Abdominoplasty (tummy tuck) and Body Contouring

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Scar Management After Surgery


Patient Experience

I am 34 years old and have had three pregnancies, resulting in one late miscarriage and two caesarean section births, one of which was an emergency section. I gained about 2.5 stone for each of my two children. Post births, On the scales, I lost the weight quiet quickly but in reality I was left with a large amount of loose skin, separated muscles ( Diastatus Recti), and a very unsightly overhanging apron of skin. I also had bad stretch marks above and below the belly button line. Although nobody sees my stomach really except me, it affected my self esteem, how I felt in front of my husband, getting changed in front of others and the ability to wear fitted clothes.

I was advised re the Tummy Tuck procedure by my own GP, but advised this would take years to get on the NHS. It was not something I knew a great deal about previously but I felt relief just to know that something could be done and that I didnít have to be this way forever. I then started researching on the internet, having the procedure done privately.

I initially made an appointment with a company who gave me a short free consultation with a sales person, then their surgeon a week later. I was not happy with the consultation as it was very brief and not all my questions were answered. They were also very pushy afterwards re: my decision. I then continued researching the procedure and surgeons within Northern Ireland who could perform the operation locally.

I found the website of Mr Brendan Fogarty informative and liked his current fields of expertise. During my consultation with Mr Fogarty, I felt he answered all my questions and gave me a realistic opinion of what he could do for me. I also found his manner to be very open, friendly and approachable. He put me at ease immediately and had time to answer all my questions. I came out of the consultation feeling very positive and informed.

I had my operation with him, about 3 months later, as this suited me around my work commitments. I was not nervous before the procedure as this was something I had chosen to do myself and in fact I couldnít wait to get it over with, to start afresh. I had been thinking about it for a very long time. I feel my own relaxed attitude was aided by the reassuring nature of Mr Fogarty and the anaesthetist who came to see me beforehand.

I fasted from 6pm the day before the operation. The process was prompt on the day and I was straight down for surgery at 8.30am. The operation lasted about 3 hours and I came around feeling fine. I remained in bed that day and felt fine. The day after surgery, I expected to feel unable to walk and very sore as I had with both my Caesareans sections but this was not the case. I was able to get out of bed unaided and go for a short walk around the corridors. With my caesareans I could not walk unaided and was in agony at times. I was also pleased that Dr Fogarty had chosen not to use a catheter on me as this aided my ability to get up and about quicker. I felt there was a huge difference post caesarean section and post abdominoplasty. I had read on the Internet that this procedure would be far worse and this was in fact far from the case which I was delighted about.

I was offered to stay for three nights in the hospital but felt well enough to leave after 2 days. I noted there was no pain in the wound itself and could already see and feel the improvement. I did have pain in my back from having to crouch over to accommodate the wound. The back pain continued for about a week and a half. I was able to go out for a short walk each day in the week post surgery. The wound itself was mainly just quiet itchy due to the healing process and the operative glue. I was also quiet swollen initially; this mainly went down very quickly except for one area in the centre, below the belly button. I woke up one morning in week four and saw it too had settled. I then had a flat tummy once again.

Post surgery, I was unable to shower for a week. The bandages came off after 1 week and I was then able to shower fully. There remained a small protective bandage for another week. This came off at week 2 at which point I was able to also take baths. I have two young children and my husband took time off work to assist me post surgery to avoid lifting. I felt this was essential and avoided me tearing any stitches. I also felt well enough to resume driving after about 2.5 weeks and this caused no issues for me. I bought two post operatives compression garments which I also felt was very worthwhile to permit changing for laundry etc. I wore my garments night and day for 6 weeks. At the start due to swelling these were sometimes uncomfortable but I kept them on to aid the end result.

Now the important part;

Mr Fogarty informed me he had removed about 2.5lbs of loose skin and that my stomach muscles had separated approx 5inches. Mr Fogarty sent me before and after photos and it is amazing to see the transformation. I still look at these photos and canít believe how bad I was beforehand. I feel the appearance of my stomach would have got worse over time and felt I was too young to have this issue.

