Abdominal Contouring

All layers of the abdominal wall (skin, fat, fascia, and muscle) are affected by changes occurring with age, pregnancy, and weight change.  Excess fat with elastic skin can be treated with abdominal liposuction.  Patients with excess fat, loose skin, and weak abdominal muscles, commonly seen after pregnancy, are ideal candidates for an abdominoplasty. 

The procedure
An abdominoplasty is a cosmetic operation not covered by insurance aimed at re-contouring the abdominal wall, but muscle tightening also may improve low back discomfort and strength. The operation can be safely performed in an outpatient or office operating room facility with general anesthesia, deep sedation, or epidural block. Incisions are designed to place scars under a preferred underwear or bathing suit pattern. After elevating the abdominal wall and redraping, excess skin and fat are removed and the abdominal muscles are tightened to improve the waist line. Often the vertical abdominal muscles are separated, a “diastasis rectus," and the hourglass narrowing above the hips are lost, both of which can be improved with internal sutures. The existing navel (umbilicus) is preserved and transposed. The procedure takes approximately 2 to 3 hours.   

Recovering
Overnight observation, drainage tubes, maintaining a flexed position, and a comprssion binder are routine.  Pain can be controlled initially with prescription medication, but tapers rapidly several days after the procedure. Laying and standing straight can be  resumed at 7 – 10 days as tolerated. Most individuals return to work 3 to 4 weeks later.   Strenuous activity and lifting (20 + pounds) can slowly escalate between 6 weeks and 12 weeks. The downsides are the scar and common surgical risks: fluid collections, bleeding, infection, and healing difficulties.

About Mini-abdominoplasty
A mini-abdominoplasty may be indicated if the excess skin, fat, and muscle weakness is mild and limited to the lower abdomen. This smaller operative procedure can be done with a smaller scar, lighter anesthesia, as an outpatient without observation, and with less pain and recovery.  If the upper rectus also has a diastasis, an endoscopic or limited plication can be performed. 

In individuals with massive abdominal obesity, a hanging flap of skin and fat (a pannus), or significant abdominal wall scarring, a panniculectomy (removal of the excess fat and skin) without raising the rest of the abdominal wall is safer than an abdominoplasty. A lower transverse and midline vertical abdominal dermal lipectomy may be indicated in certain patients. Postoperatively, observation for at least 1 night is required due to the comorbidities and increased risk in this patient population. Drains and sutures are usually removed in 2 -3 weeks. It usually takes 2 to 3 weeks to get back to work and moderate activity and 6 weeks to get back to more strenuous activity.

Patients with upper abdominal scarring, atypical upper abdominal excess, or the need for certain combined breast procedures may be best served by taking tissue from the upper abdomen in a reverse abdominoplasty.  The scar is left below the breast but still may be visible or distorted.   

A circumferential body lift, or belt lipectomy, is indicated in patients with excess skin and fat of the abdomen, flanks, and back with laxity and descent of the buttock and hips, often seen after massive weight loss. The cumulative effect is an abdominoplasty, lateral thigh lift, back dermal lipectomy, and buttock lift, and as expected, a belt lipectomy is a major surgery with additive risks, operative time, and recovery.  Therefore, a preoperative determination of safety, risks, and goals is necessary. Risks can be minimized with early postoperative ambulation, multiple suction drains, and close followup. This procedure can drastically reduce the girth, but typically cannot recreate an hourglass figure. Even limited activities can be difficult for the first few weeks and activities must be limited for several months. Results are usually quite pleasing, but the focus is more on function and safety rather than maximum cosmesis.