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					                       DOCTOR, I WANT A FLAT TUMMY!!!

  One of the most common areas of the female torso that I am asked to correct is the
abdomen. Pregnancy can ravage the abdomen and breasts and despite diet and
exercise, that prepregnancy figure may never return without a little help from the plastic
surgeon. Prior to development of liposuction in the early 1980s, there was only one
surgical option, full abdominoplasty. For many patients then and now, this is overkill for
it is hard to justify a long horizontal scar and a procedure with serious potential
complications, when only a small improvement is to be gained. Fortunately, now
liposuction, miniabdominoplasty and even endoscopic abdominoplasty are additional
choices. In general the risks and costs of abdominal reconstruction increase as the
procedures become more complex with abdominal liposuction being the least
complicated and expensive and full abdominoplasty being the riskiest and most costly.
Determining what procedure is best suited to an individual woman is based on the
physical examination and what improvement the patient wants and compromises she is
willing to make.
     During the examination the skin, subcutaneous fat, abdominal wall integrity, and
deep fat are all assessed. The elasticity of the skin is critical. This will determine how
much the skin will shrink when the underlying bulk is reduced. The location and extent
of stretch marks and surgical scars is important. Unless stretch marks are minimal or
located below the navel, it may not be possible to eliminate all of them, even with full
abdominoplasty. Some scars can be removed by abdominoplasty whereas others are
transposed to a lower position or left intact. If the rectus muscles (the two large vertical
muscles that normal run side by side down the middle of the abdomen) have been
separated during pregnancy and don’t return afterward, a bulge will occur from the
resultant abdominal wall weakness. True hernias also need to be diagnosed and
treated. Finally, if there are extensive fat deposits internally behind the abdominal wall,
the chances of achieving a completely flat abdomen will be diminished.
     The patient who can usually benefit the most from just liposuction is a patient with
good skin tone, few if any stretch marks, localized abdominal fat deposits, and good
abdominal wall muscle tone and position. Patient 1 pictured below is a 25 years old,
with no stretch marks or scars, localized fat, and good muscle tone. She has had one
pregnancy. Liposuction alone resulted in an excellent result.
     Miniabdominoplasty combines liposuction with abdominal wall tightening and only a
small amount of skin excision. The navel is not transposed and the scar is limited to an
area in the lower abdomen covered by all but the briefest of bikinis. The ideal patient
has good to moderate skin tone. Stretch marks and a c-section or horizontal scar from
previous gynecological surgery may be present. There is some laxity of the abdominal
wall. Deep fat is not extensive. With miniabdominoplasty the entire abdomen and flanks
are first aggressively suctioned. The skin and remaining fat are dissected off of the
abdominal wall, usually up to the navel, using the low horizontal scar from a previous c-
section or by making a new incision in this locale. The abdominal wall is then tighten
with heavy mattress sutures, often limited to the abdominal wall below the navel, but
occasionally to the top of the abdomen when necessary. Up to two inches of excess
skin is removed above the incision. A drain is placed and the incision is closed. The
patient is placed in a girdle for a week at which time the sutures and drain are removed.
It takes three to four months for the skin to become soft and pliant again. Occasionally a
patient needs liposuction, abdominal wall tightening, but no skin removal. This can be
performed through very small incisions in the navel and/or pubic region. The tightening
sutures can be placed under direct visualization or endoscopically directed on a
television screen. Patient 2 is 35 years old and had three pregnancies. Skin tones is
fair to moderate, stretch marks are present (and most would have remained even with
full abdominoplasty), and abdominal wall laxity is restricted to the lower abdomen. The
result of her miniabdominoplasty with removal of two inches of skin from the lower
abdomen is excellent. The abdomen is flat, the suctioned flanks and upper are
diminished, the scar is short and easy to cover, and even the stretch marks are
improved. Patient 3 is 33 years old and had one pregnancy. Her skin quality is
moderate to good, with no scars but some stretch marks. The considerable lower
abdominal bulge is due to abdominal wall weakness limited to the lower abdomen. Her
post-operative result is excellent. Her abdomen is flat and the scar is easily covered.
      Full abdominoplasty is usually performed for patients with poor quality and
excessive skin. There is usually considerable weakness of the entire anterior abdomen
wall. Though liposuction is often performed with full abdominoplasty, it is usually limited
to the flank areas. A large horizontal ellipse of skin and fat down to the abdominal wall
from the level of the navel to the pubic region is excised. The navel is left in place and a
large skin flap is developed from the skin of the upper abdomen that is usually of better
quality. This skin is stretched to the pubic region to close the incision. A hole is made in
the flap for the navel. Drains and a girdle are placed. It is often necessary for a patient
to walk around bent at the waist to keep tension off the incision for up to three weeks. It
is usually three to four month before the final result is achieved. Patient 4 is 23 years old
and one year following a pregnancy in which she gave birth to twins weighing 81/2 lbs.
each. Her skin is excessive and of poor quality. The abdominal wall has no tone and is
extremely thin. The intestines can be seen bulging in the lower abdomen. Post-
operatively she has an excellent result. The abdomen is now flat. Her incision is thin,
but can only be concealed with a whole piece bathing suit or very large bikini bottom.
     In my opinion, too many full abdominoplasties are performed, leaving patients with
long unattractive scars. This is because some surgeons are not trained to perform
miniabdominoplasty, don’t evaluate their patients well preoperatively, and don’t
understand the skin’s natural ability to shrink following aggressive liposuction. Skin
slough and poor healing are possible complications of full abdominoplasty. These do
not occur with miniabdominoplasty in which the scar is much shorter and easier to
conceal. A flat tummy is indeed possible, but you may have to make some
compromises. (Next month: breast lift and breast reduction)

  Howard N. Robinson, M.D. has been in private practice in South Florida since 1979.
He is happy to answer all questions concerning plastic and cosmetic surgery.

Howard N. Robinson, M.D.
601 N. Flamingo Rd.
Suite 317
Pembroke Pines, Florida
Phone: (954) 437-1161
Fax: (954) 437-1259
E-mail: HRobin1014@aol.com
Web Site: http://www.surgeryplastic.com

				
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