Tummy tucks or abdominoplasties are a very popular body contouring procedure because it is tremendously effective.While diet and exercise are extremely important for weight loss, it will not get rid of loose skin. Conversely, tummy tucks are not a substitute for weight loss and should not be performed in a persistently obese patient under most circumstances.

But an interesting question about weight loss and tummy tucks, often asked by patients, is how much weight will be lost after surgery.While a tummy tuck is not a weight loss surgery, clearly some weight is lost from what is removed during surgery. If so, is more weight eventually lost than what is physically removed? And if so, how much and at what point after surgery will that weight loss be seen?

These very tummy tuck questions were addressed in the February 2013 issue of the journal Plastic and Reconstructive Surgery in an article entitled ‘Weight Reduction following Abdominoplasty: A Retrospective Case Review Pilot Study’. In the studied patients who underwent abdominoplasty, all patients had weight loss after surgery that eventually exceeded that of the tissues actually removed. The maximal weight loss was achieved at roughly 12 weeks after surgery. The weight loss was attributed to an increase in satiety in most patients. In those patients that had a body mass index greater than 24.5 kg/m2 and tissues removed that weighed greater than 4.5 lbs, their weight loss was sustained at one year after surgery.

This study supports what I have seen in many tummy tuck patients. Weight loss will always be greater than what was removed in surgery and will appear at the following times after surgery. Initially in the first weeks after surgery the patient will actually weigh more than before surgery due to fluid retention. This is why I tell patients to never weigh themselves at this time. By three weeks after surgery, the retained fluids are lost and the weight loss will nearly match the tissues removed. (surgical weight loss) Over the next month, the weight loss will almost double reaching its peak 8 to 12 weeks after surgery. The study attributes this is due to satiety, and this is certainly one factor, but another important reason is the calories consumed by the body to heal a large tissue wound. Less intake and more calories burned equals more weight loss. (what one might call surgical healing weight loss) It is the combination of surgical and healing weight loss that accounts for why more is eventually lost than what is just removed.

This study also shows that the weight loss after a tummy tuck is sustained at one year after surgery, an encouraging finding for patients. Whether this is due to some change in neurocrine function or sustained enthusiasm based on the physical and financial investment in the surgery is not yet clear.

Dr. Barry Eppley

Indianapolis, Indiana

A tummy tuck can produce a dramatic change in the shape of one’s abdomen and frontal waistline. By removing a large horizontal ellipse of loose skin and fat, a tightening and flattening effect is seen when the remaining abdominal tissues are put back together. Such reapposition is known as a transposition of the remaining upper abdominal fasciocutaneous flap downward towards the pubis. The union of the abdominal flap downward towards the pubic area creates the location of the horizontal incision line.

While the downward movement of the abdominal flap over the area of removed tissues is often described as stretching down to meet the fixed pubic tissues, this is not entirely accurate. In reality, the abdominal flap does not provide 100% coverage of the excised abdominal area. The closure is accomplished because there is also some upward movement of the pubic tissues as well. While each patient is going to be different, a better understanding is that the downward movement of the abdominal flap covers approximately 80% of the distance while the upward movement of the pubic tissues is approximately 20%.

While how the wound is closed over the area excised in a tummy tuck may seem irrelevant, these tissue movements will make some anatomic changes in the shape of the pubis. The upward movement of the tissues below the abdominal cut out will create differing degrees of a pubic lift. With the lifting of the pubic also comes a change in the pubic hairline as well. It will move upward to meet the incision line creating lengthening and an elevated position of the pubic hairline.

While the lifting and flattening of the pubic mound will be a benefit to most tummy tuck patients, the elevation of the pubic hairline may be a nuisance. The pubic hairline will meet the incision and there will be no separation between the two. For some women this may necessitate hair removal methods to create a few centimeters of separation between the incision and the upper pubic hairline. Laser hair removal is the most common method used and can be particularly effective if one has a dark pubic hair color.

