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 who has lost 100 lbs with diet and exercise from her maximum weight of 260 lbs and is now 5’4” and 160 lbs. She is bothered by “ rolls of skin which make it difficult for her to tuck in her shirt”. She was motivated to lose weight so that she would be more fit to play with her grandchildren. She is shown before and again, 1 year after an extended abdominplasty with the removal of 8 lbs of skin. 680 cc of fat was removed from the upper abdomen with liposuction at the same.
She is thrilled with her new contour.
Discussion: Her improvement is dramatic. The results of abdominoplasty after significant weight loss depend on the amount of weight that was lost to get down to an ideal body weight. Patients that have lost 20 lbs look better than patients who have lost 50 lbs. Pts who have lost 50 lbs look better than patients who have lost 100 lbs, and so on. Despite adding liposuction to the “rolls” above the umbilicus, she continues to have some excess skin. When patients have gained significant weight they have expanded in a horizontal direction above the umbilicus. The contour can be improved further by excising this extra skin in a vertical direction, albeit at the expense of a visible scar in the midline. This would become a “Fleur de Lis” abdominoplasty. I find that unless a patient already has a midline scar in the upper abdomen from a prior abdominal surgery that they do not want the tradeoff of this scar for additional tightening.
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 woman in her early 50’s who wears a 36 DDD bra and is bothered by back pain, shoulder pain, difficulty exercising and postural problems. She is also bothered by axillary lipodystrophy- extra fat in the anterior axilla that makes it difficult for her to wear halter tops or dresses. She is 5’3” and 197 lbs and is shown before and again, just 4 months after bilateral breast reduction with the removal of more than 1300 gms of tissue from each breast as well as Power assisted liposuction of the anterior axilla using the S.A.F.E. technique. (Suction Aspiration Fat Equalization) Scars will typically continue to fade and improve for the first 2 years adfter surgery- she is already thrilled with her result and no longer has problems with back and shoulder pain or her posture. She looks forward to wearing summer dresses that show the top of her breasts and that she could never wear before.
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 2 in her mid 50’s who has lost 80 lbs with diet and exercise. She is bothered by the “rolls of skin which make it difficult to tuck in her skirt”. Her impetus for losing weight was to be more fit to be able to play with her grandchildren. She is shown before and again, 9 months after an extended abdominoplasty with the removal of 8 lbs of skin. Although the best results with abdominoplasty are with patients who are thin and have not had decreased elasticity of the skin from significant weight loss, she has a significant improvement. Her scar is hidden in a “thong” position.
A woman in her late 30’s who has lost more than 120 lbs with diet and exercise and is bothered by the appearance of her abdomen, She is currently 5’ 7” and 200 lbs, giving her a BMI of 31.32, She is shown just before and again, 17 months after an extended abdominoplasty with the removal of more than 5 ½ lbs of skin. We could provide additional tightening of the upper abdomen with a midline excision ( a fleur de lis pattern) but she does not wish to have a visible scar in this area. She is thrilled now to fit better in her clothes.
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.