Abdominoplasty and functional repair

In this episode of PodMD, Australian and British-trained Specialist Plastic and Reconstructive Surgeon Dr Shiba Sinha will be discussing the topic of abdominoplasty and functional repair, including the different types of abdominoplasty procedures available, the reasons for an abdominoplasty, the benefits and risks associated with the procedure and more.


RACGP

  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMD studio Dr Shiba Sinha

    Dr Shiba Sinha is an Australian and British-trained Specialist Plastic and Reconstructive Surgeon practicing in Melbourne. Dr Sinha obtained her medical degree at the University of Leeds, England. Following this, Shiba undertook a higher research degree focusing on the tissue engineering of fat at the O’Brien Institute in Melbourne and advanced Plastic and Reconstructive Surgery training in New South Wales and Victoria.

    Shiba then undertook further fellowship training in breast reconstruction at the world-renowned Queen Victoria Hospital, East Grinstead in the UK. She also undertook numerous observorships in aesthetic breast and body surgery in the UK, Europe, and Australia.

    Today, we’ll be discussing the topic of abdominoplasty and functional repair.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Shiba, thanks for talking with us on PodMD today.

    Shiba : Thank you for having me.

    Question 1
    The topic of today’s discussion is abdominoplasty and functional repair. Shiba, can you give us a brief overview about abdominoplasty?

    Shiba: Abdominoplasty is a surgical procedure where excess skin and subcutaneous tissue is removed from the lower trunk area and may be accompanied by tightening of the muscles and fascia of the abdominal wall to achieve and tighter and contoured appearance. As we age our bodies produce less collagen the skin is not able to retract to its original state. Patients can be unhappy with their body contour and in certain cases of massive weight loss the abdominal apron can cause skin irritation and hygiene issues in its most severe form. Pregnancy also results in separation of the paired rectus abdominis muscle resulting in an upper abdominal bulge, lower back pain and urinary incontinence.

    In the majority of cases it an aesthetic procedure but in certain cases it has a reconstructive component.

    Question 2
    Can you explain the different types of abdominoplasty procedures available?

    Shiba: There are several different types depending on the type of correction that is required for a patient

    Traditional abdominoplasty
    In this an incision is made from ASIS to ASIS through the supra-pubic crease and aa flap is dissected up to the costal margin and xiphoid process, the umbilicus is dissected out. The patient is flexed and the excess skin is removed. The fascia of the rectus abdominis muscle is also plicated.

    Lipoabdominoplasty
    Liposuction of the entire abdominal skin envelope and then this is followed by removal of the minimum excess abdominal skin. The use of liposuction minimises the surgical undermining and so preserves blood vessels. It is gaining popularity because has quicker recovery, less use of drains

    Mini-abdominoplasty
    For loose skin below the umbilicus and is more targeted than a full abdominoplasty. The umbilicus is not moved compared to a traditional abdominoplasty and this suits women with a previous C section scar who have that lower abdominal bulge that can be difficult to shift even with exercise. The scar is usually longer than a C section scar.

    Fleur de lis abdominoplasty
    For patients who have a large amount of skin laxity in both the horizontal and vertical directions. This creates a low horizontal scar and midline scar going from the xiphisternum downwards which is like a inverted T or Fleur de lis shape.

    Apronectomy
    This for patients who have a large excess of skin and fat hanging over the mons pubis area who are having issues with hygiene, walking etc and the excess soft tissue in this area is removed in a wedge fashion.

    Question 3
    What are some of the common reasons that people choose to undergo an abdominoplasty?

    Shiba: This can be broken down into 2 broad reasons: Aesthetic and functional

    Aesthetic reasons include the desire for an improved abdominal contour. Abdominoplasty is not a weight loss procedure and for the best results patients need to be at their ideal body weight. However despite all exercise attempts even in patients at their ideal weight they are not able remove the excess skin. Patients tend to have one or more of the following: Uneven distribution of fat, Excess sagging skin, Loss of skin elasticity and stretch marks

    The functional reasons that a patient may consider abdominoplasty is after pregnancy who have a rectus diastasis resulting in an upper abdominal bulge. If this has not improved after conservative treatment with physiotherapy and the separation is more than 3 cm on imaging then this can be treated as a functional reason for a radical abdominoplasty that is recognised by Medicare as of July 2022. Massive weight loss patients also have a flap of abdominal skin that can interfere with ADLs, clothing wear and hygiene.

