714-834-0101
Abdominoplasty (tummy tuck) is one of the most popular cosmetic surgery procedures requested by my patients.
Over the past several years, there has been an emphasis on using evidence based medicine (using published data to improve the practice of medicine). This data is compiled from Journal of Plastic and Reconstructive Surgery, Volume 126, Number 6, December 2010.
There are four levels of strength when looking at research papers:
Level I
High quality, multicenter or single center study. This is as good as it gets.
Level II
Lesser quality study, but still of great value.
Level III
Retrospective chart review study, case control study, or systematic review of these studies
Level IV
Case series study
Level V
Expert opinion, case report or clinical example
Ideally, all studies should be Level I in terms of strength. However, some procedures are very difficult to design strong research around, due to multiple factors involved. Levels 2-5 are still of interest and value, but less than level I.
There is no question smoking will significantly affect wound healing after abdominoplasty (Level I, Level II evidence). I ask all my patients who smoke to refrain from smoking for at least 4 weeks before surgery and 4 weeks after. This includes second hand smoke (probably worst than first hand smoke due to the by-products inhaled) and nicotine patch or gum. Nicotine is a powerful vasoconstrictor (chokes ALL the blood vessels in our body) and will affect wound healing. The risk is also proportional the number of cigarettes smoked over a lifetime. Smokers on average have a 12-14 fold increased risk of wound complications compared to non-smokers. I hope I have made my point!
Weight is another risk factor for complications following abdominoplasty. The main complications are wound breakdown and seroma (Level II evidence). Seroma is collection of fluid under the abdominal skin after surgery. Small seromas may absorb with time. However, some require weekly aspiration with a needle or even surgery. Obese patients (Body Mass Index over 30) and patients who had resection over 1500gm (3.3 pounds) were at higher risk of pulmonary embolus (level II evidence).
Losing weight before abdominoplasty in obese patients will significantly reduce the risk of above complications (Level II evidence). Ironically, patients who lost weight after weight loss surgery had a HIGHER risk of complications compared to patients who lost weight naturally (Level II evidence). The risk of pulmonary embolus is also higher for patients who are on hormone replacement therapy or birth control pills (Level II evidence). For this reason, I have always requested my patients stop taking the above medication two weeks prior to their surgery date.
After seroma, infection is the second most common complication following abdominoplasty. The rate is reported to be around 8% (8 infections for every 100 abdominoplasty performed). I assume this percentage includes even small infections which typically resolve with oral antibiotics and/or dressing changes. In my experience over the past ten years, I have never taken a patient to the operating room for an infection.
A study of 200 patients undergoing abdominoplasty, the risk of infection was significantly higher in patients who did not receive antibiotics before surgery, compared to patients who did (Level II evidence). No difference was seen in patients who received additional antibiotics after surgery versus patients who received the single dose pre-operatively.
In terms of pain control after surgery, there is level II evidence infiltration of a numbing medication such as xylocaine will decrease need for pain medication after abdominoplasty. The use of celecoxib (an anti-inflammatory medication similar to ibuprofen) had faster recovery compared to patients who did not (Level I evidence).
Recently, there have been several studies advocating “tacking stitch” method to decrease the risk of seroma after abdominoplasty. In this method, the underneath of the skin flap is sutured down to the abdominal wall. The goal is to minimize or eliminate any dead space or movement of the abdominal skin flap, thus reducing the risk of seroma formation. This surgical method, however, results in longer operative time (thus increasing risk of deep venous thrombosis and potentially pulmonary embolus), and lower drain output. However, there was no overall difference in the rate of seroma between patients who had the sutures and the group who had the drain (Level I evidence). Patients who had no drain or sutures had a significantly increased risk of seroma formation.
Overall, I am pleased with my approach to abdominoplasty. However, there is always room for improvement!
I do follow strict criteria screening patients who are obese or who smoke. I do take pre-cautions before surgery to minimize risk of deep venous thrombosis and pulmonary embolus. All patients receive sequential leg compression devices during surgery. Higher risk patients also receive anti-coagulation. In terms of antibiotics, all my patients receive one dose before surgery and three days after surgery. Honestly, the antibiotics given after surgery were for my own piece of mind (it made me feel better!) However, since there is no data to prove their efficacy, I will discontinue routine post-operative antibiotics. For the past 5 years, I have infiltrated the fat under the abdominal skin with the same solution used in liposuction (a combination of numbing medication with a vasoconstricting medication). It is comforting to know the use of such medication improves pain control after surgery. I have always used drains for my abdominoplasty sutures. Given the above evidence, I do not see any benefit in using the tacking suture technique. I have recently switched to Flexeril (a muscle relaxant) and Ibuprofen for pain control after surgery. I have been very pleased using this combination for my breast augmentation patients. This minimizes the risk of nausea/vomiting and especially constipation commonly seen with narcotic medication.
Michael A. Jazayeri, M.D. is a board certified plastic surgeon with over 10 years of experience. His office is located in Orange County, California. To schedule a complimentary consultation, please contact us at 714-834-0101.
Élan Institute for Plastic Surgery
2010 East First Street, Suite 270
Santa Ana, CA 92705
Phone: 714. 834. 0101
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