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Are you considering lipo-abdominoplasty and curious about what happens in the operating room? Some patients would rather not know, but others get a sense of relief from knowing how the procedure works. Not only is surgery fascinating, but understanding the steps to performing a tummy tuck helps takes some of the mystery out of it. After you read this, you’ll walk away knowing that it isn’t so scary after all. That goes double if you have a qualified surgeon you can trust to perform the surgery right.

Today, we are going to take an inside look at what happens in a liposuction-assisted abdominoplasty. This article provides a framework for everything that happens on the operating table, start to finish. All the steps are backed by extensive medical research. The goal of this procedure is to lower complication risks and minimize discomfort after surgery. And if you think that tummy tucks require drains, think again. My lipo-abdominoplasty method is a drainless technique. That means less pain and an easier recovery for patients after surgery.

It is worth mentioning that I no longer perform this specific technique today. These days, I prefer VASER lipo-abdominoplasty, which I have been doing since 2016. I’ll talk more about that in a future blog post. However, many of the principles that guide how I do the operation are the same. Performed correctly with the steps described here, this surgical method gives patients beautiful results and a safer surgery.

Are you ready to learn all about how the surgery is done? Read on to learn more.

 

What is lipo-abdominoplasty?

First, let’s clear the air on something. A lipo-abdominoplasty is not the same as a standard tummy tuck with liposuction. You can have a regular tummy tuck with liposuction added, but a lipo-abdominoplasty is an entirely different procedure. Lipo-abdominoplasty has many benefits over a traditional abdominoplasty with lipo.

If you are interested in a tummy tuck with lipo, it is important to be clear about which type of surgery will be performed. The difference between lipo-abdominoplasty and the older abdominoplasty with liposuction is how the initial dissection is made. In lipo-abdominoplasty, the dissection is made using liposuction (which has many benefits), whereas a standard tummy tuck (with or without lipo) uses a normal incision.

Lipo-abdominoplasty allows you to get lipo on your central abdomen, flanks, and all other areas that need liposuction. In the older method, you can really only get liposuction on the flanks. It doesn’t allow you to refine the middle of your tummy using liposuction. That is unfortunate because this is a common “problem area” after pregnancy or weight loss that can benefit greatly from lipo.

How can you tell the difference? The giveaway is if your surgeon uses drains. Drains are a hallmark of the old tummy tuck. In lipo-abdominoplasty, drains aren’t necessary.

 

My approach to surgery

I have found that the more aggressively we approach removing belly fat, the higher the level of patient satisfaction. By aggressive, I simply mean taking out as much fat as possible to give your body a beautiful, proportional shape. Adding liposuction to the procedure helps accomplish this. It also improves the safety of the procedure by limiting how much tissue needs to be cut.

Many years ago, it was considered unsafe to perform tummy tuck surgery and liposuction together. Thanks to advancements in science, today we can safely do both at the same time. Research shows that combination techniques such as this are proven safe when the correct steps are taken during surgery. Patient are often much happier with their results using a combination approach, compared to those who have a tummy tuck alone.3

Surgeons always want patients to report high satisfaction ratings. However, the choice of technique goes beyond patient happiness. Making surgery safer is extremely important, as are reducing pain and inconvenience after surgery. This benefits both the patient and the surgeon. Performing multiple procedures at once has proven benefits, and doing so can be more effective than abdominoplasty alone.8

 

Then and now: Advancements in tummy tuck surgery

First, let’s start with a brief overview of how surgeons approached tummy tucks in the past compared to the method we use now. Starting with basic abdominoplasty, we will delve into the research showing why lipo can be safely added to a tummy tuck, and finally, the exact steps to performing the surgery.

Note: This is how I did the operation prior to 2016. Today, I use the VASER liposculpture technique (the sculpt tummy tuck), but the research and methodology is similar.

 

Abdominoplasty and liposuction have traditionally been separate procedures

In the past, it was considered dangerous to combine abdominoplasty with liposuction. The fear was that the it would compromise too many vascular structures within the abdominal flap, resulting in tissue death. The traditional dissection and heavy undermining that was used at the time damaged important lymphatics and blood vessels in the tummy, so adding liposuction was a bad idea at the time.

