David N. Hing, MD, FACS – Tummy Tuck, Body Lift & Arm Lift
Panniculectomy
(Abdominoplasty, “Tummy Tuck”)
Panniculectomy (Abdominoplasty, “Tummy Tuck”)
Description of Procedure
The abdominal pannus is the loose fold of skin that hangs over the pubis following significant weight loss. It consists of skin and fat tissue. Stretching of the rectus muscles (the sit up or “six pack” muscles) to the side may contribute to the fullness in the lower abdomen.
Panniculectomy is the term used for the surgical removal of the abdominal pannus. It uses an incision which passes from hip to hip across the pubis along its lower edge. The upper incision passes from each hip to the belly button area. The skin and fat between these surgical incisions is removed. The expanse of skin above the belly button is loosened from the underlying abdominal muscle. If the muscles can be tightened, they are pulled to the middle with sutures. Hernias, that can occur after bariatric surgery, can be repaired as well. The upper edge is pulled downward to tighten the abdomen. The belly button is brought through the skin.
The incisions are designed to be hidden in the groin and pubic creases and to be covered by clothes and sportswear. Multiple layers of sutures are used to close the wound and produce a narrow scar.
Compression garments may be used to control swelling. Drains, soft plastic sterile tubes, are used to remove serum fluid from under the wound. Left undrained, the serum accumulation could stretch out the skin closure and undo the tightening achieved by the panniculectomy.
Am I a Good Candidate for a Panniculectomy?
Patients who benefit from panniculectomy surgery have:
• Loose skin in their abdomen draping over the pubic area.
• Reached a stable point in their weight loss.
• Medical indications for panniculectomy such as skin irritation, infection, or itching and blistering in spite of medical management, or back pain caused by the excessive weight pulling from their abdomen onto the spine.
• Documentation from other physicians or specialists attesting to the medical problems and the inability of those physicians to control the problems using non-surgical treatments.
Each patient will vary in their anatomy and proportions of loose skin and fat from the next patient. The decision to perform panniculectomy will depend on the one on one examination with your surgeon and your priorities for body contouring.
Standard Procedure Techniques
All panniculectomy techniques remove the extra skin and fat in the lower abdominal area, while the patient is positioned on his back. Here, the extra skin is pulled downward and removed in order to remove excess tissue in a vertical or top-down direction.
In many cases, with massive weight loss, the rectus abdominis, or sit up muscles, have been pushed to either side by the previous internal weight gain. After weight loss, they may remain displaced to the side, allowing the internal organs to push outward in the area between the belly button and pubic area. These muscles can be sutured back together in the midline in most cases to strengthen the abdominal muscle wall and flatten the lower abdomen.
Additional Procedures to the Panniculectomy
Not all patients have only vertical skin excess. Some patients may have stretching of their abdomen both vertically and horizontally, that is, side to side. Pulling the extra skin and fat tightly from above downward may not correct certain degrees of horizontal looseness.
An additional removal of skin as a vertical wedge over the midline above the belly button may be necessary. It is sometimes referred to as a fleur-de-lis abdominoplasty. Again, an individual, one on one consultation with your plastic surgeon will determine whether you need this to give a better result.
Liposuction may be useful in some patients, to thin areas lying separate from the panniculectomy surgical incisions. Done too close to the panniculectomy operative area, liposuction can compromise the circulation and healing near the panniculectomy. A thorough discussion following examination is essential to determining a comprehensive approach to your priorities and whether liposuction can improve your outcome and satisfaction.
Benefits/Advantages/Options
• Panniculectomy controls extra skin and fat as well as muscle laxity.
• Can be combined with breast or arm contouring procedures.
• Can be combined with liposuction in selected areas.
Other Considerations
The panniculectomy should be performed when the patient is as close to their goal body weight as possible. For example, if a patient has panniculectomy surgery and then loses weight, the tightened abdomen can loosen and show sagging.
Liposuction may be used to thin the upper abdomen before the panniculectomy to prevent moving thick skin and fat from above the belly button to the pubic area. It is safest to do the liposuction as a separate operation and wait a period of months before following up with a panniculectomy. These situations require consultation and examination by your Board Certified Plastic Surgeon.
Risks/Complications/Patient Safety
• Seromas (collections of serum fluid below the wound) requires the use of drains.
• Delayed wound healing along the incision may occur with stretching across the wound edges.
• Numbness or loss of sensation along the incision.
• Slight asymmetries in spite of careful planning.
• Bleeding and bruising, rarely requiring blood transfusions.
• Blood clots to the lungs (pulmonary emboli) are rare. Calf compression stockings applied at the time of surgery have significantly reduced this problem.
Recovery Process
Surgical drains, sterile soft plastic tubes, are placed to remove the serum fluid which may accumulate under the skin wounds. You, the patient, will be taught how to measure the amount of output on a daily basis. The drains are removed in the office once the fluid output decreases to a low level. This typically occurs within one to three weeks after surgery.
Sutures in the closure of the panniculectomy may require removal. These are removed in the office about 2 weeks after surgery.
Compression garments are used to control swelling and to smooth and flatten the skin. They may be placed over the abdomen at the time of surgery, or later, at the surgeon’s discretion.
Activity is determined by the progress of the healing. Tightening of the rectus muscles may prevent heavy lifting for six weeks. Movement is easier once the drains are removed.
Patients are admitted to the hospital overnight. A bladder catheter, placed during surgery, is usually removed the next day. Once the patient is comfortable on oral pain medications, he/she can be released to go home.
Frequently Asked Questions
Will it be painful? For the most part, pain is adequately controlled by oral pain medications. The patient may require pain medications by injection or intravenously the first day, but oral medications are enough to control discomfort after that.
Will there be scarring? There will be a scar where there is an incision. Every effort will be made to produce as thin a scar as possible, but there will always be some evidence of the surgery. Pictures of such operations performed by your surgeon can give examples of the scars.
What are some short term side effects? Numbness or decreased sensation can occur in the lower abdomen below the belly button and above the pubis. Seromas may occur even after the drain removal. If they occur, they may require removal by aspiration using a needle and syringe. Swelling after surgery may continue for four to six weeks and require the use of a compression garment.
What type of anesthesia will be used? Most panniculectomy operations are done under a general anesthesia. After the patient is put to sleep with an intravenous sedative, a breathing tube is placed in the mouth. A combination of anesthetic gases and medications controls the patient’s discomfort until the surgery is completed.
