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Abdominoplasty


Overview

Another name for abdominoplasty is tummy tuck. Because of its effectiveness at creating a tight, flat abdomen it is one of the most common procedures performed in plastic surgery. It removes excess abdominal skin and fat utilizing an incision just above the pubic bone, similar to a c-section but longer.

Example of Extended Abdominoplasty

Today's society places strong emphasis on a slender, youthful appearance of the abdomen. It is particularly frustrating for women who have given birth or have lost a significant amount of weight. Often, they are left with a loose, stretched-out stomach that frequently has stretch marks. No matter how much exercise, what type of diet, or what kind of cream is applied, the redundant skin never goes away. The reason is because the skin has lost its elasticity and can no longer shrink back.

The same patient in profile. Notice both flat stomach and creation of hour-glass figure.

The good news is that a properly performed abdominoplasty can remove not only the redundant skin but also significant portion of the stretch marks. When the correct operation is matched to the right patient, satisfaction is extremely high. There is a price to pay, however. The operation cannot be done without leaving a long scar that often extends across the lower abdomen, just above the pubic bone. If preformed properly, this scar is positioned so that it is easily hidden by even a small bikini, and certainly by underwear. The type of abdominoplasty performed can be divided into 4 types: mini, standard, extended, and the most aggressive being a complete, circumferential body lift. The most appropriate procedure for you is determined during your consultation with a plastic surgeon. He/she will assess your skin excess, skin quality, fat excess, fat distribution and body-type. Then he/she will take into consideration your goals to decide what is best for you.

Mini Abdominoplasty, AKA Mini Tummy Tuck

The mini-abdominoplasty is the least involved variation. The incision is relatively short, staying within the pelvic bones. It is slightly longer than a c-section incision. It usually does not involve repositioning of the umbilicus. The best candidate for this procedure typically has redundant skin and an abdominal pooch located below the umbilicus. Laxity of the abdominal wall below the umbilicus (a.k.a. abdominal pooch) can be dramatically flattened with a mini abdominoplasty.



Mini Abdominoplasty Incision.

Standard Abdominoplasty, AKA Standard Tummy Tuck

Standard Abdominoplasty. Frontal view shows significant improvement in hour-glass waist.

The standard abdominoplasty is the most common abdominoplasty. It does an excellent job in eliminating the abdominal pooch below the umbilicus especially in women who have given birth. In the process it produces a much flatter stomach. Many plastic surgeons go several steps further by tightening the underlying muscles to flatten the stomach and narrow the waist line. An additional bonus is the removal of all the stretch marks located below the umbilicus which is where most stretch marks occur.

Notice marked improvement of pooch below umbilicus and flattening of stomach.


In addition, a properly performed standard abdominoplasty will help create an hour-glass waist line. The only thing a standard abdominoplasty will not do well is treat fat deposits in the flank area. This can be addressed with either liposuction or by performing an extended abdominoplasty. If there is only a small or moderate amount of flank fat then liposuction is the best course. If you have a significant amount of flank fat then an extended abdominoplasty would most likely be best.

 

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Before and After of mother of two with loose, hanging abdominal skin.
Notice the flattening of the abdomen and overall reduction in waist circumference.

 

 

 

 

 

 

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Picture after the procedure with exposed incision .
The standard abdominoplasty leaves a scar from hip to hip and requires repositioning of the umbilicus to avoid positioning it too low on the abdomen. In addition to removing skin and fat, plastic surgeons have developed various techniques to tighten the underlying musculature. This allows them to tighten the abdominal wall even further, thus, creating a sculpted look.

Standard Abdominoplasty Incision.

 


Extended Abdominoplasty, AKA Extend Tummy Tuck


Extended Abdominoplasty

The extended abdominoplasty is a relatively new procedure in the world of plastic surgery. In patients with significant flank fat and/or excessive flank skin, a standard abdominoplasty will not treat the entire problem. It is true they will obtain a flat stomach but the flank problem will remain unaddressed. These patients are ideal candidates for an extended abdominoplasty. Not only will they obtain a flat stomach but also they will acquire an hour-glass waist appearance. The results are nothing less than spectacular. No other procedure can produce such an impressive waist line even in patients who never had an attractive waist line in their youth.

