What is an abdominoplasty / tummy tuck?
The purpose of abdominoplasty or tummy tuck surgery is to address the physical and functional changes that occur to the skin and muscles of the abdomen following weight gain or pregnancy. These changes usually comprise of excess skin which forms an apron or overhang in the lower portion of the tummy and separation of the tummy muscles (known as rectus divarication). Men and women can be affected by one or both of these components.
Why have a tummy tuck?
The aim of the surgery is to remove the overhang of skin and repair any rectus divarication. Many patients seek abdominoplasty surgery so that they are able to fit into or to feel more comfortable wearing certain types of clothes (that would not accommodate the excess roll of skin) or to reduce levels of self- consciousness. For others the goal of surgery is to be able to undertake certain activities (those involving the use of core strength such as lifting or doing sit ups) more easily.
What will happen before my operation?
You will meet your surgeon to talk about why you want surgery and what you want. The surgeon will make a note of any illnesses you have or have had in the past. They will also make a record of any medication you are on, including herbal remedies and medicines that are not prescribed by your doctor.
Your surgeon will examine your tummy, and may take some photographs for your medical records. They will ask you if you want to have someone with you during the examination, and ask you to sign a consent form for taking, storing and using the photographs.
The surgeon will measure your height and weight to make sure that it is safe to do an operation. If you are overweight, pregnant or planning to become pregnant, your surgeon may suggest delaying your operation.
How is the procedure performed?
Abdominoplasty surgery is usually undertaken under general anaesthetic although it can be performed under sedation and local anaesthetic.
The surgery itself involves an incision being placed low on the abdomen (usually within the underwear line) which runs from the centre of the tummy to lateral extent of the skin excess. From here the incision is usually carried up to the level of the umbilicus or tummy button and the skin and fat contained within the boundaries of the incision is removed.
The remaining skin is then lifted or undermined to the lower margin of the rib cage after the umbilicus has been separated from it.
Once these manoeuvres have been completed the rectus abdominis (‘six pack’) muscles will be visible and any stretch or separation that has occurred can be repaired by placing stitches between the inner edges of the muscles.
The next step is to bring the skin that has been undermined in the upper portion of the abdomen down to cover the defect. The operating table will be bent (so that you are in more of a sitting rather than lying position), allowing the skin to reach to the lower incision site. The deep layers of tissue are closed first, followed by the skin and finally the umbilicus is brought back out by cutting a hole in the skin that has been stretched down. Drains are often used to remove any fluid that can build up in the surgical site.
Occasionally if someone has a very high positioned umbilicus it may be necessary to keep the upper incision below the umbilicus (otherwise it would not be possible to close the defect). In these circumstances there will be an additional vertical midline scar as a result of the hole produced by separating the umbilicus from the abdominal skin. This scar may be separate to the main horizontal scar or joined to it.
In certain cases where the umbilicus position is higher than usual it may be possible to keep the umbilicus attached to the skin that is to be stretched down. In these circumstances the umbilicus is detached from the underlying muscle layer and moves downward with the skin and is sewn back onto the muscle layer in a new position. This technique is known as an umbilical ‘float’. It is used in cases where there is not a large amount of skin needing to be removed from the lower portion of the tummy and there is only a little skin slackness above the umbilicus.
A fleur de lis abdominoplasty combines the lower abdominal skin resection with an additional skin excision that runs up the middle of the abdomen, this leaves an additional vertical midline scar.
A mini tummy tuck uses an incision that is placed below the underwear or bikini line and takes out a smaller amount of skin in the lower portion of the tummy compared to normal abdominoplasty. The umbilicus is not usually relocated and any separation of the tummy muscles is not repaired.
For certain patients it is possible to combine liposuction with abdominoplasty. This is known as lipoabdominoplasty. In such cases liposuction is used to improve the contour of the front of the abdomen.
Choice of technique is normally the result of the discussion between yourself and your doctor and considers the extent of skin excess and what scar pattern you are happy with. Crucially and often the determining factor, is what technique will work best with your particular anatomy.
Combining liposuction with abdominoplasty can produce better overall abdominal shape. However, it carries with it the additional risks associated with liposuction surgery and also necessitates a change in some of the technical aspects of the surgery itself. These relate to preserving more of the blood vessels supplying the skin in the upper portion of the tummy. Not everyone is a good candidate for combining liposuction with an abdominoplasty, your surgeon will be able to discuss the potential benefits or draw backs of using this combined approach in your particular case.