I loved going shopping post surgery, when the swelling had gone down. I dropped a size in jeans and can wear more fitted clothes again. It is nice to be able to put on a dress without having to worry about a bulge above the pubic line. The caesarean section scars, the large mole and upper stretch marks are now gone. I have a repaired belly button also. I still have stretch marks below the belly button which had previously been above the belly button. I can live with these as they will hopefully fade over time and because my stomach is no longer covered in them and is flat. The whole appearance of the procedure will also improve over the next few months. It is lovely to feel slim and in a sense more normal again, to also have other people comment on how well I am looking. Yes there are much worse medical concerns but when you see your own body every day and are unhappy with it, the change to how you feel about yourself is dramatic.

I have never regretted paying privately for this surgery and think it was money extremely well spent. I am thrilled with the end result; it is lovely to have a flat and tighter stomach. I am delighted to have found Mr Fogarty and that he carried out this procedure for me. I feel so lucky to have had this procedure and would recommend it fully as I would do of Mr Fogarty. It was also lovely to be able to have the procedure done locally. I felt I was in good hands with Mr Fogarty and the end result speak for themselves

Which patients will benefit from an abdominoplasty (tummy tuck)?

An abdominoplasty or tummy tuck, as it is colloquially known, is a procedure designed to excise surplus amounts of flabby skin of the abdomen, and in particular over the lower part of the abdomen. Patients who will benefit from an abdominoplasty often will have had pregnancies in the past and/or have lost a large amount of weight. In pregnancy the abdominal skin has been stretched beyond its elastic limit, resulting in slackness of the abdomen and of course resulting in stretch marks. For this reason liposuction, which depends upon elastic skin shrinkage, is not ideal as an isolated treatment for people who have stretch marks.

A common misconception is that a tummy tuck is intended for people who wish to lose weight. However, the best results are obtained in those people who may be only slightly overweight but who have lost weight with resulting slackness of the abdominal skin. This lax skin may then be more effectively removed leaving a neater taut stomach. Thus in a patient who has lost weight there is a reduction in fat volume such that the overlying skin becomes flaccid and slack. This allows a more effective removal of excess skin with a far more enhanced cosmetic result than would otherwise be achieved by excising a very fatty skin layer. Abdominoplasty is reserved for patients whose family is complete and naturally the results of abdominoplasty would be undone if they were subsequently to have children after surgery.

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Which different types of abdominoplasty (tummy tuck) are there?

There are a number of types of abdominoplasty but they bear a number of common principles. If there is an excessive amount of skin, skin needs to be removed and this leaves a horizontal scar in the lower part of the abdomen where it can be hidden underneath the "bikini line". If there is weakening of the abdominal musculature, which is often common after pregnancies, then some muscle tightening procedures needs to be incorporated in the abdominoplasty. If there is residual excessive amounts of fatty tissue, especially in the hips and flank area then this can be addressed by fat removal by means of liposuction. The commonest type of abdominoplasty is a full abdominoplasty, this addresses all abdominal problems and allows a comprehensive abdominal rejuvenation. Through a lower abdominal incision the excess abdominal skin is removed. In addition the muscles are then tightened and the muscles that a re most predominately affected are the rectus muscles which are vertical muscles running in either side of the belly button. After wound closure liposuction may also be used if there is excessive fat tissue, especially on the flanks and hip areas. Liposuction must however be used judiciously as this can often damage the blood supply and interfere with wound healing, or in the worst cases, cause death of the abdominal skin. The majority of ladies who have had a number of children will benefit from a full abdominoplasty procedure. Because a full abdominoplasty is able to remove a very significant amount of skin (essentially the lower half of the abdominal skin) then the belly button must be relocated to an aesthetically pleasing position ie. in the mid abdomen. The belly button (umbilicus) is left attached to the underlying muscles and then a hole is made in the new tight abdominal skin and the belly button is brought through this hole. The belly button is then sutured in this location and thus leaves a circular type scar around the new belly button position.

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The next type of abdominoplasty (a modified or limited abdominoplasty) is designed for ladies with a lesser degree of skin laxity and this also leaves a scar in the pubic region. In order to remove the excessive amount of skin the scar is slightly longer than a caesarean section scar. Depending on the degree of skin excess however, scar length will vary i.e. the greater skin overhang then the longer the scar. Through this lower abdominal/pubic crease incision the muscles of the lower part of the abdomen can be tightened if there is a lower abdominal bulge. This type of abdominoplasty is also known as a mini abdominoplasty and with this technique liposuction can more safely be used in other parts of the abdomen. However the technique does not address any bulging of the abdomen above the belly button and this is more readily addressed with a full abdominoplasty.

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Would I not just be able to get away with liposuction as opposed to an abdominoplasty?