The incision line of a tummy tuck is usually the tightest and most constricted area along the newly created waistline. Despite getting a concurrent pubic lift during a tummy tuck the elevated pubis may appear as a bulge that sticks out further than the incision line. This can be aesthetically unflattering for some women in tight clothes. This can be secondarily corrected by liposuction which can make the pubic bulge completely flat and in better profile to the incision line. When such pubic bulging is recognized before undergoing a tummy tuck, it can be simultaneously treated by pubic liposuction during the tumm y tuck once the incision is closed.

Dr. Barry Eppley

Indianapolis, Indiana

The tummy tuck is one of the most commonly performed and satisfying of all body plastic surgery procedures. It is so effective because it does something that diet and exercise can not do at all…remove loose skin. Muscles can be tightened and some fat removed by non-surgical methods but loose and extra skin will only respond to surgery.  For this reason tummy tuck surgery is both highly desired and performed.

But there are many misconceptions about tummy tucks, some of which affects the timing of how the surgery is done and others about the recovery after the procedure.

A new belly button is made during a tummy tuck. The belly button is nothing more than a remnant or stalk of scar tissue from the skin down to the abdominal wall. It is never removed during a tummy tuck but rather the skin around it is. The stalk of the belly button is always preserved, it is the loose skin around it and any extra length that is removed. The stalk of the belly button is simply put back by bringing it through the abdominal skin that has been tightened over it. Reshaping of the belly button is almost always done as part of remaking it. The key to a good looking belly button result in a tummy tuck is to shorten it so that the skin dips in, the surrounding scar is on the inside, and it has more of a vertical rather than a round shape.

A c-section is a good time to have a tummy tuck as well. While loose stomach skin can be removed at the same time as a c-section delivery, it is not the best time to do it. The uterus is swollen and prevents muscle tightening and there is still considerable water weight present. In addition, being under an epidural limits how much overall abdominal reshaping can be done. It is far better to wait six months after delivery and try to lose as much weight as possible before having a tummy tuck…the result will be so much better.

A mini-tummy tuck has a faster recovery than a full tummy tuck. The only real difference in most cases between the two fundamental types of tummy tucks is the length of the incision and the amount of skin removed. Both types will have muscle plication, flank and waistline liposuction if needed, and the need for a drain after surgery. Therefore the length of their recoveries can be very similar. Choosing a mini-tummy tuck should be based on the anatomic needs not because of a perceived shorter recovery time.

A tummy tuck can adversely affect bowel function. While it is common to have some constipation after a tummy tuck, there is  no risk of any long-term digestive tract issues. Only skin, fat and muscle is manipulated during a tummy tuck  and there is no chance of inadvertent injury to the large or small intestine. Repairing a hernia at the time of a tummy tuck poses some risk but it is no greater than any other hernia repair. Since pain medication will be needed after a tummy tuck, and that has a known slowing effect on gastrointestinal mobility, women should drink plenty of fluids during their recovery and take a daily stool softener starting a week before surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Abdominal contouring is one of the most common body changes that many patients request. Pregnancy, fluctuations in weight and for some their own genetics make for this body centric area a focus of appearance and clothing wear. Numerous plastic surgery procedures exist for its modification but, in the end, they all involve methods to either reduce fat or tighten/remove skin.

At their most basic level, there are only three treatment options including non-surgical fat reduction/tissue tightening, liposuction and tummy tucks. Overshadowing these basic concepts lies a myriad of terminologies, often marketing-driven, that often makes the named procedure seem new or magically better. Often the procedure suggests and may even be explicitly stated that there is little to no recovery and limited after treatment downtime.

In an effort to help patients decide what treatment may be best for them, it is important to put them in perspective of ‘effort vs reward’. Once viewed from this approach, the options available for abdominal contouring will be better understood.

Non-surguical approaches to abdominal contouring are what I call ‘energy-based’ concepts. Whether it be radiofrequency, ultrasound or a variety of other energy types, the objective is to drive the energy past the skin (without burning it) and targeting the fat below. There can be endless debates about which type of energy is superior for this purpose but that is not the important concept to grasp about them. What is important to understand is that no non-surgical approach can produce a comparative result to surgery…period.  All of their results will be less, many times far less, than what liposuction and tummy tucks can do. The reason to do them is to see whether the limited results they can produce are enough to avoid the need for surgery. In essence, non-surgical methods are all about ‘trying’ them to see what their comparatively limited benefits may be. For the devout non-surgical person, this will be the end of the pursuit regardless of the result. For the more open-minded surgical person, it is a qualifying treatment.