Because are many ways to perform abdominoplasty surgery your surgeon will discuss with you which technique they believe will work best in your case and with a view to accommodating or best meeting your own aims. It is not usual for a surgeon to explain in detail every possible technique but if you wish to discuss this in further detail/obtain further information please ask your surgeon. If there are particular goals you wish to achieve from the surgery then you need to make sure that you have discussed these with your surgeon so that they can discuss the options available to best address them
ALTERNATIVE FORMS OF TREATMENT
Surgery is not always the right choice of treatment to change the shape of your abdomen. Diet and exercise can influence abdominal shape and should always be considered prior to undergoing any intervention. For cases of mild skin excess certain types of skin tightening therapies may have some benefit. Where the problem relates solely to subcutaneous fat deposition liposuction can be a more appropriate intervention.
WILL THE RESULTS OF SURGERY BE PERMANENT?
So long as your weight is stable the size of your abdomen should remain the same following surgery.
COMPLICATIONS AND RISKS OF SURGERY
Anyone considering surgery should approach the decision with a healthy amount of respect and caution especially when the surgery is elective (or planned) and is non-essential surgery (as aesthetic or cosmetic surgery generally is).
All surgical procedures have limitations in terms of achievable outcome and it is important that your expectations match what is possible through surgery and that you are aware of the material risks and complications. Your surgeon will discuss these risks and complications during your consultation.
GENERAL COMPLICATIONS/RISKS
Bleeding: It is possible, though unusual, to experience a bleeding episode during or after surgery. Should post-operative bleeding occur, it may need draining surgically. If a collection of blood accumulates within the surgical site (a haematoma) that is small enough to not be detected clinically this may result in a spontaneous discharge from the surgical scar at a later date (if this happens it is usually a few weeks following surgery) most small haematomas resolve spontaneously, however. A haematoma can occur at any time following injury to the abdomen.
Seroma: A seroma can be best thought of a collection of fluid beneath the skin or within the tissue at a surgical site. If this occurs there is the possibility it will need to be drained with a needle, it may resolve itself or require an operation to drain it.
Infection: Infection is unusual after surgery. If there is a collection of fluid within the abdomen (a seroma or haematoma) these can become infected. Should an infection occur, additional treatment including antibiotics, hospitalization, or additional surgery may be necessary.
Scarring: All surgery leaves scars, some more visible than others. Although good wound healing after a surgical procedure is expected, abnormal scars may occur within the skin and deeper tissues. Scars may be unattractive and a different colour compared to the surrounding skin. Scar appearance may also vary within the same scar. Scars may be asymmetrical (appear different on the right and left side of the body). There is the possibility of visible marks in the skin from sutures. In some cases, scars may require surgical revision or treatment. Scars can appear thick, red and raised all or part of the way along the incision line (a hypertrophic scar) or more rarely can involve tissues beyond the incision itself (and can resemble a badly healed burn), this is known as a keloid scar. Additionally, scars can tether to underlying structures or become abnormally pigmented. It is possible that additional treatments may be required for adverse scarring.
Delayed Healing: Wound disruption or delayed wound healing is possible. Some areas of the abdomen or umbilicus may not heal normally and may take a long time to heal. Areas of skin or umbilical tissue may die. This may require frequent dressing changes or further surgery to remove the non- healed tissue. Individuals who have decreased blood supply to the abdominal tissue from past surgery or radiation therapy may be at increased risk for delayed wound healing and poor surgical outcome as may patients with conditions such as diabetes. Smokers have a greater risk of skin loss and wound healing complications.
Skin Discoloration / Swelling: Some bruising and swelling normally occurs following abdominoplasty surgery. The skin in or near the surgical site can appear either lighter or darker than surrounding skin. Although uncommon, swelling and skin discoloration may persist for long periods of time and, in rare situations, may be permanent. Additionally, these areas may have exaggerated responses to hot or cold temperatures. Because of changes in the pattern of blood flow within the abdominal skin brought about by the surgery it is possible to develop new blood vessels which may be visible under the skin.
Sensory changes: With any form of surgery small nerve branches that supply the skin will be cut. This can lead to patches of numbness around the surgical site. It is possible that following surgery you can develop abnormal sensation in the area where you have had surgery and this may take the form of pins and needles (known as paraesthesia), hyper-sensitivity or even pain in response to normal touch (known as allodynia). Such problems may be related to nerves becoming entrapped within scar tissue and further surgery may help. It may be necessary to take medication to control any such symptoms on a permanent basis. Numbness following surgery is normal and usually resolves after 12 to 18 months.
