San Francisco Bay Area Tummy Tuck (Abdominoplasty)
A Tummy Tuck (Abdominoplasty) is designed to smooth and flatten the abdomen by excising excess skin, fat and tightening the abdominal wall. Liposuction is usually part of this procedure as it will accentuate the waist and add definition to the abdomen. Additionally, Dr. Delgado offers the option of a waist enhancement technique that tightens additional musculature (the external oblique fascia) around the waist. This procedure trims and sculpts the waistline and improves the shape of the upper buttocks as a bonus.
Most women seeking a Tummy Tuck have gone through pregnancies and have completed their childbearing. These women have found that diet and exercise, while very beneficial, fall short of restoring the abdominal tautness and contours they enjoyed prior to their pregnancies. The surgery allows a woman to achieve a level of body sculpturing that cannot be achieved by any other means. An additional benefit is that some (but not all) stretch marks can be eliminated with the removal of the excess skin. The navel (belly button or umbilicus) is remodeled as a consequence of the skin tightening procedure and this is described in more detail later (see OPERATIVE TECHNIQUE below).
In viewing the before and after photos, you will notice the consistent results of flatter, sleeker abdominal profiles, with more emphasis of the waistlines.
As the majority of people seeking surgery are women whose bodies have been altered by their pregnancies, the term “Mommy Makeover” has been coined. A “Mommy Makeover” includes a tummy tuck, very often accompanied by a breast lift or breast augmentation, as well as liposuction of areas such as the inner and/or outer thighs, flanks and post iliac crests. In response to the popularity of the “Mommy Makeover,” we have created a separate section that showcases that group of procedures. Please review the “Mommy Makeover” section, especially for the before and after photos. Dr. Delgado performs Tummy Tuck surgeries at the Marin Cosmetic Surgery Center servicing San Francisco, Marin, Napa and Sonoma County.
WHO IS A CANDIDATE?
A Tummy Tuck is appropriate for men and women who are in good health and have any combination of loose abdominal skin, excess abdominal fat, or lax abdominal musculature.
A patient may be a candidate if she has any of the following:
- Excess or loose, hanging abdominal skin, either from weight loss or pregnancy.
- An abdomen that protrudes unnaturally and out of proportion to the rest of the body.
- An abdominal muscle compartment that has been weakened by pregnancy or aging.
- Excess fat that is concentrated beneath the abdominal skin.
If a patient is planning to have more children, a standard Tummy Tuck, one that includes tightening of the abdominal muscle wall, should not be done. However, it is safe to have an Tummy Tuck that removes solely excess skin, such as can be present following a large weight loss. (See #2 under OTHER OPTIONS below.)
1) Mini-Tummy Tuck (Mini-Abdominoplasty):
This technique requires a short incision at the pubic hairline and the navel (belly button or umbilicus) is not altered. Abdominal liposuction can be performed with a mini-tummy tuck. In addition, the fibrous component (aponeurosis) of the underlying abdominal musculature can be partially tightened below the umbilicus and slightly higher. This procedure is good for patients who have the following:
- Minimal skin laxity.
- Mild to moderate abdominal fat.
- Mildly to moderately stretched abdominal muscle wall and/or abdominal muscle separation.
The best candidates for this procedure are women who have very toned bodies with relatively low body fat content.
It is important to make sure that a mini-tummy tuck is the best option. Once the base of the belly button is transected which is often performed in mini abdominoplasty, a full tummy tuck can not be performed in the future without putting the belly button at risk of loss.
2) Liposuction Alone:
With firm skin and good muscle tone present, liposuction alone can be done with satisfactory results. This is a good choice for women who plan to become pregnant in the future.
Scheduling a personal consultation with Dr. Delgado is the first step for a patient considering a Tummy Tuck. This appointment can take place either at Dr. Delgado’s San Francisco office at 450 Sutter, Suite 2433 or at his Marin County office at the Sutter Community Hospital campus, 165 Rowland Way, Suite 300. During this appointment, Dr. Delgado and the patient will discuss the patient’s concerns about his or her appearance. Digital photography and computer imaging are used to demonstrate the benefits one can expect to see in the physical anatomy after an abdominoplasty as well as where the abdominal incisions will be located.
