Abdominal Laxity After Massive Weight Loss
Abdomen is the area of the body that is situated in between the rib cage above and the thighs below. The groin crease and its continuation upwards are the landmark that separate the abdomen from the thighs. The hips are defined as the projection of the pelvis and upper thigh bone on the outer thigh, and the waist is defined as the area in between the hips and the outer rib cage.
Pregnancy and/or weight gain stretch and expand the abdominal tissue in a three-dimensional manner (vertical, horizontal, and projection). Weight gain can increase the amount of fat within the abdomen (below the abdominal muscles) and around the organ systems as well as fat above the abdominal muscles (and below the abdominal skin). Unlike any other anatomical location, the intra-abdominal fat expansion affects the muscles of the abdomen by stretching them outwards. This separates the two main abdominal muscles that are responsible for the six-pack look- rectus abdominus muscles. These muscles form two vertical bands down the abdomen that are conjoined at the midline by connective tissue.
Also, the abdominal skin will be stretched beyond its elastic capability and result in breakage of the deeper dermal layer of skin.
In many cases, after significant weight loss, the stretched out skin is unable to completely spring back and contract. The degree of deeper skin damage (dermal tear), visible as stretch marks, dictates the ability of the skin to retract to its initial form. Thus, the abdominal skin and tissue hang loosely while the abdominal wall musculature bulges out. Often there is surplus skin and underlying fat in both the upper and lower abdomen. However, the most significant changes are seen below the umbilicus, where excess tissue hangs, over the groin area to a varying degree, as a pannus.
Apart from bulging of the abdomen, the waist skin is often loose with remaining excess fatty tissue. In most patients the lower abdominal pannus can be seen merging with the lower back hip roll on the sides.
As a result of the changes in the muscle, fat, and skin of the abdomen, an abdominoplasty or a tummy tuck is probably the most valuable procedure for a weight loss patient. Abdominoplasty is a surgical procedure that removes excess abdominal skin and fat from the abdomen and tightens the underlying muscles of the abdominal wall.
Abdominoplasty For Weight Loss Patients
Types of Abdominoplasty Or Tummy Tucks Offered by Dr. Agha
There are many types of abdominoplasties that Dr. Agha performs routinely. In addition to these, Dr. Agha has developed his own signature abdominoplasty that he calls “high-definition tummy tuck” since it refines the abdominal contour in a 3-dimensional form.
The mini-abdominoplasty is performed through a smaller abdominal incision than a full tummy tuck and is best suited for a patient who only has a small amount of lower abdominal excess skin. With a mini-tummy tuck, the navel is not released and the abdominal muscles are not typically tightened. Thus, a mini tummy tuck is not suitable when abdominal muscle separation exists or when there is upper abdominal skin excess. This procedure has no practical value for most weight loss patients.
Standard Tummy Tuck
A standard tummy tuck is the most common tummy tuck technique used for most patients. This procedure utilizes an incision that is made from hip bone to hip bone. The incision is then extended through the fat as far as the abdominal muscle fascia. This is the connective tissue coverage of every muscle. At this plane and over the abdominal muscle, the lower abdominal skin and fat are elevated as far as the navel. A cut is then made around the navel to detach it from the abdominal skin. The upper abdominal skin and fat are then elevated over the muscle as far as the rib cage. The abdominal muscles are then tightened at midline above and below the navel via sutures. The excess abdominal tissue is then removed and the incision is closed via sutures. The navel is then pulled through a new navel opening and sutured in place.
High-Definition Low-Cut Tummy Tuck
This procedure was developed by Dr. Agha and is his signature tummy tuck procedure. In fact, Dr. Agha does not perform the standard tummy tuck procedure. During this procedure, Dr. Agha will recreate an hour-glass contour of your abdomen, applying many of the aesthetic features of ideal abdomen: defined rectus abdominus silhouette with oblique waist indentation, and vertically oriented navel in a narrow midline depression.