Liposuction is an invasive surgical procedure that is very effective for fat removal. No matter how it is performed, regardless of the method, it is the same when it comes to the level of invasiveness and recovery. Whether there are differences in the different technological innovations (e.g., laser, vaser etc) can be debated (particularly amongst the manufacturers) but they all involve significant trauma to the fat tissues and subsequent bruising, swelling and recovery. There may be some degree of skin tightening with the various methods of liposuction  but never confuse that with the skin removal from a tummy tuck. When you see such marketing terms as a No Scar Tummy Tuck, for example, this is nothing more than liposuction and should not be confused or used in patients that need substantative skin removed. This term is designed to attract patients who want to avoid a tummy tuck and are looking for something less invasive with less recovery…and usually what you will get will be less of a result also.

Tummy tucks remain the gold standard in body contouring when there is excess skin. No matter how a tummy tuck is done it is definitely invasive and will take more than a week or two for recovery. There are only two main tummy tucks for most non-bariatric surgery patients, a mini- and a full tummy tuck. These are based on the location of the large skin and fat cut out, a mini-tummy tuck being below the belly button and the full tummy tuck incorporating tissue removal above the belly button. The large amount of skin that is removed in a tummy tuck creates an unriveled amount of skin tightening that is largely permanent for most patients. Most tummy tucks need the adjunctive use of liposuction to either reduce the love handles where the tummy tuck doesn’t change or concurrently thin out some of the fat in the abdominal area which is not cut out. The combined tummy tuck-liposuction, also known as lipo-abdominoplasty, remains the ultimate body contouring procedure but its great benefits carry with it a significant recovery as well.

Dr. Barry Eppley

Indianapolis, Indiana

Tummy tuck or abdominoplasty surgery recontours the waistline area out into the hips. Most tummy tucks do influence the area below the location of the incision line known as the mons pubis.  While it is commonly believed that the upper abdominal skin flap covers the entire area of abdominal tissue excision in a tummy tuck, the reality is that some of the defect excision is covered by the lower skin flap being lifted. This always has the potential of affecting the mons pubis.

While the mons can be affected by pregnancy, it is most changed when one undergoes significant weight loss. With the weight loss, the pubic area becomes deflated as well causing it to sag and remain full. It may sag enough that it interferes with the urinary stream as well as sexual function.  Lifting of the mons can be incorporated into a tummy tuck design by changing the location of the lower incision and suspending and thinning of the mons concurrently.

While a monsplasty is relatively easy to perform and visually appears to be highly successful, no study has ever been performed on its outcomes. In the September issue of Aesthetic Surgery Journal, a study was published on the cosmetic and functional results after monsplasty in patients who had lost more than 50 lbs. Over 50 female patients who underwent tummy tuck surgery and were at least 3 months after surgery constituted the study population. Patients completed a satisfaction survey looking at parameters of appearance, genital visualization, hygiene and sexual function.

The average weight of the abdominal tissue removed was between 1 and 5 kgs. (average 3.25 kg) Visualization of the genitalia improved in every patient, ranging anywhere from 25% to 100%. Patients rated the appearance of their mons on a scale of 1 to 10 as 3.2 prior to surgery and 8.6 after surgery. Hygiene improved in over 60% of the patients and sex life improved in over 50% of patients. Interestingly, nearly one-third of the patients reported increased genital sensitivity. A decrease in incontinence and a change in urinary stream also occurred in some patients.

Much like plastic surgeons see and hear from patients, a monsplasty is equated with high levels of patient satisfaction as well as functional improvement. Given that a monsplasty adds little risk of complications to a tummy tuck and avoids the need for a secondary procedure, it should be employed in most every massive weight loss patient.