Liposuction is suited for patients who have got elastic skin as the principle behind liposuction is to remove any excess of fat and then the surrounding elastic skin can shrink to accommodate this reduced volume. If however, the skin is inelastic, then the skin will not shrink but in fact actually sags more after liposuction. Thus many ladies who have had a number of children or have lost a large amount of weight the skin will often have stretch marks and this is indicative that the skin has lost its elasticity. Thus, liposuction is ideal for ladies who do not have stretch marks and have elastic skin and can reduce the general volume of the abdominal skin or apron. When used as an adjunctive procedure in abdominoplasty, liposuction is used to thin the flank skin which may be more elastic and can consequently shrink.

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What can I expect at my outpatient consultation?

At your outpatient consultation Mr Fogarty will examine you himself with the aid of a female chaperone. He will take a detailed medical history in case there are any factors in your general health that will mean that an alteration or tailoring of surgical technique would be required. After examination of the abdomen he would then be in a position to tell you what options are available, and most importantly of all, to let you know if these options can marry up with your desires. A healthy dialogue between patient and doctor in cosmetic surgery is vital so that patients can have realistic expectations otherwise they may not achieve their goals. After discussion with Mr Fogarty you will be free to digest the information at home, and if needs be, you are more than welcome to have a second consultation for clarification as there must be absolutely no pressure involved in making any decisions regarding possible surge ry. In fact Mr Fogarty prefers patients to ru minate on the information at home but if they decide they wish to go ahead and have surgery they can telephone his secretary to make arrangements to have surgery at a convenient date in one of the Northern Ireland Clinics.

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What can I expect to happen on the day of surgery?

All surgery is carried out by Mr Fogarty himself and patients will require a general anaesthetic (ie be put asleep) and this is usually administered by one of Mr Fogarty's anaesthetic consultant colleagues who would also work in the NHS in the Royal Victoria Hospital, Belfast. A friend should drive you into the hospital that morning, and prior to the operation Mr Fogarty will make some marks on your abdomen in your room and this will allow you to see the position of the eventual scar. The operation itself will take two to three hours, after which you will wake up and your hips will be flexed so as to reduce any tension on the abdominal skin. Usually there are two soft silicone drains that come out of the wounds and this helps reduce any fluid swelling underneath the abdominal skin. In addition you may have a pressure garment around the abdomen which helps give extra support. Patients stay overnight in hospital and the discomfort is usually minimal on t he first night as there is local anaesthetic i njected into the wounds. The next day, if there is any discomfort this is usually settled with painkilling tablets. The morning after surgery the drains are removed in your room prior to discharge from hospital. All wounds are sutured with dissolvable sutures except for the suturing around the belly button (in the case of a full abdominoplasty). Non dissolvable stitches are used around the belly button as this area can tend to be inflamed if dissolvable sutures are used and the belly button sutures will be removed one week post operatively at the outpatient clinic.

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What is the post operative recovery like after abdominoplasty(tummy tuck)?

The day after the surgery, any wound drains will be removed that morning in your room and you will be asked to done an elasticated pressure garment around your abdomen. This will give you extra support and comfort after the surgery and reduce any potential complications. While at home you are encouraged to walk about to keep the leg muscles moving and also encouraged to drink at least 1-2 litres of fluids/water every day so as to reduce the risks of blood clots in the legs. You will find that you will be quite tight and you won't be able to fully straighten out when walking around the house in the first week and often it is more comfortable to sit in a chair with the legs elevated. One should refrain from sitting/lying about in bed however. It is difficult to have a shower or bath in the first week and it is usual just to wash ones self with a face cloth. Then one week after surgery y ou will return to Mr Fogarty's clinic where any stitches around the belly button can be removed. The rest of the suturing however is with dissolvable sutures and these wounds are inspected to ensure that healing is satisfactory. After the belly button sutures are removed you will be free to shower at home that following week, however baths are best refrained from for another week (ie two weeks post operatively). After this one week post operative appointment you will feel considerably more comfortable and be more able to walk more erect. The scarring at this stage start to become quite firm and red and thus it is wise to massage some moisturiser (eg. Nivea or vitamin E cream or Bio-oil) along the length of the scars so as to help keep them more supple. Also it will help to apply surgical tape (eg Micropore) over the dried scar and this will help prevent any scar stretching. Micropore tape may be applied for approximately 3 months after the surgery. The elasticated pressure garment that you were given f ollowing discharge from hospital can continue to be worn but many ladies also prefer to purchase a panty girdle elasticated garment from a high street department store as this gives equally good pressure and may be more comfortable to wear. Physical activities such as swimming and power walking can be resumed after four weeks but more vigorous activities such as aerobics and weights should be refrained for three months post operatively. The scars, while initially being red and thickened, do become pale white lines after approximately 9-12 months and this process takes slightly longer in paler skin types.

