Thursday, February 4, 2010

Tummy Tuck Repair

What is Tummy Tuck Revision?

Many of the emails and questions I receive are from individuals who have had a tummy tuck and now are wondering how to fix or improve their tummy tuck result. The terms used for the group of procedures used to improve tummy tuck results includes "Tummy Tuck Revision", "Tummy Tuck Repair", and "Tummy Tuck Re-do". Regardless of which term we use we are communicating the same thing: surgical and non-surgical methods of improving the appearance of the abdomen and surrounding areas of the body following a tummy tuck. There are a handful of issues that can arise following a tummy tuck which can result in dissatisfaction with the appearance of the abdomen. A list of the more commonly encountered issues following a tummy tuck procedure is listed below:

List of potential tummy tuck issues:

Poor scars: Tummy tuck scars can be improved. Wide scars can be made thin by simple scar revision. Scars that are too high can be lowered by scar revision as well; however significant lowering of scars often requires full tummy tuck revision.

Belly button/umbilicus: There are many potential problems with the appearance of the belly button following a tummy tuck. Visible scars, a belly button that is asymmetric, too much fullness surrounding the belly button, a belly button that is either too small or too large or whose shape is unappealing can be corrected. Sometimes the solution can be fairly straightforward and even accomplished in the office under local anesthesia. Other belly button problems may require more extensive repair such as re-tightening of the abdominal wall and revising the tummy tuck to allow complete rejuvenation of the umbilicus.

Excess fat: Visible amounts of fat especially near the belly button and above the pubic bone can detract from the aesthetic result of a tummy tuck. Liposuction is often a great solution if there is not excess skin laxity. Localized pockets of fat can be performed under tumescent (local) anesthetic, more extensive liposuction is usually performed under general anesthesia.

Excess skin laxity: There are various reasons to have residual skin laxity following a tummy tuck. If the amount of excess skin laxity is relatively minor this can be corrected as part of a scar revision. Larger amounts of residual skin laxity may benefit from a formal tummy tuck revision or from the addition of a complimentary tummy tuck procedure such as a reverse tummy tuck following a traditional full tummy tuck.

“Dog-ears”: This term applies to excess skin and fat at the sides of the tummy tuck incision. They look like triangles of soft-tissue and are uniformally hated by any patient that have them. This is a result of several issues often it is a combination of too much laxity for the given tummy tuck procedure and/or the design of the incision and resection of the tummy tuck tissue. Correction of this problem can be accomplished in one of two ways. Either the excess soft-tissue is removed and the scar is lengthened thereby improving the overall appearance of this area, or the previous tummy tuck procedure is extended into a circumferential tummy tuck. This has the added benefit of improving the laxity that may exist at the side of the hips as well as in the buttock area for some patients.

Uneven surface: The surface of the abdomen should be smooth and natural. Lumps and bumps detract from the overall result and should be addressed. Small irregularities can be addressed with liposuction, larger irregularities should be addressed through a methodical assessment and correction usually requiring a formal revision tummy tuck.

Pseudobursa: A pseudobursa is a pocket of extra thick scar tissue that can form under the abdominal soft tissue following a tummy tuck. The most common area for pseudobursa formation is just above the waistline incision in the middle. This is the most gravity dependant area so it is naturally the most likely area for pseudobursa formation to occur. A pseudobursa can also develop just above the belly button. The presence of the belly button stalk and the surrounding tissue can form an area for a seroma to accumulate and for a pseudobursa to form. Small or relatively thin pseudobursa, if palpable or visible can be reduced by thorough liposuction and drain placement, most pseudobursas, however, need to be removed surgically during a revision tummy tuck for definitive correction.

All the best,

Dr. Remus Repta

14 comments :

Jill said...

Hi Dr. Repta, I am quite desperate to find some answers as i am 2mo post op TT and have pseudobursa. 3 days postop 1 drain came out (i got it caught on something so doctor removed) but 2nd drain was collecting and was removed at day 6with over 45ccs - I am 5'3" 115lbs- tiny no fat. developed wave -PS aspirated 3x week if not more but did not go away. 1 drain was put back in 4 days ago until day 10 (next week) we will remove and see what happens. if fluid comes back he will do surgery to remove pseudobursa. my concern (amongst 1000) is that i feel an enormous pull like rubberband pulling me from rib area down to TT incision. it is difficult to stand straight and wondering if pseudobursa is the cause (pseudobursa is below and above belly button as i saw the wave) and if so and it dries up after attempt with drain can this be broken up via stretching and excercise etc. at that point or should we "throw in the towel" now and remove bursa. im very athletic and dont know how i will move in future if it is not removed. should i stretch alot now and be more agressive while the drain is still in? wish i could talk to you some more as i believe my doc called you yesterday after i gave him your name from this very informative blog. any response would be greatly appreciated.

Dr. Remus Repta said...

