Hidden Gems as Pointed Out by an Experienced Tummy Tuck Surgeon
All tummy tucks get rid of excess skin from the lower abdomen and hopefully a large number of stretch marks and lower abdominal scars. This alone gives a remarkable improvement but should serve as only the beginning if you truly want the ultimate tummy tuck. Besides getting rid of excess skin, what are the “little things” that yield a fabulous result after a tummy tuck? Actually, there are a lot of finer details which include a good quality scar that is properly located so it can be hidden by panties or a bathing suit bottom, a youthful appearing, vertical belly button with a hidden scar, an hour glass shaped waistline, the lack of a need to “keep it sucked it,” and an elevated mons pubis. These elements require attention to detail and proper markings preoperatively.
Let’s begin with the lower abdominal scar. The best scar is obtained by a three layered closure with the key layer being Scarpa’s fascia. This is the tension reducer that diminishes the risk of a raised, red scar or the tethered down, depressed scar appearance. The length of this scar is dictated by the amount of excess skin. One is better off to accept a longer scar than one that is too short and leaves excess skin at the ends resulting in “dog ears.” It is important to ignore natural transition areas between the abdomen proper and the mons. This will often result in a scar that is too high and is visible in even modest swimwear. I choose to place my incision below any preexisting scar from prior gynecologic surgery or C-sections. A safe bet on scar location is seven centimeters above the vulvar commissure as measured under tension. This allows for excision of any existing lower abdominal scars and places the final scar strategically low on the abdomen.
The belly button is of paramount importance. A youthful belly button has a vertical orientation, superior hooding, and is located at the level of the hip bones. With aging, pregnancies and weight fluctuations, the umbilicus may take on the appearance of a frown. During a tummy tuck the umbilical stalk is left attached to the underlying muscles and is then brought out and reattached to the skin after it is pulled tight. Surgical experience provides the basis of knowing the correct incisional pattern to emulate a youthful, vertically oriented appearance and allows the scar to be tucked into the stalk and nearly invisible. Size is of importance as an under or oversized belly button can be unattractive.
Tightening the underlying muscles and correcting the separation (diastasis) should flatten the abdomen and give a “sucked in” appearance at all times, including when one is “relaxed.” It also accentuates the hour glass shape of the ideal female figure. The male abdomen is squarer and thus correct tightening of these muscles accentuates the femininity of a woman. If left uncorrected, a patient will continue to look bloated or pregnant.
Finally, one giant plus associated with a properly done abdominoplasty is elevation of the mons pubis. The mons serves as padding over the pubic bone and at times, the padding can be excessive and with aging, pregnancy and laxity the mons will droop. No one will find a fluffy, droopy mons attractive and thus it requires surgical attention as well. I usually liposuction the mons if fatty and/or directly excise the fat below Scarpa’s fascia to help flatten it out. Suturing Scarpa’s fascia to the superior flap that is being pulled down elevates and properly positions the droopy mons and results in a youthful appearance of this area.
In my practice, I combine liposuction with the tummy tuck. We suction in the areas under the ribs and in the uppermost central abdomen so those areas are flattened to match the lower abdomen. In some patients, liposuction cannot be done in the lower central abdomen simultaneously with a tummy tuck for fear of losing the blood supply and having wound healing issues. It is important to liposuction over the hour glass area, love handles, and bra strap areas of the back to really reduce one’s waistline.
Surgeons are now employing techniques that may obviate the use of drains after surgery. No patient wants the inconvenience of drains. I employ progressive tension sutures which help the skin flap adhere to the underlying muscles. A new tissue glue has recently been approved to help tack down the flap and has exciting potential.
My last point is perhaps the most important and that is patient safety. As a surgeon, I always strive for perfection and safety. Make one hundred percent sure your surgeon takes proactive steps to prevent deep venous thrombosis (DVT or blood clots). This requires the use of pneumatic stockings during surgery and an injectable blood clot preventative after surgery.
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