Extended Abdominoplasty. Notice the significant improvement of waistline, hips, and flanks.


See the example above and to the right as well as those in the Before/After section. This procedure is only necessary when there is a significant amount of fat in the love handle and upper hip region.
The extended Abdominoplasty gives hope to the patient who is not a candidate for a standard abdominoplasty.
The incision for the extended abdominoplasty goes to the back of the hip area. In expert hands, this incision can be kept low so that even low-rise clothing can be worn without scar exposure. See below for incision placement.

 

 

Extended Abdominoplasty Incision.

Extended Abdominoplasty Incision From Behind.

Circumferential Abdominoplasty, AKA Body Lift

The circumferential body lift is a very aggressive procedure and is reserved for those patients with a significant amount of redundant skin posteriorly. Another indication for this procedure is the patient with flabby hips and droopy buttocks. The hips and buttocks can be markedly elevated to give a sleeker more youthful appearance. It must be mentioned, however, that this more aggressive operation will leave a circumferential scar and is more complicated. This will be discussed during your consultation.

Circumferential Body Lift Incision.

 

Benefits

The benefits of a properly performed abdominoplasty are breathtaking. The most impressive of which is the removal of the loose flabby abdominal skin that most patients thought would never go away. The procedure dramatically flattens the abdomen creating a sleeker, more attractive figure. An added benefit is that the skin removed is usually the skin that contains stretch marks. You can check this on yourself by simply looking at the area below your bellybutton. Most likely, this is the area where stretch marks are located, if you have any at all. The majority of these stretch marks can be completely removed. In addition to the skin, fat, and stretch mark removal, the underlying muscles are tightened. This markedly flattens the stomach, enhances the contour, and provides a more hourglass figure.

Are you a good candidate?

The most significant determinant of a good candidate for abdominoplasty is the amount of loose skin that one has below his/her bellybutton. Often, this loose skin is caused by significant weight loss or pregnancy. In both of these cases, the abdominal skin has been stretched beyond its ability to shrink back. If you can easily grab excess skin, and pinch a large amount, it is likely that an abdominoplasty would provide a highly noticeable improvement. If, on the other hand, the skin feels very thick, and is not particularly loose, it is likely that an abdominoplasty is not the procedure of choice. In this case, liposuction may be more appropriate. Often, your plastic surgeon will decide to combine liposuction with abdominoplasty. This allows him/her some element of artistic sculpting, in addition to skin and fat resection. A visual evaluation is necessary in deciding which procedure is right for the individual.

Possible complications

Outlined below are the most common and significant complications associated with the procedure. Large scar - It is important to realize that all abdominoplasties leave long scars. The total length of a scar depends on the amount of redundant fat and skin one has within the flank area.
Blood clot - Blood clot formation after abdominoplasty is more common than with other cosmetic surgery procedures. This can be minimized by wearing compressive stockings and making sure the patient walks around immediately after the operation.
Infection and wound healing problems.
Fluid or blood collection within the wound.
Asymmetry and/or contour irregularities.

Do's and Don'ts prior to surgery

Medications. Certain medications thin blood and should not be taken within 3 weeks of surgery. The most notable is aspirin and aspirin containing products. Vitamin E and many herbal products also thin the blood and should discontinued.
Sleep. It is important to get a good night's rest prior to the procedure. If you think this may be a problem, please, do not hesitate to ask your doctor for something to help you sleep.
Smoking. You must not smoke within 3 weeks before and after surgery. Smoking has a profound effect on reducing wound healing capabilities. It significantly increases the likelihood for infection, wound healing problems, and scar formation. This is especially true with abdominoplasty. It also affects your airway, what makes anesthesia much more difficult. Patients who cannot quit smoking can have just a limited abdominoplasty or none at all. After all, patients' safety is the biggest concern.
Eating. Do not eat within 8 hours of surgery and do not drink within 6 hours of surgery. It is OK to take medications with a sip of water. Please discuss all medications with your plastic surgeon and your anesthesiologist.
Arrival. It is important to arrive on time so everything goes as planned. Please be sure to have someone else drive you.

