Abdominoplasty procedure - Mr Olivier Branford · dure, with 129 000 abdominoplasty pro-cedures...

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484 Journal of AESTHETIC NURSING December 2018 Volume 7 Issue 10 SYRINGE TO SCALPEL ▼ (separation of the ‘six pack’ muscles due pregnancy). Contraindications Abdominoplasty is contraindicated in smokers due to the higher risk of infec- tion in these patients. Smoking should be discontinued for six weeks prior to surgery and a minimum of four weeks after, or un- til fully healed. Those who are not fit to undergo general anaesthesia should also not have abdomi- noplasty procedure. Consultation As ever, a comprehensive consultation is essential. This will cover: The patient’s desired aesthetic outcome Medical conditions, risk factors, medical treatments and drug and dressing allergies Current medications (patients should avoid taking aspirin, other blood thinners and anti-inflammatory drugs, as these increase bleeding), vitamins, herbal supplements (which should be stopped two weeks preoperatively due to often poorly studied or unknown effects on post-surgical bleeding), alcohol, tobacco and drug use Previous surgery Whether the patient is planning pregnancy—although this is not an absolute contraindication to abdomi- noplasty, it is best to wait until after pregnancy, as the results will be more stable and patients who have had previous abdominoplasty who become pregnant will need more careful monitoring during pregnancy. A flat and well-toned abdomen is something many of us strive for. The most common approaches for obtaining this are physi- cal activity and weight control. However, sometimes these methods cannot enable us to achieve our goals. Exercise cannot tighten loose skin or reapproximate sepa- rated muscles. Even individuals of other- wise normal body weight and proportion can develop an abdomen that protrudes, or is loose and sagging. The most com- mon causes of a protruding or loose abdo- men include: Ageing Heredity Pregnancy Prior surgery Significant fluctuations in weight. According to the latest 2017 US figures, abdominoplasty continues to be the fifth most common cosmetic surgical proce- dure, with 129 000 abdominoplasty pro- cedures being performed each year in the US alone, a 2% increase over the figures from 2016, and a 107% increase since 2000 (American Society of Plastic Surgeons, 2017). What tummy tuck surgery can’t do A tummy tuck is not a substitute for weight loss or an appropriate exercise pro- gramme. Although the results of a tummy tuck are technically permanent, the posi- tive outcome can be greatly diminished by significant fluctuations in weight. For this reason, individuals who are planning sub- stantial weight loss, or women who may be considering future pregnancies, would be advised to postpone a tummy tuck until after this time. It is important to note that a tummy tuck cannot correct stretch marks, although these may be removed or somewhat im- proved if they are located on the areas of excess skin that will be excised. Who performs abdominoplasty and where? Abdominoplasty is most commonly per- formed by plastic surgeons, who are com- prehensively trained in the standards of care for the procedure and are fluent in managing potential complications that may arise. Abdominoplasty in the United Kingdom should be performed in a facil- ity or hospital that is inspected at regular intervals by the Care Quality Commission (CQC) in order to ensure patient safety and best practices, by plastic surgeons who are on the specialist GMC register for Plastic Surgery. Candidates for abdominoplasty Those who are physically healthy, and are at a stable weight Those with realistic expectations Those who are bothered by the appearance of their abdomen Those with rectus muscle divarication Abdominoplasty procedure Abdominoplasty, also referred to as tummy tuck, involves removing excess skin and fat, and may include tightening separated muscles, creating an abdominal profile that is smother and firmer. Typically combined with liposuction to achieve optimal results, abdominoplasty includes mini, full, extended, circumferential or vertical types. In this article, Olivier Alexandre Branford, an aesthetic and reconstructive plastic surgeon, provides an up-to-date overview of this procedure OLIVIER BRANFORD Plastic Surgeon, Cadogan Clinic, London e: olivier.branford@ icloud.com © 2018 MA Healthcare Ltd

Transcript of Abdominoplasty procedure - Mr Olivier Branford · dure, with 129 000 abdominoplasty pro-cedures...

Page 1: Abdominoplasty procedure - Mr Olivier Branford · dure, with 129 000 abdominoplasty pro-cedures being performed each year in the US alone, a 2% increase over the figures from 2016,

484 Journal of AESTHETIC NURSING ► December 2018 ► Volume 7 Issue 10

SYRINGE TO SCALPEL ▼

(separation of the ‘six pack’ muscles due pregnancy).

ContraindicationsAbdominoplasty is contraindicated in smokers due to the higher risk of infec-tion in these patients. Smoking should be discontinued for six weeks prior to surgery and a minimum of four weeks after, or un-til fully healed.

Those who are not fit to undergo general anaesthesia should also not have abdomi-noplasty procedure.