Finally, Dr. Delgado will do a physical examination to assess the quality of the abdominal skin, the location of any existing scars, the degree of excess fat and the tone of the underlining musculature.
The patient will be provided with a booklet that provides detailed pre- and post-operative instructions, including the use of medications prior to surgery. There are directions to discontinue any aspirin and aspirin-containing products, including anti-inflammatory products, two weeks before and two weeks after surgery as these products have a negative effect on clotting ability. The pre-operative instructions include a complete list of medications that could pose hazards and therefore, should be avoided. However, know that Tylenol (acetaminophen) can be safely taken during this time. However, Tylenol (acetaminophen) can be safely taken during this time. However, do not exceed 1 gram over 4 hours or 4 grams per day from all sources since this can cause liver damage. The booklet also provides a list of vitamins and homeopathic preparations that promote healing and limit bruising that the patient can opt to take before and after surgery.
Dr. Delgado will order blood tests that need to be done prior to surgery so that he and the anesthesiologist will know that the blood count and blood chemistry are within normal limits, indicating that the surgery and the anesthesia should be safe for the patient. These blood tests include, but may not be limited to, a CBC (Complete Blood Count) and an Electrolyte Panel. A patient’s medical history may require that additional tests be ordered. If a patient is 50 years old, or has any personal history of heart disease, an EKG will be required, as well.
The patient is given prescriptions that need to be filled before the surgery date. These prescriptions include an antibiotic (usually Keflex) and Reglan, a medication that prepares the digestive tract for anesthesia. The patient also receives prescriptions for pain medication (Vicodin or similar) and a muscle relaxant (Robaxin). The patient will be advised to have an over-the-counter stool softener on hand.
Dr. Delgado has found that having a colonic cleansing before surgery greatly adds to the post-operative comfort. In addition, with an empty colon the abdominal fascia can be better tightened. Post-operative constipation is an issue due to the pain medication. The colonic cleansing helps with this as well.
Tummy Tuck Surgery
DAY OF SURGERY
The surgery takes place at Marin Cosmetic Surgery Center, Dr. Delgado’s private surgery suite, located in his Marin County office on the Sutter Community Hospital campus in Novato, California. This allows Dr. Delgado to offer his patients private, concierge medical care, while providing the extra measure of safety and reassurance afforded by the surgery center’s contiguous location to the hospital.
Before anesthesia is given, a surgical marking pen is used to draw a detailed “map” on the abdominal area. This architectural diagram enables the doctor to make accurate adjustments to accommodate the gravitational changes that occur as the body moves from a standing to a lying position.
After anesthesia is given, a horizontal incision is made below or at the pubic hairline towards the hipbone. The incision is strategically placed. Todays, fashion has evolved to low-rise pants and dipping swimsuit lines, but Dr. Delgado can customize the placement of the incision to accommodate a patient’s lifestyle and clothing preferences. Through this incision, the fibrous component of the abdominal muscle wall (the aponeurosis) can be tightened by lacing it centrally to achieve a flatter abdomen, much like lacing up a shoe will pull in and flatten the tongue of the shoe. The procedure is essentially the application of a surgically installed corset. If waist enhancement is desired, Dr. Delgado will also tighten the external oblique musculature, as this procedure will pull in the waist and accentuate that contour. Then, superficially, the skin is pulled downward and after the excess skin excised, the skin is sutured into position. The navel (belly button or umbilicus) maintains its vascularity, but is excised around the perimeter much like an apple core. It is then pulled through the skin to the new location. The umbilical position is unchanged in relation to the abdomen itself. Skin with stretch marks may be completely or partially excised depending on the location of the stretch mark scarring. Liposuction is used to improve the abdominal and waist contour. The abdomen is closed with two drains in place.
In the past we used the On-Q™ pain pump system for long-term (3-4 days) pain control. Dr. Delgado has changed to a much better long-term pain injection called EXPAREL. The advantage is that it is an injection that is place directly into the tissue where it is most needed. No indwelling catheters are needed and no pouch needs to be carried like the On-Q pump system. In addition, the pain control is much better.