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Is there any special preparation required for the surgery?

Preparation for surgery can help to minimise the risks of complications (see below) and also speed up recovery. One of the potential risks of abdominoplasty is a blood clot in the leg (DVT). One of the more important risk factors for this is the oral contraceptive pill and thus it is imperative that the oral contraceptive pill is stopped six weeks prior to surgery, and of course alternative contraception used. Because smoking can reduce the blood supply to the skin it is also ideal if one can stop smoking six weeks prior to surgery. Two weeks prior to surgery any medication such as Aspirin or nonsteroidal anti-inflammatory drugs NSAIDs (eg Brufen or Diclofenac/Volterol) should be stopped as these thin the blood. One week prior to surgery vitamin C 1 mg twice per day will be helpful as this will promote wound healing. Some ladies also find that the homeopathic remedy Arnica is useful to reduce bruising . This may be started 2 days prior to surgery and continued for one week after surgery. For 3 days before surgery it will help if one has a daily shower with an antiseptic shower gel/surgical scrub (eg Hibiscrub or Hydrex) to reduce the risks of wound infection. Finally if there is any amount of weight that should be lost to achieve your ideal weight this is best carried out prior to the surgery as this will allow Mr Fogarty to excise any excessive redundant skin and achieve a much better cosmetic result than if one is more overweight.

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What are the potential complications of abdominoplasty surgery?

All surgical operations carry with them the potential for complications. The complications of abdominoplasty surgery are well recognised and Mr Fogarty and his team take many precautions to reduce these risks but the risks cannot be eliminated totally. In chronological order the potential complications that may occur following abdominoplasty include the following:-

Haematoma; (1% risk) after any operation there is potential that blood vessels can start to bleed when ones blood pressure becomes more elevated. If this were to occur one would develop a haematoma or blood clot underneath the skin. Small collections of blood can be drained away by the drains, however larger collections would require a return to theatre for removal of the blood clot. This should not affect the overall cosmetic result and if it were to happen it tends to occur in the first 6-8 hours after surgery which is why it is best to stay overnight after surgery so that the nursing staff can observe for any early signs of this and prevent any escalation of the problem.

Infection; (1% of cases) any wound is prone to infection and we can minimise this risk by giving antibiotics around the time of surgery and also patients are advised to shower daily for approximately 3 days prior to surgery, preferably with a medicated shower gel (eg one containing Chlorhexidine or Betadene if not allergic to iodine).

Wound breakdown (dehiscence); because of the size and location of the wound there is always potential that small areas may not heal as quickly as would be desirable. This can happen because of the tension on the skin which reduces its blood supply and also another significant factor which reduces the blood supply is smoking and thus this should be stopped six weeks prior to surgery. Vitamin C should may be taken pre operatively as this promotes more rapid wound healing. In the event of a wound breaking down simple dressing may be placed over the wound and this can be showered off on a daily basis and a new dressing placed underneath the pressure garment or panty girdle.

Seroma; (3% of cases) a seroma is a collection of fluid that will occur underneath the abdominal skin. This occurs because there is a raw space underneath the skin between the skin and the muscles. The drains and the pressure garment help to reduce the risk of this but if a collection of fluid occurs then it is usually resolves itself in the fullness of time and only very rarely, if it is a large collection of fluid, does this have to be drained off. In order to drain any seroma fluid this can be done in the outpatient clinic with a syringe and needle but this is rarely necessary.

Numbness; after any surgical incision there is often numbness around the wound. With elevation of the lower abdominal skin and stretching of the skin one finds there is an extensive area of numbness between the belly button and the pubic hair. This area of numbness gradually reduces in size over approximately 2-3 months although there can be some permanent numbness especially over the pubic area.