Anesthesia

The anesthesiologist will discuss what type of anesthesia is best for you. General anesthesia is the most common choice for abdominoplasty. Local anesthesia and sedation are not possible with abdominoplasty because it would be too uncomfortable for the patient.

After the procedure

Immediately. Normally, you will go home about 2 hours after surgery. You may have a drain in place after the surgery to remove excess fluid. It usually stays in place for 1-2 weeks and then it is removed without pain. You will be sent home with pain medication and most likely an antibiotic.

That evening. You must take it easy and make sure you take your pain medication as necessary. There is no need to have pain. In fact, taking pain medication will allow you to walk, eat, and feel relatively normal. This allows you to heal faster. It is important to walk around at least a little bit to get the blood circulating. It might be hard to believe, but walking will make you feel better and help the anesthesia wear off faster. It is essential that you walk in a flexed forward position. When laying down, or sleeping, it is important to maintain the flexed forward position. This is best accomplished by placing large pillows under your feet and your head. The next day. It is important to walk around as much as possible with the abdominal binder on. The abdominal binder plays an important role in protecting the incision as well as minimizing swelling. For this reason, it is a good idea to keep the binder on at all times except when showering for the first week. You must remember, it takes 6 weeks for the major swelling to subside and 6 months for it to go away completely. Ask your surgeon when you will be able to shower. Simply remove the binder and the bandages and let the cool shower water rinse over you. Be sure to remain flexed forward. Use regular soap gently. Do not worry about the drain. Simply, hold it and wash around it. While you are showering, have someone wash and dry the binder for you. Afterward, reapply some new gauze and put the binder back on.

First week. It is very important to not do too much as this will increase the drainage and delay healing.

Afterward. Sit ups and abdominal exercising should not be done until at least 8 weeks. This is how long it takes for the tightened muscles to heal.

Recovery time

As mentioned above, you will be encouraged to walk around the very next day. Returning to work can be somewhat variable depending on your job. If your job is sedentary you will be able to return to work in 10 to 14 days. If your job is labor intensive it may take up to 6 weeks to return. Expect to have bruising and swelling. You may resume light exercise that does not require abdominal activity at approximately the 4th week. Abdominal activity, however, should not be attempted prior to 8 weeks and should only be done when there is absolutely no pain. The majority of the bruising and swelling will have subsided by 3 weeks but complete resolution will take at least 6 months to occur. Typically, scars heal in a very methodical manner. For the first 6 to 8 weeks the scar becomes red as the body heals. After that stage, however, the scar becomes much less red and thinner. By one year, the scar is usually very light and easily hidden by underwear or a bikini.

Cost

The cost varies accordingly to a body type. A mini-abdominoplasty usually costs between $4,000 and $6,000; standard abdominoplasty between $4,500 and $7,000; and extended $7,000 and $9,000.

Consultation

We have outlined below what you can expect from your abdominoplasty consultation. Read carefully, as there are many suggestions that will save you time, clear up questions, and help you convey to your plastic surgeon what you want to accomplish.

Health History

All cosmetic surgery consultations begin with a thorough health history. This is especially true if general anesthesia is being used, but also applies to local anesthesia. Abdominoplasties are almost always done under general anesthesia because of the extensive amount of tissue undermining necessary. For this reason it is especially important that your health is optimized. Prior to meeting with the plastic surgeon you will be given a health history questionnaire to fill out in the waiting area. There are 5 areas of your health you will be asked about. Be sure to answer it with detail so that your plastic surgeon and anesthesiologist can be optimized for you.

  • General Health

General health problems are important to discuss so that your surgery is as safe as possible. Be sure to mention any chronic illness. Of particular concern are high blood pressure, diabetes, heart problems, liver and kidney disease, stroke, cancer, bleeding problems, and wound healing problems.

What will the plastic surgeon do if I have medical problems?

In short, he will make sure your health is optimized as much as possible to ensure your safety. This may mean referring you to your private physician.

If you have a health problem you can often save yourself time by getting a letter from your private physician prior to your cosmetic consultation stating what the health problem is, how it is being treated, and whether or not you are able to tolerate general anesthesia safely.

If you are seeing any specialist (cardiologist, kidney doctor, psychiatrist, etc. ) be sure to bring a letter from them stating you are able to tolerate surgery.