Another great advancement to abdominoplasty is the use of Quill™ sutures. Dr. Delgado abandoned the use of the Insorb™ internal staple closure to the Quill barbed suture technique. The Quill suture is a suture that has one-way barbs on them. This is much like a fishhook that goes in and difficult to pull out. The advantage is that the sutures are locked into place as the suture is applied and no knots are required. The result is an even tension closure with beautiful incisions. The Quill is also used for the muscle repair-closure as well. Dr. Delgado is very impressed with this new advancement for closure.
After the skin closure is complete, large cotton pads, with Vaseline™ (petroleum jelly) and 2.5% hydrocortisone cream applied to the skin side, are placed over the abdomen and these are secured with an abdominal compression garment with Velcro closure.
General anesthesia is used for abdominoplasty surgery. It is performed at a hospital or an outpatient surgery center. At Marin Cosmetic Surgery Center, an accredited outpatient surgery center, a board certified anesthesiologist provides general anesthesia. (See credentials for Randy Gaynor, MD on our website.) The anesthesiologist calls the patient the night before surgery to review his/her medical history, confirm last minute instructions and answer any questions he/she may have related to the anesthesia.
The first few hours after surgery are spent in the recovery room with a Registered Nurse trained in post-anesthesia recovery and with Dr. Delgado and the anesthesiologist, Dr. Gaynor, checking on the patient’s status periodically. When the patient is fully alert and comfortable, he/she may go home with a responsible adult.
If it is the only surgical procedure a patient is having, he/she may go home the same day. The Exparel intra-operative pain shots greatly helps with postoperative discomfort, as it dissolves into the surgical site for three to four days following surgery.
A patient must have adequate help at home for the day of surgery, as he/she should not get out of bed unaccompanied for the first 24 hours. Due to lingering effects of general anesthesia, a patient can become dizzy and fall unexpectedly during this time period. Also, due to discomfort of the surgery itself, it is best that a patient has someone to prepare food and keep liquids easily accessible. It is good to have someone to remind the patient to take his/her antibiotic and pain medications on time and other medications as needed, as he/she may still be a little foggy from residual anesthesia, as well as the pain medication itself. The Jackson-Pratt drains will need to be emptied twice a day or more and it is helpful to be able to delegate this to a caretaker.
Very often, especially if other procedures are performed, a 23-hour overnight stay at the Marin Cosmetic surgery center is required. This is a welcome option for many patients as it assures optimal management of pain and (although rare) nausea, provides licensed medical supervision during the most critical post-operative and post-anesthesia time period and relieves the patient (and the family) of the chore of emptying the Jackson-Pratt drains while he/she are most active.
Dr. Delgado personally checks on overnight patients the following morning before discharging them to go home with a friend or family member.
If the patient lives some distance from Marin Cosmetic Surgery Center and he/she is not staying overnight at the surgery center, it is often recommended that they spend the first night after surgery in a local hotel, such as Best Western Marin County Oaks Inn at 215 Alameda del Prado or Courtyard by Marriott at 1400 Hamilton Parkway. If a patient does not have a friend or family member to stay with them, Marin Cosmetic Surgery Center has specially trained post-surgery caretakers who can stay with the patient, assisting with medications, drains, positioning and safe ambulation.
The early postoperative recovery is focused on preventing blood clots the day of surgery and throughout the recovery period. These are some of the important steps in prevention:
- Pneumatic sleeve leggings are used around the calves before, during and after surgery, until the patient is again walking.
- When in bed, the patient’s knees should be bent, or flexed, by having pillows under the knee joints. This provides un-obstructed venous blood flow.
- The patient’s temperature is controlled, especially during surgery.
- The patient is discharged home with T.E.D.™ (Thrombo Embolic Deterrent) stockings (anti-embolism compression stockings).
- The patient is advised to ambulate every hour at home while awake.
The patient will not be able to stand up straight immediately after surgery, as it will be more comfortable to stand and walk a little bit bent over. This is because the skin is stretched and sewn snugly to give the smoothest and flattest result possible. The skin eases and stretches out within a week or so to where the patient will be able to stand and walk normally.