Dr. Barry Eppley

Indianapolis, Indiana

Liposuction remains one of the most common body contouring operations in cosmetic surgery. While often viewed as ‘simple’ with little recovery and promising dramatic results from the perspective of how it is often marketed and promoted, liposuction is a very invasive procedure that induces a lot of tissue trauma. The small size of the cannula entrance sites belies what happens underneath in a broader surface area of treated fat. While in small volume face or body areas, this tissue trauma is not that significant. That is certainly not true when it comes to liters of fat extraction and much larger body areas such as the abdomen and flanks and when commonly combined with an abdominoplasty procedure.

To help make the liposuction of fat easier, reduce blood loss and help with immediate after surgery discomfort, all liposuction procedures today are done with the pretreatment infusion of a wetting solution, often called a Hunstad solution. Through hydrostatic tissue distention and the use of lidocaine and epinephrine drugs, liposuction has become a more effective procedure. But using such a solution does expose the patient to elevated levels of lidocaine and epinephrine, which like all drugs have potential side effects.

While many principles and methodologies of liposuction have been studied over the years, certain concepts of the effects of liposuction are ingrained as truths. This is why it is refreshing when a study appears that revisits some of the established concepts of liposuction in a scientific and quantitative manner. In the September 2012 issue of Plastic and Reconstructive Surgery, a paper was published entitled ‘ Prospective Study of Lidocaine, Bupivacaine and Epinephrine Levels and Blood Loss in Patients undergoing Liposuction and Abdominoplasty’. These study results come from a single plastic surgeon’s practice and looked at 322 consecutive cases of liposuction and/or abdominoplasty. As the title suggests, drug levels and blood loss were assessed in the patients.

The study highlighted some significant findings. In over 300 cases, no incidences of pulmonary emboli or deaths occurred. One infection (0.3%) and one deep vein thrombosis (DVT) occurred. (0.3%) No lidocaine or epinephrine toxicity was seen in any patient. The maximum dose of lidocaine was 37.7mg/kg. (35 mg/kg has been shown to be perfectly safe when infused in dilute form in fat) Lidocaine levels peaked 8 to 12 hours after being infused. The maximum dose of epinephrine was 10mg (0.13 mg/kg) and it peaked 2 to 4 hours after infusion. Hemoglobin levels dropped nearly 2 grams one day after liposuction.  Abdominoplasty surgery resulted in nearly 300cc of additional blood loss. The proportion of the infused wetting solution in the aspirate (what is seen in the collection canister) was just over 10%.

What does all this mean? Morbid and lethal risks of liposuction and abdominoplasty are very rare. Risks of infection and DVT are very low. Lidocaine levels in super wet infusions for liposuction are within safe limits and do not exhibit toxicity. The peak levels of lidocaine do not occur until much later than one would think due to the effects of the epinephrine. Epinephrine levels of 1:500,000 were found to be safe and resulted in no elevation of liver enzymes. (the traditional use of epinephrine in Hunstad solutions is 1:1,000,000) Blood loss is more significant than it appears in the liposuction collection canister, which is usually 1% to 3% . The blood loss after liposuction is up to 10% of the total liposuction aspirate and largely occurs from bleeding into the treated tissue after surgery. This is higher than previously thought.

From one of the best liposuction studies ever performed, the conclusions are:

1)  Liposuction can be very safely performed when the removal of fat aspirate is less than 5000cc and the wetting solution is of a similar volume. (superwet technique)

2) Epinephrine doses in the wetting solution can be safely done at 1:500,000. This may help reduce blood loss and allow the local anesthetic effects of lidocaine to persist longer after surgery.

3) Blood loss is more significant from liposuction than is commonly perceived. Patients should have good hemoglobin levels before combined liposuction and abdominoplasty surgery.

4) More of the infused wetting solution stays behind (not suctioned out) than what one would think.

Dr. Barry Eppley

Indianapolis, Indiana

Liposuction remains the most effective method of instantaneous fat reduction. Studies and surveys have repeatedly shown that its initial effects are very visible and, as a result, has a high patient satisfaction rating. But well done long-term studies are lacking that evaluate what happens to the contours of the treated areas as well as other body fat sites.

