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

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

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

Tummy tuck or abdominoplasty is one of the most common cosmetic body procedures performed. Most plastic surgeons feel that it is also one of the most satisfying procedures based on the results seen as well as the views expressed by patients. This is certainly visually supported by the many before and after photographs seen in online plastic surgery practices as well as all over the internet in many forums.

But despite these perceptions and experiences of plastic surgeons, do these high satisfaction rates translate into an improved quality of life for the patient? Besides the better shape of the waistline and stomach area, does it improve a patient’s self-esteem and their overall life? In end, the value of any cosmetic procedure is primarily about how it makes a patient feel and secondarily about the improved cosmetic change.

In the June 2012 issue of Plastic and Reconstructive Surgery, a study reported on the effect of abdominoplasty on quality of life, self-esteem and emotional stability…those factors not seen in before and after pictures. Through self-developed questionnaires, the Rosenberg Self-Esteem Questionnaire and the Freiberg Personality Inventory, sixty-three abdominoplasty patients from Germany and Greece participated in the study. In all areas tested, increasing values were found. Nearly 85% were satisfied with their cosmetic outcome, over 90% would have the surgery again, and nearly 90% would recommend the operation. High ratings were given for self-esteem and emotional stability.

The authors of the study conclude that tummy tuck surgery improves quality of life, particularly family life, mobility and independency from assistance. Equally important, patient’s self-esteem and emotional stability were very high after surgery. This study confirms what most plastic surgeon know from a lot of experience, tummy tuck patients feel better about themselves after surgery.

A tummy tuck encompasses a wide range of aesthetic trunk issues. From the smaller 5’ 2” petite  woman with a small amount of loose lower abdominal skin over multiple pregnancies to the larger 6’ 3” man who has lost over 125lbs after bariatric surgery, a tummy tuck is a diverse collection of abdominal skin and fat excesses. Some patients are bothered by the aesthetics of some loose skin and a few stretch marks while others have issues of hygiene and chronic skin infections from an overhanging pannus.

Satisfaction from having a tummy tuck depends to a large degree on how effectively it solves the primary problem for having it. Given that there is a relatively low horizontal scar left in its wake, the aesthetic trade-off in more minor abdominal contour deformities may lead to a higher rate of dissatisfaction. Although this study did not separate patients by the magnitude of their deformity, I suspect those patients who reported dissatisfaction with the tummy tuck procedure did not feel that the scar was a better substitute than their primary abdominal concerns.   

Dr. Barry Eppley

Indianapolis, Indiana

Reshaping of one’s stomach and waistline through a tummy tuck or abdominoplasty is a plastic surgery procedure that has a long history of success. The procedure has evolved over the years from the relatively simple excision of loose skin and fat to a more comprehensive procedure that may include liposuction, fascial muscle reshaping and flap tension releasing sutures. While abdominoplasties historically were done as an overnight stay, they are usually done today as an outpatient procedure.

With rare exception, whether having a mini- or full tummy tuck with or without liposuction, the procedure is done under general anesthesia as a same day surgery. Exceptions may include those patients who have medical conditions that should be monitored after surgery, those patients that come from considerable distances, have no one or transportation to take them home, or have no one to be with them on the first night after surgery.

While this is a common postoperative course for tummy tucks today, many people are surprised to hear that it is an outpatient. Their surprise may be one of historical precedent or because they may be concerned about the medical safety of that management approach. There are always ‘reports’ and actual stories of patients who have suffered major medical problems after tummy tuck surgery. While that has not been my experience, the concern is understandable.

So what is the medical evidence of outpatient tummy tuck safety? In a recent issue (#32) of the Aesthetic Surgery Journal, a study from the Division of Plastic Surgery at the University of Texas in Galveston studied this very question. A retrospective study was done on over 300 patients who had a full abdominoplasty with one surgeon over an 18 year period who were done as an outpatient. Postoperative recovery and complications rates were specifically evaluated. The study results showed that no patient developed any major medical problems such as deep vein thrombosis, pulmonary embolism, need for blood transfusion, any intra-abdominal problems or even death. Local complications did occur of which the most common was a fluid collection or seroma formation at a rate of near 20%.

This study supports what many plastic surgeons already know by their own practice experience. Full tummy tucks can be very safely performed and discharged to home within hours after surgery without risk of major medical problems. This does not mean that major medical problems can not occur which is why many precautions are taken before and during surgery. The use of aggressive antinausea prophylaxis, adequate IV fluid hydration, use of sequential lower leg compression devices and good pain control so early ambulation can be done are all important steps that contribute to major complication prevention, particularly deep vein thrombosis and pulmonary embolism.

The success of outpatient tummy tuck surgery is highly dependent on good patient selection. Assessing the patient who is at higher risk of thromboembolism and combining other major plastic surgery procedures with tummy tucks may change the procedure from outpatient to an overnight stay.