Dr. Delgado encourages early ambulation to reduce swelling and promote blood circulation. The patient should avoid any strenuous activity, lifting, or bending. The pain is described as moderate and is successfully controlled with pain medications and the Exparel pain injection. This significantly improves within three to seven days.
The drains will be removed at seven to ten days. This can be done at Dr. Delgado’s San Francisco office or at his Marin County office. The drains are used to remove any fluid that accumulates underneath the skin. Prior to drain removal and for 24 hours following drain removal, bathing is restricted to sponge baths only, keeping the dressings entirely dry. The patient may shower 24 hours after drain removal. By this time, the drain site incisions will have sealed and the patient is again “waterproof” and considered safe from bacteria entering at these sites.
Bruising and swelling begins to dissipate at seven to ten days and sutures are removed in approximately ten days. Sutures can be removed at either the San Francisco or the Marin County office.
The abdominal compression garment is worn for approximately four to six weeks. A patient should be able to go back to work 10-14 days after surgery, although jobs demanding higher levels of physical activity may require a longer recovery period. It is strongly advised that a patient wait until six weeks after surgery to insure adequate healing has taken place before he/she resume any formal exercise.
It takes at least six months to see the final results. By this time, most of the tightness and numbness will have resolved and the incisions will begin to fade.
RISKS AND COMPLICATIONS
Like all surgeries, Tummy Tucks carry the risks of bleeding, infection, blood clots and the risk of anesthesia. However, the combination of Dr. Delgado’s team of licensed and credentialed professionals and Marin Cosmetic Surgery Center, an accredited, state-of-the-art facility, contiguous to a hospital, minimizes these risks, making these procedures very safe.
Abdominoplasty surgery produces a long incision. These incisions usually heal excellently, but occasionally will form scars that respond well to scar management or other medical treatments, such as steroid injections. If fluid accumulates underneath the skin after the drains are pulled, it can be successfully aspirated in the office.
The results are dramatic and long lasting. Most patients find that a flatter and firmer abdomen boosts his/her confidence and makes them feel more confident in clothing. Unless a significant amount of weight is gained or lost, a patient can expect to retain his or her new shape for many years.
Frequently Asked Questions
About Tummy Tuck Surgery
1. How is a tummy tuck performed?
During an abdominoplasty, Dr. Delgado makes a horizontal incision across along the lower abdomen, staying inside within the underwear coverage area line. The underlying muscle is tightened like a corset. Excess skin is pulled down and meticulously trimmed and the incision line is sewn closed. The belly button (navel) does not change from its original location in the abdomen, but it is pulled through a tiny incision made in the newly tightened abdominal skin. Tiny sutures reaffix it to the skin surface, resulting in a flat reset as an “innie” style belly button (navel).
2. What can I expect during my initial consultation?
Dr. Delgado sees patients for consultations in both his offices, with one being located in San Francisco and the other being located north of the Golden Gate Bridge, in the city of Novato, in Marin County. He sees patients in both locations for consultations. In your initial consultation, Dr. Delgado will inquire about your concerns and goals, both short-term and long-term. Dr. Delgado, in addition, will confirm that you are certain you will not become pregnant in the future. This is because the procedure is intended only for patients who have completed childbearing or have no intentions or ability to become pregnant in the future. Dr. Delgado will perform a physical examination to assess the degree of your skin laxity, determine any slackness in the belly button and your abdominal wall and evaluate the appearance of the belly button (navel). He will show you an outline of where the incisions will be located and how long they would be. Dr. Delgado will have the opportunity to review before and after photographs of patients that he has performed surgery on so that you have an impression of his artistic work and talent. You will be presented with a DVD that shows patient testimonials as well as a DVD of a patient’s total experience. An exact price quote for your procedure will be prepared and given to you the day of your consultation for review.
