A mother of 2 in her early 40’s who is bothered by the appearance of her stomach. She was especially concerned about the scar placement and wanted to make sure that it would be placed in a thong position where it would be hidden by most clothing styles. She is shown before and again, 1 year after an extended abdominoplasty. EXPAREL was used during surgery to decrease her need for narcotics after surgery. Progressive Tension Sutures were placed at the time of surgery to decrease the risk of seroma. Her scar placement is 6.5 cm from the vaginal fornix to keep the scar low, in a “ thong” position. Tattoos have been blurred for her privacy. Nearly 5 lbs of skin were removed with the extended abdominoplasty.
A mother of 2 in her late 50’s who is bothered by bulging of her abdomen in clothing. She felt that her left side bulged more and on exam was noted to had an inguinal hernia on that side. She has had 2 C-sections. Her umbilicus is relatively high and in her case we “floated” the umbilicus by pulling it down lower, avoiding a scar around the umbilicus and a midline scar from the umbilical slit in the lower abdomen. She is shown before and again, more than 3 years after her extended abdominoplasty with floating of the umbilicus. Her inguinal hernia was repaired by General Surgery at the same time. Her scar is placed low in a “thong” position where it is hidden by most clothing styles.
Discussion: Floating of the umbilicus is a technique that I find useful in patients with a relatively high umbilicus that do not have much looseness in the upper stomach and wish to avoid a scar around the umbilicus and a vertical slit scar in the lower abdomen. The umbilicus is detached at its base and brought down lower, instead of cutting around the top of the umbilicus and popping it back up through in the new position. It does not “pull the sheet tight” in the upper abdomen as much as with a traditional technique but can work well in some cases as shown here. Liposuction was used to form a midline groove above the umbilicus. The abdominal muscles are still tightened and bring in the waist and correct the muscle bulge. Her incision is “extended” to allow better tightening of the sides and has higher tension placed on the sides to better shape the stomach.
A mother of 3, including twins, in her mid 40’s. She had gained 70 lbs with her pregnancy and “carried large”. She also had a hernia of the muscle wall above the umbilicus. (a ventral hernia).
Exparel was used during her surgery as part of our Enhanced Recovery after Surgery (ERAS) protocol. Exparel is a Liposomal Marcaine, an injection placed at the time of surgery that slowly breaks down and releases long-acting local anesthetic for the first 72 hours after surgery. Pain varies between patients but she was amazed that she did not require any narcotics after surgery, and stopped taking ibuprofen after two weeks. She reports that she is already down in size from a 10/8 to a 6.
She is 5’5” and 149 lbs and is shown just 6 weeks after her surgery. Her ventral hernia was repaired at the same time by general surgery. It is early to show her result, because swelling will continue to go away over the next 5 months and the scars will continue to fade for the next two years. Nonetheless, the early results are dramatic. She is thrilled to be able to wear fitted clothes now. The oblique view shows the “champagne groove” and the hollow around the umbilicus that were sculpted at the time of surgery.
A mother of 3 in her later 50’s who is bothered by excess skin and bulging of her abdomen after pregnancies that makes it difficult to wear fitted clothing. She is 5’4” and 148 lbs and is shown before and again, 8 ½ months after abdominoplasty .
Exparel was used during her surgery as part of our Enhanced Recovery after Surgery (ERAS) protocol. Exparel is a Liposomal Marcaine, an injection placed at the time of surgery that slowly breaks down and releases long-acting local anesthetic for the first 72 hours after surgery. It has been shown to decrease the need for narcotics after surgery by 70%.
Her case illustrates the challenge of a relatively high umbilicus ( belly button). When the umbilicus is lower, and the skin is looser, then the skin is removed entirely from just above the umbilicus to the mons pubis. When the skin is not as loose and the umbilicus is higher, then this skin that was originally around the umbilicus is still present at the end. If the upper abdomen was not loose, then a cut could be made deep to the umbilicus , puling it down a little lower, a so called “umbilical float” or a “floating of the umbilicus”. This would not have allowed us to “ pull the sheet tight” and smooth her upper abdomen. Another option would have been to place the lower abdominal scar much higher, in the mid-abdomen. This is usually not a good tradeoff, because it is more attractive to have this lower scar in the “thong position” where the lower edge is 6 ½-7 cm from the vaginal area. The third option, which was chosen in her case, is to close the small opening from the skin that previously surrounded the umbilicus. as a small vertical slit. This does leave a small scar somewhere between the umbilicus position and lower abdominal scar, but is the best tradeoff in her case.
This scar as with all of the scars will continue to fade and improve for two years or more after surgery. Her umbilicus was initially deviated to the right. During surgery I use a “plumb line” of a temporary silk suture while I tighten the muscles that are stretched by pregnancy to guide me in trying to bring the umbilicus back to the middle.
A mother of 2 in her later 50’s who had a lap band in 2007, that was removed in 2014 and then had an endoscopic gastric sleeve in 2014. She has lost 100 lbs and been at a stable weight for the last 2 years. She is bothered by fullness and laxity of the abdominal skin and would like to be able to wear fitted clothing.