Dr. Barry Eppley

Indianapolis, Indiana    

A tummy tuck is a well known body contouring procedure in plastic surgery but it is far from just a simple tuck. In most cases a wide excision of loose skin and fat is done often encompassing up to one-third of the surface area of the abdominal wall. This is often combined with liposuction along the sides into the back to create a better waistline defining effect. This more extensive procedure is understated by the use of the word ‘tuck’ and is better described as an abdominoplasty or abdominal reshaping procedure. While the procedure will forever be known as the tummy tuck, today’s abdominoplasty procedures are a far cry from just a simple nip and tuck.

Abdominal contouring through either liposuction alone or combined with some form of a tummy tuck are very common and popular body contouring procedures. Whether it is done to help with fat removal alone from weight gain and aging, pregnancy-induced abdominal changes or abdominal deformities from massive weight loss, these procedures provide very effective changes that can be long-lasting.

While they are commonly done, does this mean that patients are usually satisfied with them? As a plastic surgeon, I would tell you that they are tremendously satisfying for patients based on observations of results and comments from patients. But such anectodal evidence may seem self-serving as it is not objectively collected and sometimes one only hears or sees what they want to be true. Patients are also concerned about complications and recovery and these can understandably give one pause when considering these abdominal shaping surgeries.

In the May 2012 issue of Plastic and Reconstructive Surgery, this exact question was studied. A published paper from a private practice in Kansas studied  the effects on the quality of life in 360 liposuction or combined lipoabdominoplasty patients. One of the objectives of the study was to compare liposuction and tummy tucks parameters from the patient’ viewpoint. These included the results, recovery, complications and psychological effects from the surgeries. The patient numbers broke down into 219 liposuction, 13 tummy tuck alone patients and 128 patients who had a combined tummy tuck and liposuction procedure.

To no surprise, liposuction patients had less pain and quicker recoveries than the tummy tuck patients. The average time off work was 6 days for liposuction and 16 days for tummy tucks. Conversely, tummy tucks with or without liposuction reported more significant results and improvement in abdominal contours than liposuction alone. Half of the liposuction patients felt that the procedure did not provide enough results. Overall nearly 86% of patients reported improved self-esteem  and nearly 70% reported an improved quality of life. Collectively, high levels of patient satisfaction were reported at near 89%.

The complication rate for any clinical series of a procedure is always of interest. In this study, it was close to 11%. Tummy tucks had more complications than liposuction with infection and delayed healing being the predominant issues.

For patients, this study has several relevant findings. Better results come from tummy tuck-based abdominal contouring procedures than just liposuction alone. Thus if in doubt between choosing between these two procedures, be aware that higher levels of disappointment occur with liposuction alone. After surgery scar concerns from having a tummy tuck is very uncommon. But to achieve this better result from a tummy tuck comes the price of more pain and recovery, having at least double the time until one can return to work. Nearly 100% of tummy tuck patients say they would undergo the operation again and would recommend it to others based on their experience.     

Dr. Barry Eppley

Indianapolis, Indiana   

A tummy tuck or abdominoplasty is one of the most common and successful of all cosmetic body contouring procedures. Besides the obvious removal of a segment of lower abdominal skin and fat, the underlying muscles are frequently manipulated as well. Usually spoken of in terms of tightening, this part of a tummy tuck is often the most misunderstood part of the operation due to its relative obscurity from the outside.

Frequent questions about the internal tightening of a tummy tuck include whether the muscles are cut, how tight they are made and what the recovery will be like. (e.g., how long will it be before I can stand up straight?) Such questions, while understandable, reflect a basic misconception of how this part of the operation is really done.

While there are numerous abdominal muscles, the only ones that are manipulated in a tummy tuck as the central ones known as the rectus muscles. These are very big, wide and long muscles that run vertically from the lower edge of the rib cage all the way down to the pubic region. They are the largest of the abdominal muscles and make up the entire central part of the abdominal musculature. Like all muscle, they are encased ion fascia very much like a casing around sausage. This covering or fascia is very thick and stout in comparison to the muscle which is very soft and jelly-like.

While the paired rectus muscles normally meet in the midline, pregnancy can cause these vertically-oriented muscles to separate and a gap develop between them. This is most evident below the belly button but can also extend above the belly button as well. This gap does not mean that the abdominal contents are exposed as the overlying fascia remains attached but stretched. There is a resultant midline muscle deficiency but not a fascial separation. Occasionally a hernia may be present because of this separation around the bellybutton, which is a natural weak point of the fascia.

When these muscles are tightened during a tummy tuck, no muscle is ever cut. Rather, the rectus muscles are brought back together in the midline by sutures which sew the fascia, not the muscle together. Technically, this maneuver is a fascial tightening, not a true muscle tightening. When done properly and with care, there is minimal trauma or injury to the muscle tissue which lies immediately underneath these fascial sutures. What type and size of sutures used to do this midline rectus fascial tightening is a matter of a plastic surgeon’s preference.