Modern tummy tuck techniques like the one we will talk about today keep these vital structure intact, allowing combination procedures to become a possibility. It is also one reason that a tummy tuck without drains is possible. Research shows that intensive liposuction performed alongside modern abdominoplasty even results in better patient outcomes.7

 

Traditional abdominoplasty had limitations

Older abdominoplasty methods involves a wider dissection in the abdominal flap. This compromised blood supply to the surgical site. That falls short of what we can offer patients today. However, it is not that uncommon to see surgeons still performing surgery this way. Today, we can achieve better results without the need for heavy undermining and deep dissection. All it takes are some simple changes in the operating room.

In traditional abdominoplasty, the vascular zone in the inferior abdomen is more or less cut away and discarded. The blood supply to the central abdomen is transected during abdominal flap elevation. Therefore, liposuction to the central abdomen is not recommended.7 This central abdomen is typically an area that would greatly benefit from liposuction, so you can begin to see why traditional abdominoplasty doesn’t give the best results.

But what if the blood supply to the central abdomen could be preserved? Recent research supports that preserving blood supply to the abdominal flap makes extensive lipo possible, without compromising the skin. Certain perforators can be spared during surgery so that this may occur.7 The surgical method described below will show you how I do this..

 

Advancements in Tummy Tucks: High lateral tension abdominoplasty

When Lockwood introduced the high lateral tension abdominoplasty in 1995, everything changed. His technique showed that limited undermining could be done without sacrificing results. Most importantly, it preserved blood flow.5 Surgeons who followed Lockwood’s protocol saw great improvement in the safety and efficacy of the procedure. This new approach to surgery opened up the door for lipo-abdominoplasty as we know it today.

Eventually, it became widely accepted that liposuction and abdominoplasty can be performed at the same time. Adding lipo achieves better fat removal and improves skin tightness. Research also indicates that supplementing modern abdominoplasty with liposuction lowers the risk of complications because less tissue needs to be cut.7,8,10

 

Why a combination approach is better

Studies support the premise that it is safe to perform extensive fat removal with liposuction during abdominoplasty.7,8,10 When performed properly, it has significant aesthetic advantages compared to traditional abdominoplasty, and can reduce complication rates. In my practice, I have seen a decrease in post-surgical problems thanks to a combination technique and operating above the abdominal wall to preserve blood flow.

This approach to abdominoplasty gives better results than classic abdominoplasty alone. Patients loved the results as well. In an evaluation of 360 patients, 99.2 percent of those who received a combination of liposuction alongside abdominoplasty reported satisfaction with their surgical outcome.9

 

Scarpa fascia preservation

A great result is not just about adding liposuction, of course. There are other changes we can make in the operating room to improve patient safety. Limiting the surface area of dissection is a key factor.

In my surgical method, the dissection is made in the tissue above the abdominal wall. A classic plane of dissection should be avoided. A more superficial dissection in the infraumbilical area offers better results to preserve lymphatics.1 Scarpa fascia and deep fat compartment preservation has many advantages. It reduces hematoma and infection rates compared to traditional abdominoplasty while achieving equal (if not better) aesthetic results. Leaving a thin layer on the fascia also decreases seroma formation.4 Importantly, it means I can offer patients a drainless tummy tuck.

 

Tummy tuck complications

I chose this surgical method because it was the safest and most effective tummy tuck available at the time. My goal is to always improve patient safety while maximizing aesthetic results. All surgeries carry a risk of complications, and we always want to keep risks low. Seroma and hematoma are the most common complications for abdominoplasty. The surgical steps I will describe reduce seroma formation, lower the risk of infection by eliminating drains, preserve blood flow, and reduce discomfort after surgery.

No surgeon can guarantee that you won’t have a complication, but the quality of the surgeon and their surgical technique can greatly reduce your risks. Most complications resolve quickly. The most common complications are those that are the least dangerous. Most people walk away from surgery without any complications at all.

For example, if you get a seroma, a simple needle aspiration usually makes it go away. Minor dehiscence or necrosis is very uncommon, but it usually occurs along the incision line where tension is greatest. In the unusual event that dehiscence or necrosis occurs, it is less than 2 cm in size, and often resolves with minor wound care. Infection is also unlikely, but it can usually be spotted early on and easily treated with a prolonged round of oral antibiotics.

Patients over age 40, smoking and obesity can increase the risk of complications. But the surgeon you choose and the method s/he uses can lower your risks. Using the surgical steps below, research suggests the seroma rate is very low at only 1-2%. To date, my patients have had a zero percent seroma rate using this approach. Performed correctly by a qualified surgeon, it is extremely safe.