Be sure to let your plastic surgeon know if you have ever had a blood clot. Abdominoplasties have a higher incidence of causing blood clots compared to any other cosmetic procedure.

  • Past Surgical Historys

On your questionnaire you will be asked about previous surgeries. Be sure to identify any problems you may have had with anesthesia. Of particular concern are previous cosmetic surgeries especially if you do not like the result and are interested in revision. With abdominoplasty it is especially important to mention all abdominal surgeries including C-section, gall bladder, and hernia operations.

  • Medications

Be sure to list all medications you take including aspirin and over-the-counter medications. These are important as they may increase bleeding and affect your surgery. It is extremely important to stop taking aspirin and aspirin containing products at least 2 weeks before surgery. Tylenol is a good alternative. Here is a partial list of aspirin containing products and other products to be avoided prior to surgery.

  • Allergies to Medications

Information about medications that cause allergies is very important so that these medications can be avoided. Of particular importance is the reaction you had, especially if you had trouble breathing. Be sure to include this information! Nausea is not an allergy but it is important to mention as well.

  • Smoking, Drinking and Drug Use

These will certainly affect your surgery and MUST be mentioned so that your surgery can be optimized. Smoking causes a profound decrease in wound healing and will lead to worse scarring and a less favorable result. With large procedures such as a face lift, neck lift, tummy tuck, and breast lift smoking must be stopped at least 3 weeks before and after surgery. Otherwise, the results could be disastrous leading to non-healing wounds, poor scarring, and/or infection. With smaller procedures such as eyelid surgery, nose surgery, breast augmentation, and liposuction smoking will hurt the overall result but this may or may not be noticeable. In this case smoking cessation is strongly advised but is not mandatory.


Specific Abdominal Issues

During your consultation you must be very accurate with abdominal problems. Of particular concern is a history of abdominal hernia. This problem must be addressed during your consultation. If a hernia is present it can often be fixed during the surgery or if it is large it may need to be fixed with the help of a general surgeon. Another issue that complicates abdominoplasty is previous abdominal surgery. The scars may affect the blood supply of the skin. Once again, any history of blood clot must be discussed.


What Do You Want To Change?

It is important that you have a clear idea of what you want changed when you go for consultation. The least favorite thing any plastic surgeon wants to hear is "what do you think I need done. "

Look in a mirror and identify what bothers you. Be specific. It may be helpful to look back at younger pictures to see if that problem always existed or if it is part of aging. Bring the picture as it may be helpful.

Common complaints are: loose skin, excess fat, stretch marks (especially below the bellybutton), abdominal pooch below the naval, lack of a waist line, droopy buttocks, and disproportionately large waist compared to buttocks and/or breasts. All these complaints can be helped with abdominoplasty by use of different techniques.


Physical Exam

The key to the abdominal physical exam is to determine exactly what is causing the problem. Some problems can be treated with liposuction while others require a tummy tuck. Sometimes a combination of the 2 is best. This section will help you decide what is best for you. Abdominal cosmetic surgery can be broken down into the following 5 categories: liposuction alone, mini-abdominoplasty, standard abdominoplasty, extended abdominoplasty and circumferential abdominoplasty


  • Liposuction

Liposuction alone is excellent when skin excess is not a problem and there is a localized excess fat deposit. Liposuction requires that the patient's skin has the ability to shrink back once the fat is removed. Patients with poor skin quality, demonstrated by many stretch marks and cellulite are not good candidates for liposuction. This is better discussed under the liposuction section. Often, patients convince themselves that If I could just suck this fat out then my stomach would be flat.This may be true, but if they have a lot of excess skin or their skin quality is poor then they will be disappointed. Liposuction may leave them with loose, hanging skin often with waviness.

If there is a significant amount of excess skin then the only way to get rid of it is to cut it out via a tummy tuck. Frequently, non-plastic surgeons will perform liposuction and these patients end up with disappointing results. The scars caused by a tummy tuck are very long but this is almost never a complaint. Satisfaction is uniformly high. Once it has been decided that skin excision is necessary the next question is how far to the back should the excision go. The answer is relatively straightforward.