How tight this fascial tightening or plication is done is usually no more than it takes to bring the muscle bellies back to touch in the midline. There is no advantage to trying to make them any closer or tighter than what their natural position would have been. Making them any tighter increases pain after surgery without any visible improvement in appearance. More tightening will also not give one a ‘six-pack’, as this is not possible no matter how the fascial suturing is done.

It is this fascial tightening that induces much of the discomfort after tummy tuck surgery. It is also that which make can make it difficult to stand erect in the first few days after surgery. However if the fascial tightening is not overdone most patients can stand erect and their pain is not unduly severe.

Dr. Barry Eppley

Indianapolis, Indiana

While tummy tucks have always been used to recontour the post-pregnancy body, they have grown in popularity over the past decade due to increased use of weight loss methods. (e.g., bariatric surgery) While it is major body surgery, it is tremendously effective at removing loose skin and fat from the abdomen and major complications with it are actually fairly rare. By far the most common complication is that of a seroma or fluid build-up after surgery. That is why drains are placed and used after surgery as a prevention method.

The occurrence of seromas after tummy tucks is very common. Even though drains are used for a week or two after surgery, they can still occur. I usually counsel my Indianapolis tummy tuck patients that up to 30% of patients will develop seromas two to three weeks after surgery despite the use of drains. The larger the tummy tuck and the greater amount of skin and fat removed, the more likely one will develop it. While drains are helpful, they definitely are not completely preventative of seromas.

While most seromas are treated non-surgically by needle aspiration, they pose a nuisance for patients. Most seromas will require multiple needle aspirations (taps) spaced a week apart for up to a month after drain removal. This causes an inconvenience for patients and some intermittent mild discomfort as the fluid accumulates.

Prevention or decreased incidence of this well recognized after tummy tuck problem has focused on two surgical techniques. Both center around the concept of the reduction of so called ‘dead space’. Closure of the size of the abdominal dead space through progressive tension sutures or quilting sutures has been found to be fairly effective as the tummy tuck is being closed. By suturing the underside of the skin back down to the abdominal wall closes down the space that has been made during the procedure. The other approach is to not make as much dead space to begin with. More limited upper abdominal flap dissection and the use of liposuction to help loosen and stretch it downward to bring the two skin edges together has also been found to be effective.

In the October 2011 issue of Plastic and Reconstructive Surgery, a clinical study was reported that employed both of these intraoperative maneuvers to decrease seroma formation after tummy tuck surgery. The authors approach was to use a longer tummy tuck incision, limited undermining of the upper abdominal skin flap to just the tunnel needed for rectus fascial plication with liposuction undermining out laterally, and the use of progressive tension sutures. These techniques enabled drains to not be used after surgery. To study the outcome of this tummy tuck approach, 113 patients over a 6 year period were studied. Postoperative seromas occurred in 10 of the patients. (9%)

While these tummy tuck techniques did not completely eliminate all seromas, the low incidence was fairly impressive given that drains were not used after surgery. Their results illustrate that drain-free tummy tucks are possible and actually have a lower seroma incidence than those in which drains are used in my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Excess body weight is a well known health risk. Large accumulations of body fat contribute to cardiovascular disease and diabetes and lower one’s lifespan. Significant and sustained weight loss through a diet and exercise program is the best treatment approach and there is endless medical evidence to support the effectiveness of overall body fat reduction.

It has long been hoped that the surgical removal of some of this fat, liposuction being the easiest way to do it, would offer some similar albeit less significant health benefits. To date, there has been no medical evidence that would support this hypothesis. (hope) It was presumed that the amount of fat removed in most safe liposuction extractions was simply too small to make a difference. In addition, it has always been assumed that the fat that really matters, from a health standpoint, was visceral or largely intra-abdominal fat. Outer or subcutaneous fat only mattered because it contributed to making undesired body rolls and bulges. 

A recent study given at the 2011 annual American Society of Plastic Surgeons meeting in Denver presented some interesting findings on potential health benefits from liposuction surgery. In over 300 hundred patients who had either liposuction, a tummy tuck or both combined, blood levels of triglycerides, cholesterol and white blood cells were done both before and after surgery. Triglyceride levels in patients with normal levels before surgery were unchanged. However, in patients with elevated triglyceride levels before surgery (defined as greater than 150 mg/dl), they showed a triglyceride level reduction of over 40 percent. Such significant level reductions are usually associated with drug therapies which often are even this good. White blood cell counts, viewed as an indicator of chronic inflammation and disease inducer, dropped an average of 10 percent.

Does this mean that liposuction is good for your overall health? That is a stretch at this point but this liposuction study clearly shows blood chemistry changes that reduce certain disease risk factors. Much more work needs to be done but it does provide some proof that subcutaneous fat may have a greater metabolic role to play than previously thought. It is not just an idle depot of excess fat whose only role is as a creator of undesired rolls and bulges. At the least it may be comforting to know there may be some benefit, small as it may turn out to be, that a shortcut approach to fat reduction with liposuction may also be good for you.

Dr. Barry Eppley

Indianapolis, Indiana