For more information about complications that can happen see my article: Surviving your tummy tuck: An authoritative guide to the potential risks and complication of an abdominoplasty

 

Tummy tuck without drains

While many surgeons still use drains for a tummy tuck, they are falling out of favor. Nowadays, I do not believe drains are necessary. There is no solid evidence that using drains lowers the chance of seroma development.

Drains are undesirable for many reasons. Aside from being cumbersome, they have been linked to longer hospital stays, increased risk of infection, and worse discomfort after surgery.6 For surgeons who still rely on drains, limiting dissection has been shown to significantly reduce the time that drains are needed.4 Liposuction can be used for this purpose.

In my method, drains are eliminated entirely. There are two reasons that make this possible. First, the use of liposuction limits dissection. Second, the tissue is dissected either just above the Scarpa fascia (which is how I preferred to do it at the time), or just below the Scarpa, taking care not to get too close to the abdominal wall in order to preserve lymphatics.

 

Surgery: A step-by-step guide to the operation

Prior to 2016, I performed lipo-abdominoplasty exclusively. The steps below describe the method I used to maximize aesthetic outcomes for the patient while eliminating the need for drains. The total surgery time is about 4-5 hours. The liposuction part of the procedure can take up nearly a third of the total time.

This method involves intensive liposuction in all areas without worry of bloody supply problems or necrosis. Using liposuction to dissect the tissue, there is no need for the extensive dissection required of a classic tummy tuck. This has many benefits. You will not need drains with this method. It is much more comfortable for the patient and has an easier recovery. Anesthetic from lipo also gives good pain relief during the first day of recovery.

The steps of this operation are:

Z

Preparing you for surgery

Z

Shaping the abdomen with liposuction

Z

Elevating the skin

Z

Tightening loose or torn abdominal muscles

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Remove loose skin

Z

Positioning the belly button

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Marking and removing remaining skin

Z

Closing all layers

Step 1: Preparing the patient

First, I greet the patient in the anaesthetic bay to go over the all the final details of their procedure. While I always make sure that there has been plenty of time to discuss your wishes and expectations leading up to surgery many patients understandably feel a bit nervous on surgery day (especially if it is their first time). My goal is to allow enough time to alleviate any concerns or last-minute questions you might have so you can walk into surgery knowing you are in the best hands.

I make also initial markings at this stage with the patient standing upright. The aim of these markings is to plan the incision so that your scar will be easily hidden in underwear or a bikini. It is helpful to bring your preferred style of underwear that you plan to wear afterwards for this purpose. Doing the markings together allows you to have a say in the process, which makes it much more likely that you’ll be even more thrilled with your results.

A use a spirit level to make nice, straight lines that will guide skin resection. The planned liposuction is also marked out. After the markings are finalized, my anaesthetist provides you with any necessary pre-meds.

Once in the operating room, you will lay on the cushioned operating table and the anaesthetist delivers the safe recommended dose of anaesthesia. When you have drifted off to a peaceful sleep, your arms will be outstretched on arm boards. The surgical site will be prepped with Betadine and draped. I follow a strict aseptic technique to maximize your safety.

Step 2: Liposuction of the abdomen

Abdominal liposuction done by Dr Beldholm

Liposuction is performed initially and extensively. It can take 1-1.5 hours depending on the amount of fat that needs to be removed. There are two steps to performing abdominal liposuction:

I begin by making access holes for the liposuction using a nr11 scalpel. The first step is to inject 3-6 liters of “wetting solution”, which is a mixture of local anaesthetic and adrenaline. The fluid is injected gently deep into the areas marked for liposuction. This allows for safe fat removal. It also gives excellent pain relief for up to 12 hours after surgery.

Now, onto the best part: removing the fat. Liposuction is performed using 4-6 mm diameter metal liposuction cannulas. There are a range of lipo cannulas, and they all have different names. The one that I use is called a mercedes cannulae due to the fact that it has three holes at the tip.

Once liposuction is completed and the fat is gone, the skin will appear far looser than before. It can be moved quite easily, which allows the skin to be pulled down taut for a nice, flat result. After liposuctioning the abdomen, I again prep the area with Betadine and change gloves.