She is shown before and again, nearly 7 months after an extended abdominoplasty with the removal of nearly 5 lbs of skin. She was 5 feet tall and 139 lbs before her surgery. She is thrilled with the improvement of her abdomen and loves catching sight of herself in a mirror now when she walks by in her fitted clothing. Exparel was used to limit her need for narcotics after surgery, and progressive tension sutures were uses to decrease her risk of seroma formation. Her scar is placed low, in a thong position, where it is most easily hidden by clothing.
As is typical in a patient with significant weight loss she continues to have some looseness of the skin of the
upper abdomen, but not enough in her mind to trade it for a vertical scar ( Fleur de Lis abdominoplasty)
A mother of 3 in her early 60’s who has lost significant weight after an endoscopic gastric sleeve 2 years before. She is bothered by the “pouch” of her abdomen that makes it difficult to wear fitted clothes. She is shown before and again, 6 months after an extended abdominoplasty.
A mother of 2 in her early 30’s who is bothered by bulging and laxity of her abdomen. She is 5’3” and 146 lbs and is shown just before and again, 6 weeks after an abominoplasty. Exparel was used to limit her postoperative need for narcotics. Progressive tension sutures were used to decrease her risk of seroma. Scars are typically at their thickest and reddest at 6 weeks and will then begin to fade and improve over the next 2 years. Her abdominal incision is placed low, in a “thong” position, where it is hidden by most clothing styles. There is typically still significant swelling in the abdominal skin a the 6 week mark that takes 6 months to fully resolve. Having said that, she has an excellent contour already, and tightening of the loose abdominal muscles have given her a nice waistline.
A mother of 3 ( including twins) in her early 40’s who is bothered by bulging and loose skin of her abdomen. She would like to be comfortable wearing fitted clothing. She is 4’10” and 124 lbs and is shown before and again, 4 ½ months after an extended abdominoplasty. She has severe stretching of the abdominal wall from her pregnancies and her umbilicus is deviated to her right. An attempt was made to bring it closer to the midline with the tightening of the muscle wall but it remains deviated to the right. Despite this, she has had an excellent correction of her abdominal contour and loves being able to wear fitted clothes and t shirts now.
Update: Our patient is now seen at 8 months. All swelling has resolved and the scars continue to fade and improve.
A mother of 4 in her early 50’s was bothered by the appearance of her abdomen which she describes as a “loaf of bread” when she is leaning forward. She finds it difficult to wear fitted clothing and is also bothered by the wrinkled appearance of the skin. She is shown before and again, 6 months after an extended abdominoplasty. She is thrilled by the new appearance of her abdomen, and is able to reach into her closet and grab some clothing without worrying about how it will hide her abdomen. Her scar is placed in a “thong” position where it is hiddent by most clothing styles.
A mother of 2 in her early 50’s who is bothered by the appearance of her stomach. She has had two treatments elsewhere with cool sculpting, but did not see any improvement. This is not surprising. She does have excess fat of the stomach wall, but her main issue is stretching of the abdominal muscles and skin from pregnancy, neither of which are treated or improved with cool sculpting. When she first saw me her BMI was 33 and I had her lose 25 lbs with diet and exercise to get ready for her surgery to bring her BMI down below 30. Abdominplasty is not procedure for patients who are significantly overweight. Fat that is inside the abdomen, around the intestines (omental fat) can make it difficult to tighten the abdominal wall. I tell my patients that you cannot put 40 lbs of potatoes in a 20 lb bag. Not only will the muscles stretch back out, but there would be a much greater risk of having a blood clot from increased pressure on the abdominal veins, as well as difficulty taking deep breaths because the diaphragms are at the bottom of the lungs but at the top of the abdomen and would not be able to descend normally.
She still has a thicker layer of subcutaneous fat over her abdomen, and chose to have a “lipo-abdominplasty” which combines liposuction of this fat at the time of the abdominoplasty. The technique is modified to limit the undermining of the abdominal skin to better preserve the blood supply. In her case, an “extended lipo-abdominoplasty” was performed to give better tightening of her sides. A “high lateral tension” pattern was used which has visibly improved her upper thighs. She is shown just 7 weeks after her surgery. There is typically significant swelling in the lower abdomen that takes 6 months to fully resolve. And the scars around the umbilicus and in the “thong line” are at their thickest and reddest at this time, and gradually improve over the next 2 years. Even so, she has a dramatic improvement in her contour. Her waistline is narrower and her stomach is flatter from the muscle tightening. The abdomen has a beautiful contour from liposuction of 1050 cc from the abdomen. And the skin is dramatically tighter after the excision of 5 ½ lbs of skin. Her umbilicus (belly button) was deviated to her left side by uneven stretching of her pregnancies. I have brought it back to the midline using our plumb-line technique with differential tightening of the abdominal muscles.
She is thrilled with her early result and is happy to be able to head back to the gym now.