The hi-definition tummy tuck is very different than the standard tummy tuck and was trade marked by Dr. Agha in 2007. The procedure has a low-cut incision that is 1 ½ inches lower than the standard tummy tuck incision and removes about 1 1/2 inches of pubic hair. It therefore lifts the pubic area in every patient and corrects pubic laxity that most tummy tuck patients have. Next abdominal skin and fat are elevated over the muscle in a specific way that was developed by Dr. Agha. The abdominal muscles are then tightened and a sculpted abdominal look created.
The hi-definition abdominoplasty recreates a 3-dimensional not flat, natural-looking but re-defined abdomen that most your gym-going friends will envy.
This technique is reserved for those patients that have excess of the waist tissue in addition to that of the abdomen. In addition to the steps performed in the high-definition tummy tuck, Dr. Agha extends the abdominoplasty incisions over the hip area on each side and removes skin and fat from the waist regions. The extended tummy tuck is a customized procedure. That means the incision can be extended 1 inch or 5 inches more than the full tummy tuck depending on the patient’s needs. The extended tummy tuck is what many weight loss patients who want abdominal correction need, unless they plan to have a circumferential tummy tuck or a more comprehensive lower body lift.
Circumferential Tummy Tuck
Also known as “belt abdominoplasty or belt lipectomy”, this procedure is reserved for those patients who present with lower body laxity. The typical patient is unhappy with the looseness of her/his abdomen, waist excess, and buttocks sagging.
The circumferential abdominoplasty procedure is designed to rid patients of the excess fat and skin all the way around the waistline. The procedure has three components:
A) Tummy tuck to remove the excess abdominal tissue and tighten the abdominal muscle wall
B) Removing the excess tissue at the waist
C) Removal of the lower back/upper buttocks excess skin together with a buttock lift
D) The circumferential tummy tuck is the most basic form of a body lift.
Inverted-T or Fleur-de-lis Tummy Tuck
This procedure is best suited for those patients who have lost significant weight and end up with fullness of their sides and flanks as well as a large hanging pannus. The patient often starts with an apple body shape or V-shape and presents with both vertical and circumferential abdominal tissue laxity after weight loss. These patients often will have very wide aprons that start below the rib cage and extend as a lower body pannus. The width of the apron dictates what type of a tummy tuck is needed. For these patients, a standard or full tummy tuck will only correct for the vertical laxity of the abdomen and does little for the loose sides and flanks. Hence, a Fleur-de-lis tummy tuck or a flankplasty may be needed in order to tighten the abdominal circumference.
The Fleur-de-lis procedure combines the use of a horizontal incision over the lower abdomen with a vertical incision on the mid-abdomen, forming an “inverted-T” pattern. Through this inverted T incision, the abdominal muscles are tightened, the excess circumferential abdominal tissue is removed via the vertical part of the incision, and the lower abdominal tissue excised through the horizontal incision.
Fleur-de-lis abdominoplasty is also suitable for those patients who already have a large midline incision due to previous abdominal surgery or open gastric bypass surgery.
Whereas most plastic surgeons are quick to perform a fleur-de-lis, Dr. Agha will make every effort not to place an unsightly scar on his patients.
Dr. Agha personally prefers a flankplasty to a fleur-de-lis abdominoplasty since the incisions are placed on the sides rather than the center of the abdomen. Also, with flankplasty, not only the abdomen is tightened circumferentially, but also the back skin is pulled forward and tightened.
Correction of the abdominal laxity involves both the abdominal region and its surrounding tissues. Some weight loss patients present with a roll of tissue below the breasts and over the lower chest. In these cases, the excess tissue appears as a roll that extends from the front towards the back. Typically, these patients would have had a larger upper body before the weight loss, such as a V-shaped body shape. In these patients with upper abdominal rolls, correction of lower abdominal tissue excess through a tummy tuck does very little for the lower chest/ upper abdominal skin rolls. This is because of the connective attachments of the upper abdominal rolls to the rib cage. To get rid of these rolls, a reverse abdominoplasty is required to remove excess skin and fat in the area under the breasts.
