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Abdominoplasty by Design: Good Aesthetic Planning Avoids an Unfixable Problem

January 10, 2016- By Douglas Mackenzie

Writing this post was prompted by two recent patients I saw that had the same problem with their abdominoplasty scars that they got elsewhere, by different surgeons. They actually came to me for other reasons, but the subject of their abdominoplasty scars came up. They already knew that not much could be done about their situation.

Sometimes surgical outcomes are not what we want or expect. Usually these unexpected outcomes arise from minor complications, rarely from major complications, and often just from the unpredictable way the body heals and scars. The good news is that in the vast majority of these cases, we can fix the problem. A re-operation, typically much less involved than the original surgery, often done under local anesthesia in the office, usually does the job. Rarely, it takes more than one procedure. But the point is, we have a fixable situation, and we fix it.

The really tough problems that don’t lend themselves to easy solutions are usually due to bad planning, poor aesthetic sensibility, bad judgement, or a combination thereof. The problem both these women had fell in this category.

First, a brief description of abdominoplasty (tummy tuck) and a walk through the procedure. Sorry for the detailed and maybe confusing technical description, but it will help understand how poor planning leads to bad results. This discussion applies to common tummy tucks for most people, not for the extremes of mini tummy tucks or body lifts.

With a tummy tuck, a plastic surgeon strives to remove excess skin and fat from the central and lower abdomen, tighten the underlying abdominal wall (often stretched from pregnancy), and leave scars that are as discreet and hidden as possible. Liposuction is often done, especially around the waist, to compliment the abdominal contouring of the tummy tuck.

Diagram showing sequence of steps of a tummy tuck (abdominoplasty)
The basic sequence of steps of a tummy tuck (abdominoplasty)

Most women (especially those who have had children) have the entire width of skin and the underlying fat layer removed from the belly button down to the pubic area. The top border of this removal arcs downward to each side from the umbilicus, while the bottom border arcs upward to each side from the pubic area. This area narrows and meets at the hips, to produce a wedge-shaped removal of skin and fat. This removal includes any previous c-section scar, and imagining a c-section scar location is a good indication of where the resulting abdominoplasty scar should fall, curving upward toward the hips on each side.

With that large removal of skin and fat, the upper skin and fat layer must be undermined all the way to the rib cage, and brought down to cover the gap. This covers the umbilicus (belly button), which contrary to popular belief isn’t actually moved, and a small hole is made to bring up the umbilicus. A scar results, but tends to be fairly discreet within the contours of the belly button.

The long lower scar should be covered completely or nearly so by underwear and most bikini bottoms, depending somewhat on the style. The scar should be nowhere near the belly button; it should NOT be visible across the abdomen.

Now, here is a potential problem. If the remaining upper skin is not very loose, or not very wide, it may not stretch all the way down to the pubic area. So there are basically two choices at hand. Less of a width of skin is removed, by either bringing the upper incision lower, or the lower incision higher. Bringing the lower incision higher is technically easier, but then leaves a scar above where it should be, in the visible area of the lower abdomen. One of the women I saw had her scar several centimeters above an existing c-section scar, which should have given the surgeon a clue where to put the lower incision! Not good. The other alternative of keeping the lower incision low while moving the upper incision down will keep some skin that when released from around the umbilicus, has the hole of the umbilicus within it. That hole now migrates downward as the upper skin is brought towards the pubic area for closure. The hole must be closed and a small vertical scar in the center lower abdomen results. Despite this small additional scar, the aesthetic result is much better as the main long scar stays low and covered.

Women after tummy tucks should feel comfortable wearing a two piece bathing suit again. If their anatomy or lack of upper skin stretch dictates that their procedure needs to be modified, a small low vertical scar will not preclude them from feeling good about their result and wearing a two-piece. However, if the bad decision of raising the lower scar is made, the unattractive situation of a visible horizontal scar across the lower abdomen will result. Both of these women said they would never again wear a two piece bathing suit.

But it gets worse. There is really no good option to fix this problem. Lowering the scar would require expanding the skin between the umbilicus and the scar – a long ordeal with staged surgeries, significant risks, and no assurance of a great outcome. If the original procedure was done long ago, it’s possible that the upper abdominal skin has relaxed and loosened enough that essentially doing another complete tummy tuck could be done. I’ve seen tattoos do an awesome job concealing surgery scars, especially abdominoplasty scars, and for women with bad tummy tuck scar placement that’s not a bad option.

During your tummy tuck consultation, have the plastic surgeon describe exactly where your scars will be located. If you have concerns, or you’re told that you can’t have a low scar placed just above the pubic area, find a different plastic surgeon!

– Douglas Mackenzie, MD, Pacific Plastic Surgery, Santa Barbara, CA

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