But when fat is so dramatically removed, questions abound about this effect on both the treated and untreated body areas. Many unsupported beliefs exist such as that fat will never return to the treated area, fat will always return to the treated area and fat will just grow in other body area later negating the effects of the surgery. This latter statement is widely believed in the spirit of the so-called ‘fat homeostatic’ theory or fat redistribution concept.

This belief in fat redistribution was ‘confirmed’ by a published study last year that showed a small increase in arm and upper back fat one year after abdominal liposuction in women. This study was limited by the very small number of patients that were treated and was certainly criticized on that basis. But despite limited information, the belief that fat returns or appears elsewhere after liposuction persists.

The most definitive study to date on this topic appeared in the August 2012 issue of Plastic and Reconstructive Surgery entitled ‘ Photographic Measurements in 301 Cases of Liposuction and Abdominoplasty Reveal Fat Reduction without Redistribution’. In a prospective manner, over 300 patients from a single plastic surgeon’s practice undergoing liposuction and a tummy tuck were studied using measurements and standardized photos both before and at least 3 months after surgery.  Upper body measurements were compared between women who underwent simultaneous breast surgery and a group of women that had breast surgery alone to determine whether fat redistribution occurs.

The study results show that the average weight change was just over 2 lbs after lower body liposuction and 4.5 lbs when combined with a tummy tuck. Liposuction was shown to reduce the circumferential width  of the abdomen, thighs, knee and  arm. To no surprise, width reduction of the abdomen and hips was more effectively achieved when liposuction was combined with a tummy tuck. There was no difference in upper body measurements when the body contouring patients were compared to women who only had cosmetic breast surgery alone. For those patients that were followed at one year and beyond (15% of study patients), there was no evidence of fat re-accumulation.

Despite the common belief that liposuction results may not be stable or that fat shifts around and accumulates elsewhere, this significant study provides evidence to the contrary. Liposuction results can be stable and upholds a preoperative advisory given by many plastic surgeons that weight control equals stability of liposuction results. But fat accumulating elsewhere because it was taken from one location has yet to be supported by high volume patient studies.

Dr. Barry Eppley

Indianapolis, Indiana

The rise in plastic surgery affects all age and both sexes. One of these ‘groups’ that seek body-altering surgery is women, specifically mommies. Looking to reverse the effects of pregnancy on their bodies, they seek breast enhancements and tummy tucks. When put together in a combined procedure, it has become known as a Mommy Makeover. Generally done between the ages of 21  to the early 40s, over 300,000 such procedures were reported to be done last year. Women appear for the surgery when their efforts to lose weight and make some headway towards returning to their pre-pregnancy figure has failed. It takes many women a while to discover that there is no non-surgical way to get rid of loose stretch-out abdominal skin. Surveys show that up to two-thirds of women would have Mommy Makeovers if cost were not an obstacle.

While a tummy tuck treats excessive lower abdominal skin and fat, the massive weight loss patient presents more of a challenge. The amount of loose skin almost always goes beyond the traditional horizontally-oriented elliptical excision abdominal pattern. Liposuction has little value in these patients because their contour problems are almost exclusively loose skin. Most of the bariatric patients have skin excesses that involves all three dimensions of the abdomen, including extending into the back. The amount of overall skin creates excessive abdominal girth.

For the bariatric patient an extended abdominoplasty approach is often used that wraps completely around the waistline. Known historically as the belt lipectomy and today as a lower body lift, removing tissue that goes beyond the hips is needed to prevent large dogears and redundant mounds of residual skin in the flanks. But this cutout pattern does not account for the one dimension of extra skin that massive weight loss patients have…the area above the belly button. While pulling this area down with a tummy tuck will help, there will still be substantial loose skin above the final horizontal incision line.