  • Mini Abdominoplasty

If your problem is limited to a small amount of loose skin and excess fat below the bellybutton then a mini-abdominoplasty may be all that is necessary. As the name implies, a mini-abdominoplasty creates a smaller scar. The tradeoff, however, is that it may not obtain the results you are looking for. Generally, if you can only pinch an inch or two then this will probably suffice. The incision stays inside the hip bones and the belly button is not transplanted like in a standard abdominoplasty. It is merely pulled downward toward the pubis.

Mini Abdominoplasty Incision.

  • Standard Abdominoplasty, AKA Standard Tummy Tuck

If there is more than an inch or two of excess skin then a standard abdominoplasty is probably necessary. This does an excellent job of removing loose skin, excess fat, and creating a flat stomach. It also helps to create a curvy waist but not as dramatically as an extended abdominoplasty does. Below are the components of an abdominoplasty:

  • Skin Excision


In general, you can expect the scar to extend from hip to hip. The scars do not fade until about 6 months and will always remain visible. Hydrocortisone 1% cream does a good job of limiting the redness. The good news is that the scar can easily be hidden by underwear or a bikini; patients rarely complain about it. The trade off is more than worth it. Another big advantage with skin excision is that the stretch marks located below the bellybutton will be gone forever! The better quality skin located above the bellybutton is brought down in its place.

Standard Abdominoplasty Incision.

Keep in mind, it takes 1-2 years for an abdominoplasty scar to soften and lighten.

 

Actual After picture with incision exposed. Typical scar after an Abdominoplasty. Notice also the scar around the umbilicus. Your scar may vary. Some become almost undetectable, other may form thicker, more noticeable scars.


  • Abdominal Muscle Tightening
Often, with age, weight gain, or pregnancy the stomach muscles separate in the midline causing a diastases. This leads to additional bulging. Therefore, muscle tightening is very helpful in obtaining a desirable, flat stomach. The stomach muscles are tightened during the procedure by suturing them together in the midline.

  • Belly Button Transposition


It is usually necessary to transplant the belly button because of the large amount of skin that is removed. Failure to transplant would lead to an unnaturally low location that would look strange. Different plastic surgeons create different types of belly buttons. You should be sure to discuss with your plastic surgeon your preference of belly button. Do you prefer a small vs. moderately sized bellybutton? Would you prefer a round one or one that is slightly longer vertically than horizontally? In some patients, it is possible to create a hooded appearance which some people find attractive.

  • Liposuction


Performing liposuction on the abdomen at the same time as the abdominoplasty can be dangerous. Many plastic surgeons will not perform them together as it may jeopardize the blood supply to the skin. In some patients limited liposuction is possible. These are generally patients with good skin quality and who do not smoke cigarettes. If you have a significant amount of extra skin then liposuction may be too dangerous to perform concomitantly and would have to be done as a second procedure.

Extended Abdominoplasty

When the redundant skin goes around toward the back, then there is no other way to remove it but to extend the excision to include this area. This can be identified by grasping the skin over the lateral waist and around to the flanks. Extending the excision to include this skin and fat does a spectacular job of creating an hour-glass figure. In doing so, the waist becomes much smaller. This makes the buttocks appear much more attractive and curvy. Furthermore, the breasts appear larger. The reason for this is that the waist is the focal point of the body around which everything else is evaluated. A smaller waist significantly impacts both the breasts and buttocks.

The down side of the extended abdominoplasty is the additional operating time necessary, the additional cost, and of course the longer scar.

 

Extended Abdominoplasty Incision.

Extended Abdominoplasty Incision from Behind.

 

 

 

 

 

 

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Frontal View of Extended Abdominoplasty.

Lateral View of Extended Abdominoplasty.

 

 

 

 

 

Circumferential Abdominoplasty

As its name implies, this goes completely around the body. This procedure is commonly performed in patients who have lost massive (greater than 100 lbs) amounts of weight. This is not uncommon with patients who had gastric bypass surgery and are left with a significant amount of hanging skin that goes completely around the body. Another name for this procedure is a body lift. This is useful to lift the buttocks and thigh skin back up into an attractive position.

Circumferential Body Lift Incision.