Scars and keloid scars; after any surgical incision a scar develops. All abdominoplasty operations share with them a lower abdominal scar running underneath the bikini line. The extent of the scar will depend on how much skin must be removed. All scars tend to be red and firm in the first few months but become pale white over approximately 9-12 months. They will however still form permanent white lines. In a small number of patients their scars do not mature in this fashion but actually become lumpy and become raised and indeed continue to become raised as time progresses. This is a condition known as keloid scarring and only occurs in 1 in 300 patients. This tends to occur because of a genetic predisposition in that some patients scar producing cells are pre-programmed this way. If a keloid were to develop then further treatment in the form of repeated steroid injections into the scar would be required.

Skin necrosis (death); (less than 1% of cases) can occur because of a poor blood supply to the skin secondary to either increased tension on the skin and/or cigarette smoking in particular. The incidence of this has greatly reduced as we have realised that liposuction is a contributing factor that reduces the blood supply to the skin. If skin necrosis were to occur it may manifest as slow wound healing or at its worst larger areas of skin can break down and form wounds that could potentially require skin grafting. The latter is extremely rare.

Deep Venous Thrombosis (DVT); a DVT will occur when the blood in the calves form a clot. The danger with a clot is that this will then dislodge and move towards the heart causing what is known as a pulmonary embolism (PE). The risk of this happening is less than 1%. One of the contributing factors for this is the use of the oral contraceptive pill and this should be stopped six weeks prior to surgery. Also patients are encouraged to drink water to maintain their hydration and encouraged to walk around the house in the immediate post operative period and try to sit in a chair with a stool for one's heels as opposed to lying in bed.

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Abdominoplasty and Body Contouring Surgery Summary Points: :

      Type of anaesthesia             General

      Duration of surgery               2-3 hours

      Hospital stay                          Overnight

      Time off work                          10-14 days

      Return to light sports              4-6 weeks

      Return to gym/vigorous
      exercise                                  3 Months

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Notes for patients undergoing abdominoplasty Generally The best results after abdominoplasty are achieved if one is at your ideal weight thus make every effort to achieve this and certainly try not to put on any weight in the hope that the surgery will take care of it. However try not to be on a stringent diet too close to the time of surgery as one could be malnourished and this slows wound healing. 6 weeks pre-operatively Stop taking the oral contraceptive at this stage, taking alternative precautions against pregnancy. Ideally stop smoking at this stage to reduce the risk of skin necrosis(death). 2 weeks pre-operatively Stop taking any aspirin or aspirin containing products as these may increase the risk of bleeding. Also any nonsteroidal anti-inflammatory drugs (NSAIDs) such as Brufen or Volterol such should be stopped, as should any Vitamin E tablets or multi vitamins containing vitamin E. 1 week pre-operatively It is advisable to take 1 gm vitamin C twice a day to improve wound healing. Some patients also find homeopathic remedies such as Arnica may reduce bruising. One should also purchase a panty girdle to cover the abdomen so this can be worn after the surgery. Sizing should be such so as to put firm pressure on the abdomen remembering that there will be some reduction in waistline after surgery. Night before surgery /
morning of surgery
If your surgery is planned for the morning it is wise to have a shower the night before the surgery with a medicated shower gel/surgical scrub (e.g. hibiscrub /hydrex) and wash ones hair. Nail polish should be removed prior to surgery for the anaesthetic equipment requirement. The day of surgery Dress in loose clothing with a shirt,zip-up top and slip on shoes as you may uncomfortable initially after surgery. Also pack the panty girdle to wear after surgery along with usual toiletries for overnight stay. Day 1 after surgery You will be going home today and will have been given some tablets to take home, (antibiotics and painkilling tablets). NB if you have any allergies, especially Penicillin, please let Mr Fogarty's secretary know in advance..A friend should drive you home. Day 2 post-operatively Clean oneself with a facecloth. You should be able to wash your hair in the shower today but avoid getting the bandages too wet. 1 week post-operatively You should be reviewed today for a wound check at Mr Fogarty's clinic. The bandaging will be removed but there are no sutures to be removed. You may have the wounds re-taped for extra support and improved scarring. You may resume driving at this stage if you feel fully comfortable and confident in your safety on the road! 2 weeks post operatively You may be able to return to work if this involves light activities /lifting. 6 weeks post-operatively You will have a review again at Mr Fogarty's Outpatient Clinic and the vast majority of any swelling and skin tightness will have settled by this stage. The panty girdle /pressure garment may be dispensed with at this stage. Most patients do not need to be seen again after this stage unless they have any concerns. 3 months post-operative Stop applying surgical support tape by this stage Full vigorous sporting activities may be resumed.

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