This upper abdominal skin excess has led to the concept of the fleur-de-lis abdominoplasty or tummy tuck. In this approach, a vertical cutout is added to the tummy tuck pattern. This is shaped as an inverted U that extends to just below the xiphoid process. When one’s weight loss exceeds 75 or 100 lbs, this excisional pattern can achieve most of the needed aesthetic goals. It includes a horizontal and vertical skin excision which improves abdominal girth by cinching in the waistline and flattening the upper abdominal contour as well as getting rid of an overhanging pannus and much of the pubic sag.

The fleur-de-lis pattern certainly increases the abdominal scar burden in the most noticeable way…right down the center of the abdomen. In the early days of bariatric surgery when gastric by pass was done through an open approach, the existing scar made this consideration a non-issue. Today most bypasses are done laparoscopically so no such scar exists. Patients have to consider this scar trade-off relative to how much upper abdominal loose skin they have. Most bariatric patients consider that a good trade-off once they realize that the upper abdominal area will not be as tight as they would like. Older patients will almost always choose the fleur-de-lis while younger patients are understandably more cautious and conscious about it.

One additional advantage of the fleur-de-lis abdominoplasty is that it provides wide exposure for the repair of hernias. Such hernias are not rare even in the laparoscopically-assisted gastric bypass patient. Estimates are that up to 10% of bariatric patients will develop one or more abdominal hernias.

The addition of the vertical closure in this type of tummy tuck does create the potential for wound separation or skin necrosis at the vertical and horizontal skin junctions. Between the tension at this area and diminished blood perfusion at the edges of the skin flaps, small separations weeks after surgery are frequent. Not being too aggressive with the horizontal excision pattern in this type of abdominoplasty will allow for less tension in this area and a lower incidence of this problem.

Because of the extent of surgery in the fleur-de-lis abdominoplasty and the time required to do it, this is often done as a stand alone procedure. This is particularly so if the horizontal excision wraps around the waistline circumferentially.

Dr. Barry Eppley

Indianapolis, Indiana

The concept of a Mommy Makeover has become a very popular plastic surgery procedure in the past decade. While sounding like a novel procedure, it is really nothing more than combining traditional breast and abdominal reshaping procedures in a single one-time operation. When put together they change the two body parts most affected by pregnancy and the birthing process.

The trend towards more women having Mommy Makeovers done is affected by numerous factors. As more women become aware of what can be done to restore their bodies, they are wanting to embrace those changes for an improved self-image. Some do it sooner after their pregnancies than others depending upon how quickly they can lose their baby weight and how much exercise can help with some non-surgical reshaping.

Magazine articles with celebrity examples has also helped create a style trend that has popularized (and sometimes sensationalized) how to bounce back after having a baby. Many famous moms and how they look afterwards has created awareness of what is possible, although whether they have had surgery to do so often remains more mysterious. The suspicion is that many have had surgery and clearly some have. And just like those celebrity moms that are on the cover of the magazines in the checkout counter of the grocery store, average women want to also look and feel great.

A major factor that has also created the modern-day Mommy Makeover is that combined breast and abdominal procedures can be safely done together. Often taking three to five hours of surgery time, the procedure is still done as an outpatient with little reason to stay overnite for most women. Careful attention to anti-thrombolytic prophylaxis, avoiding indwelling bladder catheters, and early ambulation has led to decreased risks of DVT, PE and urinary tract infections. While one should never underestimate the at home recovery process, within four to six weeks one can return to all normal activities. Depending upon the type of abdominal reshaping procedure, this recovery period could be even less.

Embarking on a Mommy Makeover should not be done until every effort has been made on your own to change one’s body. The timing will be different, however, between the breasts and the abdomen. There are no exercises, creams or potions that are going to restore breast volume or lift up sagging breasts. One only has to wait until one has stopped breast feeding and any breast engorgement is gone. The abdomen is a different story as clearly everyone can lose some of their baby weight. But loose skin, stretch marks, misshapen belly buttons and rectus diastasi are not going to be improved by exercise, no matter how hard one tries. You are not going to exercise loose skin away. When you put these two issues together, the earliest that most women should undergo the procedure is around six months after delivery.

Dr. Barry Eppley

Indianapolis, Indiana