Suture extrusion: As well as stitches (sutures) in the skin, you will have deeper sutures to hold the deep layers of connective tissue and the lower layer of the skin (known as dermis) together. These sutures are made out of material which is broken down by the body – often called dissolving sutures. Some people can develop redness in an area of the incision that is fully healed (3 or more weeks following surgery) and it appears that pus comes out. This is the body’s response to the stitch and the ‘pus’ represents the white blood cells trying to dissolve the suture (causing localized inflammation but without infection). Such areas are normally managed with simple dressings. It is possible to develop multiple suture extrusions at the same time or at different times during the healing process.
Allergic Reactions: Local allergies to tape, suture material and glues, blood products, topical preparations or injected agents can cause skin reactions. Serious systemic reactions including shock (anaphylaxis) may occur to drugs used during surgery and prescription medications. Allergic reactions may require additional treatment and can result in severe illness or death. Often, they result in minor irritation/discomfort and resolve reasonably quickly.
Deep vein thrombosis, cardiac and pulmonary complications: Any procedure requiring general anaesthesia increases the risk of the formation of blood clots in the legs. Such clots can dislodge and move to the lungs, causing shortness of breath and strain on the heart. Such clots can potentially be fatal. If you experience shortness of breath, chest pains or palpitations (abnormal heart beats) following your surgery it is important you seek medical advice immediately.
Blood Transfusion: Blood loss during surgery may require treatment with a blood transfusion. It is possible for viral transmission to occur with such treatment (HIV, hepatitis, and others). Having a blood transfusion can result in a transfusion reaction that can cause serious illness.
COMPLICATIONS SPECIFIC TO ABDOMINOPLASTY SURGERY
Umbilical necrosis: If there is any problem with the blood supply to the umbilicus (because the umbilicus has been separated from the abdominal skin), this may affect the healing and even the survival of the umbilicus. In the worst-case scenario the entire umbilicus may die. If you are unlucky enough for this to happen, you may require revision surgery in the future to address poor scarring or to reconstruct a new umbilicus for you.
Skin and fat necrosis: If the blood supply to the skin is insufficient following surgery (which can be for a variety of reasons) it can necrose (die). If this happens the skin will form an eschar (scab) which may need to be removed surgically. Dressings are likely to be required for a period of time and further surgery may be needed to correct adverse scars. The areas of skin most susceptible to wound healing problems following abdominoplasty surgery are lower central portion of the incision in a standard abdominoplasty or the ‘T’ junction (where the vertical scar joins the horizontal scar) in a fleur de lis abdominoplasty. If there is inadequate blood supply to the subcutaneous tissue (which is composed in a large part by fat cells) this too can die (and be replaced by scar tissue). This may produce areas of firmness within the abdominal skin. Fat necrosis may also result in discharge of liquid from the surgical incision due to fat liquification. Additional surgery to remove areas of fat necrosis may be necessary. If an area of fat necrosis were to become infected, it would require further treatment with antibiotics or surgery. There is the possibility of contour irregularities in the skin that may result from fat necrosis. The larger your body mass index (BMI) the more at risk you are of this complication.
Changes in skin sensation: You are likely to experience loss of sensation in the lower portion of the abdomen (below the level of the umbilicus) following abdominoplasty surgery. This usually improves with time but can take several years to do so. Some patients do not recover sensation in this area following surgery.
Skin Contour Irregularities: Contour and shape irregularities may occur after abdominoplasty. Visible and palpable wrinkling may occur. Residual skin irregularities at the ends of the incisions or “dog ears” are always a possibility when there is excessive redundant skin. This may improve with time, or you may elect to have this surgically corrected.
Firmness: Excessive firmness of the abdominal skin can occur after surgery due to internal scarring or fat necrosis. The occurrence of this is not predictable. If an area of fat necrosis or scarring appears, this may require biopsy or additional surgical treatment.
Damage to Deeper Structures: There is the potential for injury to deeper structures including nerves, blood vessels, muscles, and internal abdominal organs, including the bowel (leading to the potential need for further surgery) to occur during an abdominoplasty. Injury to the bowel may require removal of a segment of damaged bowel and could result in the need for stoma bag formation.
ASYMMETRY OF THE ABDOMEN AND UMBILICUS
Everyone is different on the right-hand side of their face and body compared to the left. Any pre-existing asymmetry between the sides of your abdomen (such as extent of overhang, position of fatty deposits or skin folds) will influence the outcome of your surgery.
Asymmetry of the abdomen can result in any of the following:
Scar asymmetry: The shape, length and position of the scar may differ between sides following surgery.
