Operative Details and Safety in the Tummy Tuck

In the operating room, the patient is positioned on the operating table so that he
or she can be flexed at the hips and knees (“beach chair”) to take tension off the incision at the time of closure. The arms are placed on arm boards, with the wrists and hands elevated so that the elbow is not hyperextended to prevent neuropraxia. Antiembolism stockings and sequential compression devices are placed before induction so that venous pooling does not occur. An upper body warm air blanket is used, and the room is kept warm. The anesthesiologist is asked to keep the patient well hydrated to maintain good tissue perfusion. Antibiotic coverage is given before incision.

Operative Details in Tummy Tuck

The lower incision of the abdominoplasty is taken down to fascia, staying superficial at level of lymphatics. The flap is then elevated cephalad along the suprafascial plane. Care is taken to leave behind the white mesh-like cellular layer overlying the fascia (fascia of Gallaudet), which contains a fine vascular network that resorbs serous exudate. The tissue is elevated off the underlying fascia with use of electrocautery along the suprafascial loose areolar plane up to the umbilicus. Once the flap elevation is level with the umbilicus, it is carefully separated from the abdominal flap. Scissor dissection is taken down to fascia, spreading and dividing in a cone shape away from the umbilical stalk to preserve deep perforators to the umbilicus. Care is taken to ensure that an occult umbilical hernia is not missed; if it is found, it is repaired once the flap is elevated and the fascia defect exposed. The flap may be divided at vertical midline to allow easier elevation of the flap superiorly

The abdominal flap may be elevated superiorly up to the costal margins as needed, but care should be taken to avoid undermining too widely. Fascial laxity or dehiscence is marked with an ellipse and closed, running or interrupted, with buried knots as these may sometimes be palpated by the patient. If laxity persists, two additional fusiform plications of the external oblique fascia can be added. If the umbilical stalk is long, the umbilical dermis may be tacked to the rectus fascia so that on closure, there will be an invagination at the umbilicus.

At this point, general thinning of the abdominal flap can be performed if needed by direct excision of the fat deep to the superficial fascia, preserving the blood supply that runs in the superficial fascial system and deep dermal plexus.

Progressive tension sutures are placed between the superficial fascia on the flap and the abdominal fascia. Quilting sutures may help to eliminate dead space, to control flap advancement and placement, to prevent flap sliding, and to take tension off the closure. To aid in closure, the operating table is placed in beach chair position with about 30 degrees of flexion at the hips. The flap is advanced and checked for smoothness. If there are areas of tension laterally, these are released with blunt or discontinuous dissection, carefully preserving intercostal perforators as they are encountered. Three layered closure with SFS, deep dermal, and running subcuticular to avoid any tension on the skin closure and prevent flap thinning or depression as well as scar widening.

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