3. Is there anything I need to do to prepare for surgery?
The most important preparation you need to make is to prepare your family (or friend caregiver) and your home for your recovery. Make it as comfortable and uneventful as possible. Initially, your family/caregiver will be required to help you initially get in and out of bed and to and from the bathroom. You will need them to prepare food for you and assist you with your medications. If it is your habit to smoke, you need to discontinue this entirely. This needs to be stopped at least four weeks prior to surgery as smoking significantly impedes normal healing and can compromise your final results. Dr. Delgado and his staff will explain all the elements for the blood clot prevention program, which is a pro-active educational process designed to help prevent the serious complications of blood clots and thromboembolism. Prior to surgery, it is important to avoid all blood-thinning products that inhibit the blood’s ability to clot. These products include all non-steroid anti-inflammatory medications (e.g. Advil, aspirin, Motrin, Aleve, ibuprofen) and medications containing aspirin. Fish oil and certain herbal supplements need to be avoided for the same reason. Dr. Delgado will be providing a 20-page information booklet with these and other details to help you prepare for surgery.
4. How long does the procedure take?
It takes approximately four to five hours. Often times, liposuction is done at the same time, which takes an additional hour or so. It also depends on if there is a waist-enhancement procedure performed, which takes more time as well. The length of time also depends if there are additional procedures, such as breast surgery; much like a Mommy Makeover. Dr. Delgado will be able to give you a fairly accurate time for your surgical procedure.
5. What type of anesthesia is administered?
Abdominoplasty surgery requires general anesthesia. An LMA (or laryngeal mask airway) is a new, state-of-the-art technique that allows the patient to breathe unassisted during the procedure. Short acting anesthesia medications are given to maintain an adequate, but light level of general anesthesia. This allows the patient to awaken very quickly at the end of the procedure. However, with a Tummy Tuck procedure, it is required that a short period of paralysis is performed, so that the abdominal muscles can be adequately tightened. This, again, is a short-acting paralysis, which quickly wears off before the procedure is concluded. Unless the muscles are in a relaxed state, this cannot be adequately accomplished. The anesthesiologist manages the patient’s breathing during this short phase. For most of the procedure, however, the patient breathes on their own.
6. Will I be able to return home the same day?
Most patients are able to return home the day of surgery. Significant advances have been made regarding the early postop recovery with the addition of the long acting Exparel directly into the surgical site for three to four days following surgery. This greatly reduces the amount of discomfort during the early postoperative period. However, if other procedures are added, an overnight stay may be required for safety and pain management.
7. When can I return to work?
You will be able to return to work and most other activities within two to three weeks following your procedure. However, intense exercise and other strenuous activities should be avoided for at least six weeks to avoid unnecessary swelling and excessive stress on freshly healed structures. Driving generally can be resumed usually within reach in seven to ten days.
8. How significant are my scars following my procedure?
All surgical procedures leave incisional scars. Dr. Delgado understands that you want these scars located in the most inconspicuous areas, so that regular clothing will conceal them. The scar is located low on the abdomen, just above the pubic hairline on most patients. The scar traverses from hipbone to hipbone. The exact length of the scar will depend on how much extra skin is to be removed. The scars can be easily hidden with clothing and will significantly blend into your skin tone over the subsequent year. Women tend to wear a large variety of clothing styles and they can opt to have a lower or higher incision.
9. Will I be able to have children after an abdominoplasty?
We recommend that the childbearing years be completed. The internal tightening of the muscles could adversely affect a future pregnancy and, therefore, pregnancy is highly discouraged following a Tummy Tuck. We do not recommend it.
10. How can I tell if I am a good candidate
Many women, after childbearing years, require a Tummy Tuck to reclaim their pre-pregnancy bodies. The results of pregnancy can cause irreversible stretching, increased laxity of the skin, increased muscle laxity around the mid torso region and unwelcome increased fat deposits. A patient may best benefit from a Mommy Makeover, which, in addition to an Abdominoplasty, includes breast surgery and liposuction. This has become a very popular surgery combination. Other patients who are good candidates are patients who lose a large amount of weight, resulting in excess skin, which responds extremely well with a Tummy Tuck procedure.
11. What is the cost of tummy tuck surgery?
The cost of tummy tuck surgery is about $12,000. That includes Dr. Delgado’s professional fee, Esperal for pain control, Marin Cosmetic Surgery Center fee, the anesthesiologist’s fee and all follow up care. It may be more if additional procedures are added such as; waist enhancement and additional liposuction. At the time of your consultation you will be given a detailed estimate of all your surgery fees.