    Question 4
    What are the benefits and risks associated with an abdominoplasty?

    Shiba: Benefits
    Can achieve impressive results providing an improvement to physical and psychological well being.
    Improved core abdominal strength

    Risks
    Specific risks include
    Bleeding or haematoma which will require a return to theatre for drainage
    Infection which is higher in smokers
    Seroma or fluid accumulation in up to 20%
    Numbness or sensation changes
    DVT/PE (mitigated by calf compression and low molecular weight heparin)
    Poor wound healing (more common in those with a BMI over 30
    Scar can take 1-2 years to fade and some can become hypertrophic or keloid
    Expectation mismatch which goes for any aesthetic procedure

    Question 5
    How does a plastic surgeon determine the best approach for an abdominoplasty?

    Shiba: The most important thing first for GP and specialists are to ensure that patients are physically and psychologically healthy and that they are considering this surgery for themselves and have reasonable expectations and a support system in place post surgery. Physically healthy parameters would include ideal weight, completed family and ceased smoking/ vaping for 6 weeks in my hands.

    The first step is a dialogue between the patient and the surgeon regarding the steps that have led them to considering an abdominoplasty and their expectations. In terms of examination a surgeon will assess the abdominal profile; the distribution of fat: whether in the upper abdomen, lower abdomen, flanks; vector of skin laxity and the quality of skin and the location of previous abdominal scars. If a patient has a separation between the rectus abdominis muscles then this needs to be confirmed on imaging

    Question 6
    Have there been any developments in treatment in the last years or are there any in trials or development now?

    Shiba:
    – The increasing use of liposuction with abdominoplasty which can lead to a shorter recovery time as the amount of dissection is minimised.
    – Drainless techniques: quilting down the abdominal flap to minimise seroma
    – Research done in Australia to show that functional abdominoplasty improves symptoms of abdominal pain, urinary incontinence which led to the functional abdominoplasty Medicare item number. This has been very important in improving accessibility for those patients who have a functional reason for abdominoplasty.

    Question 7
    How does a plastic surgeon minimize scarring after abdominoplasty surgery?

    Shiba: Ideally the scar should be sitting in a low position that be hidden in underwear or swimwear.
    Each plastic surgeon will have their own algorithm for scar management but all scars have a lifecycle where they mature and the appearance changes with time. Standard line scar management is taping with micropore for at least 6 weeks, silicone tape has some evidence for use. Encouragement of scar massage by the patient

    Question 8
    What can patients expect during the recovery process after the surgery?

    Shiba: Generally a traditional abdominoplasty requires an overnight stay. Sometimes a mini-abdominoplasty or lipoabdominoplasty patients can go home on the same day. Post procedure discomfort can last 1 -2 weeks as can the tightness. They will also be encourage to be in a flexed position initially. Patients will be fitted with a compression garment that needs to be worn for 6 weeks to help minimise bruising and swelling.

    Question 9
    What advice do you have for GPs in terms of referring or assisting patients for an abdominoplasty?

    Shiba: GPs are key in determining whether the patient would meet the criteria for a functional abdominoplasty and the patient can be referred to a public hospital which accept these referrals as not all do. For aesthetic abdominoplasties due to the recent changes in regulations these patients do need a GP referral. GPs have a holistic view of their patient and they may be able to suggest pre-operative weight loss strategies, smoking cessation. Furthermore referral to a clinical psychologist if there is psychological distress associated with the presentation.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on abdominoplasty.

    Shiba:
    1. Abdominoplasty has both aesthetic and functional benefits in post partum and massive weight loss patients
    2. Abdominoplasty is not a weight loss tool and ideal body weight should be achieved prior to surgery for optimal results
    3. A specialist plastic surgeon will be able to determine the appropriate abdominoplasty type for each patient.

    Thanks for your time and the insights you’ve provided.

    Shiba: Thank you

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.