darker pigmentation in your skin, a big issue is the scar may hyper pigment and be quite dark. Some scars get red and ropey. Those are the ones that we deal with the most. There’s an algorithm for treating this and if that were to occur, I will go over that with you but I’m not going to waste your time talking to you about what we do about that right now.

Delayed healing – we talked about that – would be poor blood supply to the skin edges.

Stroma would be fluid that accumulates under the skin. So the drains are finally taken out and then a couple of days later, you notice that you’re poochy, and there’s a little bubbly feeling. That would be fluid that reaccumulated that your body hasn’t reabsorbed.  That is taken care of by aspirating this in the office. So to do that I just numb the skin, put a little needle in and draw off the fluid. Huge nuisance because you have to come in every couple of days for me to do that, but eminently treatable.

Dog ears are a little pooches of skin at the end of the incision, and I do sometimes see that. Mostly it’s because these abdominoplasties are only going to correct the loose skin on the front of the abdominal wall. And if you have loose skin that continues around your hips onto your buttock area, I have to stop my incision somewhere. I can’t keep going because then there’s the sheet and you’re not prepped.

So if you get a dog ear, it’s because you have loose skin over your hips and that’s not the area that I’m correcting. But if it’s a small dog ear, I can correct that in the office usually at about the fifth to six month.

The big complications would be pulmonary, that would be pneumonia. And that occurs because you’re not breathing deeply after surgery. If you think about it, you take a big deep breath, it causes your diaphragm to go down, you just had your muscles tightened and it really hurts, so you don’t take a big deep breath. We give you an incentive spirometer little device to breathe into and that will help with that.

And then of course, the biggie would be blood clots in the legs or the lungs. Blood clots occur because you’re not moving around very much, so inactivity is a risk factor. Also compression of the abdominal wall from the muscle tightness and then the girdle, and then we put you in bed in sort of a squished up position. All of those are risk factors for getting a blood clot.

I will talk about this at length with you so that you know what your risk is. There is a scale that I do on every patient, a risk assessment for blood clots, and if you have a high risk, we need to talk about whether or not you should have the operation, number one, and if you do decide to have the operation should you have anticoagulation afterwards.

That of course is the biggie, the blood clots. For most women, their risk is under 0.5%. So less than a half of a percent, but it’s the big one.

Limitations of Tummy Tuck Surgery

What are the limitations of this operation? Well, to me, there are two big ones. If your skin is really not very good; if you have lots of stretch marks, and a lot of looseness and you’re older, you just don’t have good elasticity and nothing’s going to give it back. So even cutting off the skin and tightening the muscle, you’re not going to have a taught look.

So if you come in and say, “I want to look like a bodybuilder with that shiny, oily skin, it’s all greased up and it’s all taught and you can see all my muscles underneath of it”,  good chance is that’s not going to be possible. If your muscles are weak and your fascia is weak, there’s only so much tightening I can do.

If you carry a lot of your weight intra abdominally, meaning that you have fat that’s stored around the internal organs, think of men with their beer bellies, I can’t make that go away. We can’t take that out because it’s actually dangerous to do that. And there’s only so much I can tighten on top. When I start to tighten the muscles, you are not going to suddenly have your internal fat just magically disappear and dissolve. So if you’re quite protuberant and you’re overweight, the first thing you need to do is lose weight.

There are subsequent changes to the contour. Most of this is just the aging process, the elasticity of your skin and also your weight.

What to Expect Postoperatively

I’d like to touch on the postoperative course. You will probably need to be off work, if you work, for at least two weeks. Depending on your job it could be longer. If you have additional operation with us, say a hysterectomy or bladder sling, you could maybe need to be off work longer.

Exercising by the third or fourth week, you can be walking and strolling. By six weeks you can be doing some cardio activities. But anything involving the abdominal wall has to wait for about three months.

From the operation to the time where we say “oh you’re healed, this is what you’re going to look like” is usually five to six months, but it may take your scar even up to nine to twelve months to get completely pale and look normal.

So there are fairly significant restrictions after this operation. If you have young children at home, it can be very hard those first two weeks to do anything for them and you will most likely need someone to be there at home with you to take care of them. Driving is when you’re not taking your pain medicine after surgery, and that’s usually going to be about a week to nine days before patients feel comfortable to come in driving.

Conclusion

There are many other things to discuss about abdominoplasty. But I think this will give you a good overall feel for the operation. Hopefully this podcast will complement your consultation with me. There’s so much information, I recognize that patients can’t retain all of it.

It’s pretty common for me, and I remember it because I talk about it all the time and of course I do the operation, but this way between the podcast and your consultation, hopefully we haven’t left anything out that is a major topic of discussion.

That’s our podcast for today on abdominoplasty or tummy tuck.

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Thanks for listening. Have a great day and don’t forget to use your sunblock.

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