3, Initial dissection

Dr Bernard Beldholm - Abdominal Dissection

Next, I proceed with the initial dissection. The first incision is made on the line that has been marked out previously. I find that a normal incision tends to have better healing than a beveled one.

Any blood vessels that open up during dissection can be sealed with Diathermy.

Next, I dissect the skin off the underlying tissues. The way that this is done in a liposuction-based tummy tuck is quite different from traditional abdominoplasty This way is much safer. I dissect the tissues staying above the Scarpa fascia up to the umbilicus, and then going below the Scarpa fascia. In the traditional tummy tuck the dissection is done on the fascia of the abdomen. But in the liposuction-based tummy tuck the dissection is made above this layer. This preserves lymphatics and improves healing. It also minimizes the possibility of seroma formation, making drains unnecessary.

Once I reach the belly button, the dissection is minimized and an epigastric tunnel is made down to the abdominal wall. This allows me to reach the rectus abdominis muscles and see how much separation exists between the muscles. The tunnel is dissected gently to avoid vascular damage, thereby preserving blood flow to the rectus muscle and skin.

Step 3: Repairing muscle separation

Diastasis Recti Corrected by Surgery

Next, I repair and tighten the rectus muscles. One of the main benefits of abdominoplasty is the ability to tighten the core. The rectus abdominis muscle is usually the one that is separated during pregnancy. It leaves a tear along the linea alba at the center of the tummy. Muscle separation from injury or weight loss can be addressed in the same way.

Separation of the rectus muscles is evaluated at this point. I first mark out the muscle edges above the Scarpa fascia. The tissue here will often be quite loose, which is what causes the belly bulge in patients with torn ab muscles (diastasis recti) from pregnancy.

The separated muscles are brought together with permanent barbed sutures all the way down to the inferior skin edge. I use what is called a V-Loc suture. V-Loc 1 permanent sutures are useful because there is no need to tie knots, which means you don’t have to worry about feeling palpable lumps and bumps in the skin after the surgery. It also saves a bit of time and tediousness since I do not have to tie knots during surgery.

The tummy will become visibly tighter and flatter as I work my way toward the belly button with sutures.

Repair of diastasis recti

Step 4: Final dissection to address remaining loose skin

Abdominal Flap

Once the abdominal wall is tightened, there will be further looseness of the skin. This will need a final dissection to make the skin taut and smooth. At this point, I will decide on the extent of skin resection.

Before completing this final step, I adjust the operating table at a slight bend so that the skin is closed under slight tension. Closing the skin under tension prevents overhangs of loose tissue to give you a better final result since the skin will relax out over the next 3-6 months post op.

The degree of bend can be somewhere around 15 degrees, though this varies from patient to patient. I have found that slimmer patient who need less liposuction usually require less bend. For heavier patients that may have had a significant amount of liposuction, I tend to bend the table more because these patients often have more skin looseness in the months following surgery.

The skin is pulled down to the middle toward the pubis to make the upper abdomen nice and tight. I use plication stitches, which help ensure that there is enough tightness in the upper abdomen. These stitches are absorbable, and they also help make closing the skin a bit easier. Another benefit is that stitching the skin down also lowers the chance of fluid collecting under the skin. The skin is closed down the midline and any excess skin is removed.

Step 5: Positioning the new belly button

Umbilicus

Next, I shape the belly button. Creating a natural-looking navel is important to a successful aesthetic result The patient’s own belly button will be moved and reattached in the desired area. Older tummy tuck methods used to cut away the belly button entirely. Other outdated methods involved stretching the skin while leaving the belly button in place. This left the belly button in an unnatural position that made it obvious that the patient had cosmetic surgery.

My goal is to place the belly button in a natural position. A piece of drain is temporarily placed in the umbilical stalk with 2/0 Silk stitch. The purpose of this is to mark out the new umbilical position. By feeling for the small plastic marker under the skin, it helps me identify exactly where the belly button is supposed to be.

Next, a small incision is made where the new belly button will be positioned. I mark out a new hole (oval, about 1.5 cm) where the belly button will come through.

Three sutures are used around the umbilical stalk. These are pulled through the hole that I created previously. ARTISS tissue glue is sprayed into the epigastric tunnel and a two minute compression is done. I make sure to bring the belly button through while pushing the skin down. Doing so allows the scar to be hidden inside the umbilical stalk where you it is less obvious.