A reverse tummy tuck is a relatively uncommon procedure that can be used in conjunction with breast reduction or breast lift or an upper body lift. Dr. Agha performs a reverse tummy tuck in 2 different ways depending on the need of the patient.
1) In a female patient, when the mammary crease and the breast are low on the chest, usually over the 11-12 rib rather than the 6 rib, a reverse tummy tuck with reconstruction of the mammary crease at a higher position results in a tighter upper abdomen, a higher mammary crease, and breast positioning over the mid-chest. In these cases, an incision is made along the mammary crease through which the breast unit is lifted and the mammary crease is reconstructed about 2 inches higher. The lifting of the mammary crease results in tightening of the upper abdomen without actual removal of the upper abdominal skin and tissue.
2) When the breast and mammary crease have not moved down on the chest, then a reverse tummy tuck is only needed in order to tighten the upper abdomen. In these cases, an incision is made along the mammary crease through which a crescent of upper abdominal skin and tissue is removed and the upper abdomen is lifted and secured at the mammary crease incision.
Diagram is needed
Sometimes, the crescent excisions under each breast on the left and right side are joined together across the midline to excise a larger segment of lower chest and upper abdominal skin excess.
A reverse tummy tuck is best done at the time of a bra-line upper body lift and breast reshaping procedures. Dr. Agha has extensive experience with this procedure and has published his experience with over 88 reverse abdominoplasty surgeries with reconstruction of mammary crease at a higher position. This is the highest series of published reverse abdominoplasties. (Management of upper abdominal laxity after massive weight loss: reverse abdominoplasty and inframammary fold reconstruction. Agha-Mohammadi S, Hurwitz DJ. Aesthetic Plast Surg. 2010 Apr;34(2):226-31).
Abdominoplasty for Weight Loss Patients
As has been mentioned above, weight loss patients often have sagging skin of the upper and lower body. The degree of the skin laxity varies from one patient to another and some may opt for a less extensive body contouring procedures.
However, most weight loss patients benefit from an extended tummy tuck or circumferential abdominoplasty or a lower body lift. When a patient does not want a circumferential incision, an extended tummy tuck uses a customized longer tummy tuck incision to not only remove lower abdominal skin excess, but also some of the waist tissue on the sides. For other patients who want a circumferential tummy tuck, a 360-degree incision on the lower abdomen and back is used to remove excess abdominal tissue, waist tissue, and lower back/upper buttocks hip roll. In both of these tummy tuck surgeries, the vertical incision of Fleur-de-lis is reserved for those rare patients who have lost significant abdominal girth and have a wide abdominal pannus.
Is Circumferential Abdominoplasty the Same as a Lower Body Lift?
Although most plastic surgeons use the terms circumferential abdominoplasty, belt lipectomy, and a lower body lift interchangeably, Dr. Agha believe that the lower body lift is a more comprehensive surgery and should not be mistaken for a circumferential abdominoplasty.
Circumferential tummy tuck and lower body lift differ in the amount of work done. Both procedures utilize the same 360 degrees incision, but in our practice, a high-definition lower body lift includes:
1) Tummy tuck to remove the excess abdominal tissue
2) Monsplasty- correction of pubic laxity and sag
3) Removal of the excess tissue at the waist
4) Outer thigh lift
5) Anterior thigh lift (thigh front lift)
6) Removal of the lower back excess skin together with a buttock lift
7) Liposuction of lower back, love-handles, and waist. In Dr. Agha’s practice, lower body lift is typically performed in association with liposuction to bring about a better body contour and shape. Dr. Agha works to completely re-contour the body shape, enhancing and showcasing the patient’s weight loss success with a sculpted and tightened body.
Thus, a high-definition lower body lift offers torso and thigh correction while the circumferential abdominoplasty is a torso correction and does little for the thighs.
To learn more about recovery after a tummy tuck, please visit our tummy tuck pages here.