Umbilical asymmetry: The position of the umbilicus may not be placed centrally in the abdomen, in respect to horizontal position on the abdominal wall. Normal position for the umbilicus vertically is between half and two thirds of the way down the abdomen (although it can lie higher or lower than this in certain individuals).
ABDOMINAL SHAPE
Changes in abdominal shape: Although abdominoplasty surgery will remove the excess skin from the abdominal region and tighten the abdominal muscles there is no guarantee that it will give you a flat tummy. Overall abdominal shape is governed not only by the skin but also by underlying muscle tone (for which you can do exercise to improve) and the amount of fat stored by the body inside the abdomen. At the suture line there may be a step off between the thin skin of the groin region (which has little in the way of subcutaneous fat) and the skin of the upper portion of the abdomen which has been moved down. This skin has a much greater thickness of underlying fat and whilst if liposuction has been included in the surgery it will help to reduce any mismatch there is no guarantee that a step off will not be present after surgery.
Mons Pubis: The mons pubis is the area covered by pubic hair and can often sag following weight gain (and especially with subsequent weight loss). Mons position and shape can be improved by surgery but there is a limitation on what can be achieved both in terms of tissue tightness (as there is a risk of distortion of the labia) and tissue thinning (relating to degree of fullness of the mons area).
It is possible, though unusual, for women to develop distortion of their labia and pubic area. Should this occur, additional treatment including revisional surgery may be necessary.
SPECIFIC HEALTH FACTORS AFFECTING THE OUTCOME OF ABDOMINOPLASTY SURGERY
Body mass index: Research has shown that the higher your body mass index (BMI) the more likely you are to have a complication post-surgery. Achieving the healthiest BMI possible prior to surgery is always recommended.
https://www.nhs.uk/live-well/healthy-weight/bmi-calculator/
Smoking: Smoking or vaping with a nicotine vape (or using a nicotine patch or gum) reduces blood flow to the tissues and results in poorer scarring, wound healing and is associated with a higher rate of complications in general. You are advised to stop smoking 6 weeks prior to surgery and to refrain from smoking thereafter.
Medications: Certain medications can interfere with wound healing and increase the likelihood of infections following abdominoplasty. It is important that you inform your surgeon of all the medications you are on.
Diabetes: Diabetes affects immune system function, as well as tissue perfusion (blood flow) and wound healing. You are at higher risk for developing complications following surgery if you suffer with diabetes.
ADDITIONAL CONSIDERATIONS RELATING TO ABDOMINOPLASTY SURGERY
Surgical plan: Although a pre-operative plan will have been discussed prior to the operation, there are multiple ways of undertaking an individual procedure. Each technique has been developed to achieve the same end result (though may result in differing scar patterns). It may sometimes be necessary to alter the initial plan discussed with you at the time of operation due to anatomic considerations that become apparent during the course of the surgery. Your surgeon will discuss with you what may be subject to change or what these changes may be; this varies between different types of procedure.
Unsatisfactory Result: Although good results are always aimed for, they cannot be guaranteed. You may be disappointed with the results of abdominoplasty surgery. Asymmetry in scar shape and size, umbilical shape and position, wound disruption, poor healing, and loss of sensation may occur after surgery. Unsatisfactory surgical scar location or visible deformities at the ends of the incisions (dog ears) may occur. Liposuction may be necessary to thin subcutaneous that is outside of the normal surgical location for abdominoplasty surgery and this may be classed as an additional procedure and incur an extra charge. It may be necessary to perform additional surgery to attempt to improve your results.
Although the risks and complications occur infrequently, the above risks are particularly associated with abdominoplasty surgery. In addition to the risks and complications outlined above there are others that can and do occur, though these are even more uncommon. The outcomes of surgery and medicine are influenced by many factors beyond the control of your surgeon and as such cannot be predicted.
CHOOSING A SURGEON
If you decide to have a tummy tuck, only go to a surgeon who is properly trained and on the specialist register held by the General Medical Council. They will talk to you about what is possible for you or might give the best results. Members of several different organisations do cosmetic surgery, so your general practitioner (GP) is the best person to advise you on who to see.
You should talk to your surgeon before your operation about when and how to pay. Nobody needs an urgent tummy tuck. If you are not given time to think about it, you should look elsewhere.
Disclaimer
This document is designed to give you useful information. It is not advice on your specific needs and circumstances. It does not replace the need for you to have a thorough consultation, so you should get advice from a suitably qualified medical practitioner. We – The BAAPS and BAPRAS – have no liability for any decision you make about the surgery you decide to have.