Step 6: Marking and removing the lower abdominal skin

Removal of Abdominal Skin

One of the critical steps of the operation is marking out how much skin to remove. The patient should be bent slightly (approximately 15 degrees or so, depending again on the patient) for the final flap closure and resection. The lower flap should be pulled firmly down. I use an alice forcep to mark out the extent of skin resection.

There are many methods for finalizing the skin markings, along with special instruments. Some surgeons make multiple incisions in order to remove the skin in segments. I have found that I can reliably identify the perfect amount of skin resection using my forceps. My assistant pulls the skin 45 degrees to the side, while I have the alice forceps attached to the lower skin. I then push up against the skin to feel out the bump.

Markings are done on both the right and left side. Skin on the right and left side will then be removed.

Step 7: Closing the layers and Final refinement of the result

Finally, I close the tissue along the Scarpa fascia using permanent sutures. The Scarpa can tolerate quite a lot of tension, which holds everything together nicely. And now, for the end result: A beautiful, flat tummy.

 

A look ahead: Making Surgery Better

Tummy tucks have come a long way in the last century. New techniques aim to improve aesthetic outcomes, complication rates, and patient satisfaction. Lipo-abdominoplasty is an excellent way to get rid of extra skin and fat on the tummy, and it has many benefits to the patient when it is done correctly.

My drainless method preserves blood flow, limits dissection, and makes your recovery easier. Abdominoplasty has undergone tremendous improvements over the last several decades, and will continue to change. There is not only one “right” way to do a tummy tucks. With that said, modern techniques like this can greatly improve patient safety by lowering complication risks and reducing recovery time. In the ever-evolving field of body contouring, we should always keep patient safety and aesthetic results in mind.

 

References:

  1. Ferreira, António, et al. “Abdominoplasty With Scarpa Fascia Preservation.” Annals of Plastic Surgery, vol. 76, 4 June 2016, doi:10.1097/prs.0b013e3181d0ac59.
  2. Dutot, Marie-Charlotte, et al. “Improving Safety after Abdominoplasty.” Plastic and Reconstructive Surgery, vol. 142, no. 2, 2018, pp. 355–362., doi:10.1097/prs.0000000000004572.
  3. Heller, Justin B., et al. “Outcome Analysis of Combined Lipoabdominoplasty versus Conventional Abdominoplasty.” Plastic and Reconstructive Surgery, vol. 121, no. 5, 2008, pp. 1821–1829., doi:10.1097/prs.0b013e31816b1350.
  4. Hurvitz, Keith A, et al. “Evidence-Based Medicine: Abdominoplasty.” Plastic and Reconstructive Surgery, vol. 133, no. 5, May 2014, pp. 1214–1221., doi:10.1097/PRS.0000000000000088.
  5. Lockwood, Ted. “High-Lateral-Tension Abdominoplasty with Superficial Fascial System Suspension.” Plastic and Reconstructive Surgery, vol. 96, no. 3, 1995, pp. 603–615., doi:10.1097/00006534-199509000-00012.
  6. Quaba, Awf A., et al. “The No-Drain, No-Quilt Abdominoplasty.” Plastic and Reconstructive Surgery, vol. 135, no. 3, 2015, pp. 751–760., doi:10.1097/prs.0000000000001031.
  7. Smith, Lane F., and Lane F. Smith. “Safely Combining Abdominoplasty with Aggressive Abdominal Liposuction Based on Perforator Vessels.” Plastic and Reconstructive Surgery, vol. 135, no. 5, 2015, pp. 1357–1366., doi:10.1097/prs.0000000000001200.
  8. Sozer, Sadri Ozan, et al. “Abdominoplasty with Circumferential Liposuction.” Plastic and Reconstructive Surgery, vol. 142, no. 4, 2018, pp. 891–901., doi:10.1097/prs.0000000000004819.
  9. Swanson, Eric. “Prospective Outcome Study of 360 Patients Treated with Liposuction, Lipoabdominoplasty, and Abdominoplasty.” Plastic and Reconstructive Surgery, vol. 129, no. 4, 2012, pp. 965–978., doi:10.1097/prs.0b013e318244237f.
  10. Vieira, Brittany L., et al. “Is There a Limit? A Risk Assessment Model of Liposuction and Lipoaspirate Volume on Complications in Abdominoplasty.” Plastic and Reconstructive Surgery, vol. 141, no. 4, 2018, pp. 892–901., doi:10.1097/prs.0000000000004212.

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