Consultation As ever, a comprehensive consultation is essential. This will cover:

► The patient’s desired aesthetic outcome ► Medical conditions, risk factors, medical treatments and drug and dressing allergies

► Current medications (patients should avoid taking aspirin, other blood thinners and anti-inflammatory drugs, as these increase bleeding), vitamins, herbal supplements (which should be stopped two weeks preoperatively due to often poorly studied or unknown effects on post-surgical bleeding), alcohol, tobacco and drug use

► Previous surgery ► Whether the patient is planning pregnancy—although this is not an absolute contraindication to abdomi-noplasty, it is best to wait until after pregnancy, as the results will be more stable and patients who have had previous abdominoplasty who become pregnant will need more careful monitoring during pregnancy.

A flat and well-toned abdomen is something many of us strive for. The most common approaches for obtaining this are physi-

cal activity and weight control. However, sometimes these methods cannot enable us to achieve our goals. Exercise cannot tighten loose skin or reapproximate sepa-rated muscles. Even individuals of other-wise normal body weight and proportion can develop an abdomen that protrudes, or is loose and sagging. The most com-mon causes of a protruding or loose abdo-men include:

► Ageing ► Heredity ► Pregnancy ► Prior surgery ► Significant fluctuations in weight.According to the latest 2017 US figures,

abdominoplasty continues to be the fifth most common cosmetic surgical proce-dure, with 129 000 abdominoplasty pro-cedures being performed each year in the US alone, a 2% increase over the figures from 2016, and a 107% increase since 2000 (American Society of Plastic Surgeons, 2017).

What tummy tuck surgery can’t doA tummy tuck is not a substitute for

weight loss or an appropriate exercise pro-gramme. Although the results of a tummy tuck are technically permanent, the posi-tive outcome can be greatly diminished by significant fluctuations in weight. For this reason, individuals who are planning sub-stantial weight loss, or women who may be considering future pregnancies, would be advised to postpone a tummy tuck until after this time.

It is important to note that a tummy tuck cannot correct stretch marks, although these may be removed or somewhat im-proved if they are located on the areas of excess skin that will be excised.

Who performs abdominoplasty and where?Abdominoplasty is most commonly per-formed by plastic surgeons, who are com-prehensively trained in the standards of care for the procedure and are fluent in managing potential complications that may arise. Abdominoplasty in the United Kingdom should be performed in a facil-ity or hospital that is inspected at regular intervals by the Care Quality Commission (CQC) in order to ensure patient safety and best practices, by plastic surgeons who are on the specialist GMC register for Plastic Surgery.

Candidates for abdominoplasty

► Those who are physically healthy, and are at a stable weight

► Those with realistic expectations ► Those who are bothered by the appearance of their abdomen

► Those with rectus muscle divarication

Abdominoplasty procedureAbdominoplasty, also referred to as tummy tuck, involves removing excess skin and fat, and may include tightening separated muscles, creating an abdominal profile that is smother and firmer. Typically combined with liposuction to achieve optimal results, abdominoplasty includes mini, full, extended, circumferential or vertical types. In this article, Olivier Alexandre Branford, an aesthetic and reconstructive plastic surgeon, provides an up-to-date overview of this procedure

OLIVIER BRANFORD

Plastic Surgeon, Cadogan Clinic, London e: olivier.branford@ icloud.com

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▼ SYRINGE TO SCALPEL

The surgeon should also: ► Assess for abdominal scars and hernias ► Take waist and maximum abdominal measurements, with careful assessment of flank fullness which often requires simultaneous liposuction for optimal results

► Take standard clinical photographs ► Discuss any risks or potential complica-tions

► Discuss what type of abdominoplasty is best suited to the patient (mini/full/extended/circumferential/’Fleur-de-lis’)

► Discuss the ability to have a successful pregnancy after abdominoplasty

► Depending on the type of abdomino-plasty and patient characteristics some abdominoplasties may be performed as day case procedures or more typically as inpatient stay for one to two nights. Patients should arrange for someone to drive them home upon discharge from hospital.

What types of abdominoplasty are performed?Mini abdominoplastyMini abdominoplasty is indicated in pa-tients with mild to moderate skin excess in the lower abdomen and mild or infra-umbilical divarication. This type of proce-dure avoids the need for umbilicus repo-sitioning and scar.

Full/traditional/standard abdominoplasty Full abdominoplasty (also referred to as ‘tra-ditional’ or ‘standard’ abdominoplasty) is indicated in patients with severe skin excess and severe rectus divarication. This type of procedure involves removal of the abdomi-nal skin and fat up to a point just above the umbilicus.

Fleur-de-lis abdominoplasty Fleur-de-lis abdominoplasty procedure is indicated in those with vertical skin ex-

cess, and is particularly suited to those who have experienced significant weight loss. This leaves a vertical midline scar in addition to the lower scar.

Extended abdominoplastyThis is indicated when the loose skin extends into the flank area (lower sides below the waist laterally).

