Fixing prior tummy tucks

When you do a lot of a particular surgery, it’s not uncommon to see patients that have had a procedure elsewhere, that come in to see if a previous result can be improved.  Recently, I performed two full “re-do” tummy tucks….which is the topic of this blog.
While there isn’t a formal classification system, I would suggest that patients seeking out a re-do tummy tuck, or “secondary abdominoplasty”, fit into one of four main groups.
These are:
1.   the “under-done” first operation
2.   scar-related issues
3.   recurrent abdominal wall stretch
4.   an unsatisfactory umbilicus
The first group, in my experience, is the most common.  It includes people that had a mini-abdominoplasty when they probably should have had a standard or extended tummy tuck, or patients that didn’t have plication (repair) of the upper abdominal wall muscle fascia when they probably should have.
The second group includes both widened or irregular incisional scars, as well as poorly placed incisions.  It also includes patients that had wound healing complications after their first procedure.
The third group, less common, are patients who despite a good first operation, seem to have poor quality fascia that stretches out sooner than ideal, or bulges in other locations after the midline separation is repaired.
The fourth group have belly-button issues: too big in diameter, too small, heavy scarring, and so on.
The first step in treatment is to find out the patient’s story and do a good physical assessment.  Is the problem primarily one of skin laxity?  Where is this laxity located?  Is it a muscle wall problem?  Or subcutaneous fat?
For patients that had a mini-tummy tuck the first time, we typically see a pattern of upper abdominal looseness or bulging and lateral “dog ears” (excess skin towards the sides of the trunk).  This can often be improved by converting the patient to a standard or extended abdominoplasty, excising the extra skin, and re-doing the muscle repair in both the upper and lower abdomen.  It does mean a longer incision.  Additionally, sometimes there is a small vertical incision in the midline, due to the closure of the umbilical cut-out.  Overall, good results are seen.
For patients with scar issues, standard techniques of scar treatment and revision can be used.  For those where surgery is required, the old scar is excised, and a careful re-closure of the tissues, including scarpa’s fascia, dermis and a tidy subcuticular closure, is performed.  If there is some laxity in the skin above the scar, we can borrow that looseness, to move the scar to a somewhat lower location.
Poor quality “stretchy” fascia is a challenge to deal with.  I’ve seen this problem most often in women that have had 3 or more children, but there are other causes as well.  Repair methods can include re-suturing the fascia, or adding some internal supporting structure, like hernia mesh or dermal matrix – but both of these have associated trade-offs as well.
Finally, and one of the most challenging of all 4 types, is to fix the badly distorted umbilicus.  Our surgical techniques here are limited, and sometimes the results are a compromise.  Large belly buttons can be reduced in size, but may stretch out again, despite internal sutures.  Stenotic, tiny belly buttons can be enlarged with V-Y Plasty techniques – but sometimes will scar down again.  We win some, and lose some.  This is a category where realistic expectations and clear communication between surgeon and patient is especially important.
in summary, this is a diverse group of patients.  Many times, we can offer the patients a nice improvement, and a happy conclusion to their tummy tuck story.

 

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