Circumferential abdominoplasty or ‘body lift’ Circumferential abdominoplasty (also known as ‘body lift’) is a 360° abdomino-plasty procedure that involves the removal of loose skin and fatty tissue of the lower back and buttocks, in addition to the ex-tended tummy tuck.

Type of anaesthesia usedAbdominoplasty is performed under gen-eral anaesthesia supplemented by local anaesthesia.

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How abdominoplasty is performedAbdominoplasty procedure is typically combined with liposuction, in order to remove fat and improve the contours of the abdomen.

The incision for abdominoplasty is made in the swimwear/underwear line in order to minimise any visible scarring, as low as allows closure after excision of the tissue, in the pubic hairline. It is useful if the patient brings small underwear with them to the hospital to allow the surgeon to mark the incision inconspicuously.

A full tummy tuck requires a curved incision that extends at least from the anterior pelvis on either side and an inci-sion around the navel. The length of the main incision will be determined by the amount of excess skin the patient has. Once the abdominal skin is lifted, the underlying weakened abdominal muscles are repaired if required. This does lead to more pain in the immediate post-opera-tive period, but can help reduce the risk of bulge centrally above the umbilicus, and improves core strength.

The upper abdominal skin is pulled down like a window blind. The excess skin is trimmed and the remaining skin is su-tured together without excessive tension, although the hips may need to be flexed to allow closure. Incisions are closed with three layers of sutures. A new opening for the navel is created, which is passed through to the surface and sutured into position.

The ideal umbilicus should be planned to be retracted inferiorly to minimise scar visibility when the patient looks down, ideally with superior hooding and a nar-row vertical axis. Surgeons may use no drains (usually the surgery is then com-bined with deep quilting sutures to close the cavity), or one to two drains after full abdominoplasty. Skin adhesive and surgi-cal tape is applied.

RecoveryPost-procedure, pain can take one to two weeks to subside and tightness may be felt for a few weeks. Aches may occasionally be felt intermittently during the healing

period for several months until the inter-nal scar tissue softens. These aches may be improved by gentle massage of the area.

Patients are fitted with a post-surgical garment or abdominal binder to give support, which may help with speedier resolution of bruising and swelling. This should be worn day and night for 4–6 weeks. It is important that any creases in the garment are smoothed out in order to prevent ridges from forming during heal-ing. Showering may be commenced on day one post-operatively, and wounds/dressings should be allowed to fully dry before reapplying the garment.

Driving should be discontinued for four weeks, or until the patient may be fully in control of their vehicle in an emergency situation.

Strenuous exercises should also be avoid-ed for at least 6 weeks, or 12 weeks if the muscles are tightened.

It may take 6–12 weeks for all of the post-operative swelling to resolve. Results con-tinue to improve for 12–18 months as inter-nal and external scarring softens. ©

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Abdominoplasty procedure is typically combined with liposuction, in order to remove fat and improve the contours of the abdomen

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▼ PSYCHOLOGY

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CPD reflective questions ► What types of abdominoplasty are available?

► What complications may occur? ► What are the recommendations during recovery?

Key points ► Abdominoplasty is contraindicated in smokers

► Patients should aim for a stable weight prior to surgery

► Abdominoplasty is frequently combined with liposuction

► Swelling may last 6 to 12 weeks and final results may take many months to see as scars mature and tissues soften

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ComplicationsPossible risks associated with abdomino-plasty procedure include:

► Risks related to anaesthesia ► Bleeding or haematoma (a collection of blood which usually needs evacuating)

► Infection, especially in smokers ► Fluid accumulation (seroma) in up to 20% of patients, which may require one or more drainage sessions using a needle through the skin. This is usually done in the dressing clinic at 1–2 weeks post-surgery

► Numbness or other changes in skin sensation

► Poor wound healing, especially in those with a body mass index of over 30

► Skin loss ► Unfavourable scarring. This may include overactive scarring, in which it can take 12–18 months for scars to fully mature and appear less pink and flat; stretched scars; indented scars; or asymmetrical scars

► Asymmetry ► Persistent pain ► Recurrent looseness of skin

► Possibility of revision surgery including ‘dog ears’, also known as ‘standing cones’, which are the pleats at either end of the scar. These require the scar to be lengthened by new incisions

► Fatty tissue found deep in the skin might die (fat necrosis) and become hard

► Urinary retention ► Deep vein thrombosis, cardiac and pulmonary complications.

ConclusionsAbdominoplasty may give a huge boost to self-confidence and remains a safe and ef-fective procedure. Its enduring popularity in the top five cosmetic surgery procedures is a testament to this. It should be treated as both a cosmetic and functional proce-dure, with optimal planning to ensure inconspicuous scars and optimised body contouring, with reapproximation of sepa-rated muscles when required.

ReferencesAmerican Society of Plastic Surgeons. 2017 Plastic

surgery report. 2017. https://tinyurl.com/y7989ltx (accessed 15 November 2018)

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