Hello Jill,

There are several additional entries for pseudobursa in my blog as well as some information on my website if you'd like to learn more. It sounds like your surgeon is doing all of the appropriate steps to minimize the effects of the pseudobursa. I would continue with the drain unless output is significantly decreased and would aggressively continue wearing the abdominalbinder +/- the use of foam under the binder such as lipo-foam or equivalent. This may help the two sides stick and heal together. Whether this occures depends in part on how much healing of the pseudobursa has occurred. Is the tightness that you feel increased over the last month or soor has it been there since the surgery. If it has increased than the pseudobursa is likely the culprit. I would wait until the drain comes out and see how you do. If the pseudobursa is still around and an issue then you will likely choose to have it removed. If it does well and you all you are experiencing is the tightness than certainly there is no harm in giving it some time with stretching and massage to see if improves. Right around 6wks is when your body tends to put the most amount of collagen so as the peak of this process subsides you may start feeling the tightness improve.

All the best,

Dr. Repta

Jill said...

Thanks Dr.Repta,you're a rock star! It is quite comforting knowing that i can reach out to someone most knowledgable about the subject and can't thank you enough for posting this very needed and informative blog. i have read most of it especially all concerning pseudobursa and tummy tuck and this has relieved ALOT of stress during this waiting game to find out my results. FYI i am a mother of 3 little ones, very athletic,and a manic mutlitasker who has to put everything on hold during this time. thank g-d my husband has been so supportive (he doesnt even mind that i havent showered in 2 months) and i have help with kids. I told my PS that when this is all over I will have a "de-compression party" (the burning of all my compression outfits) - I'll keep you posted! :) jill

Anonymous said...

Hi Dr. Repta, I'm desperate, I had a rummy tuck two years ago and one year ago in Dec. he did a revision to get rid of scar tissue.
I had lots of drainage in both procedures and I must say the dr tried everything he could think of-- even now I am using an ultrasound machine to help reduce the scar tissue. I still have lumps which thanks to you I think it is pseudobursa. Its not fluid anymore but just hard lumps.
I plan to go back to my surgeon, but I am wondering if you can recommend a really top doctor for this correction in the Miami beach/broward county area. I don't know if I should give up and live with it and not mess around any more or get it properly corrected.

I really wanted to have a flat belly after my surgeon (who is a top Breast man) did a great job on my breast so I thought he would do the tummy tuck as well.. He claimed that he never had this result and thinks it might have been from prior tumescent liposuction.

any good advice you can give me would be so apreciated.

Thanks Dottie

Anonymous said...

hi Dr. Repta, I am desperate, its been two years since my tummy tuck and one year ago I had a revision where he tried to get rid of some of the massive scar tissue. The Dr. has done whatever he tought including right now I am using an ultrasound machine to hopefully reduce the scar tissue. In both procedures I had major fluid build up requireing cat scans etc. but it was merely fluid.

I had this dr -- top in breast reconstruction and reduction and he did a fine job on my breast so I thought he would do a good job with the abdominasplasty. He said he never had this result and is amazed and thinks it might have to do with prior tumescent liposuction.

I am at wits end and wonder if I shold live with it or now that I see your blog I believe it is pseudobursa as you say. I plan to go back to doctor but wondering if you can recommend another doctor on the miami beach/Ft.Lauderdale are who might be expert in correction. I would very much appreciate your advice and glad to read your blog. Should I just leave well enough along??? I don't want to but sure don't want to keep messing up.

thanks so much Dot

Dr. Remus Repta said...

Hello Anonymous from Miami,

Sorry to hear about your experience. The complexity of what you describe probably warrants a little more information. Send my office some photos and we can set up a phone consult to get a better idea of is likely going on and what the best course of action would be.

My office managers email is:

officemanager@aaaplasticsurgery.com

All the best,

Dr Repta

Anonymous said...

Hi Dr. Repta,
I happened upon your blog by accident and thought that I would take this opportunity to ask you a question. I had a full TT with liposuction of my flanks in January. I am 5'0" and wearing a size 0-2. I developed fatty necrosis where my surgeon placed a vertical incision to close me. It was terrible, although not a bad as some, it took months to close. I had an appointment today with my surgeon and she is doing a scar revision and excising some skin that didn't get as tight from the wound.
I am scared to death of developing fatty necrosis again. I followed directions to the letter, workout, non-smoker, and don't drink. What are the chances of this happening again? I do trust my surgeon, but your opinion and expertise would greatly ease my anxiety. This is to be done under local anesthesia in her office. Thank you for your time!!

Dr. Remus Repta said...

Hello Anonymous,

Sorry to hear about your healing issue. Fortunately it is far less likely to occur again with your scar revision. Tissue necrosis can occur from a number of different reasons but the combination of vascular compromise and tension is usually the culprit during the original tummy tuck procedure. A scar revision is far less likely to suffer from this, however, proper undermining and suturing of the deeper layers of the tissue is important to result in a high quality incision.

All the best,

Dr Remus Repta
Phoenix/Scottsdale AZ

Anonymous said...

I am 9 wks post TT, lipo of hips and incisional hernia repair. I had one drain removed two weeks post op and the other accidentally came out at 3 weeks while still producing 75cc in a 24 hr period, 3 days later a small opening in my incision line began draining, I returned to my PS who removed some fat necrosis and we began wet to dry packing with dacon solution, I began smelling a foul odor at 4 wks post op and it was time for my checkup with my general surgeon so he again did some debreeding of what he termed fat necrosis, my incision was healing beautifully with the exception of the 1inch hole that the doctors had made, I have and still live in my binder,, my general surgeon placed me on doxycycline and cultured my drainage which after 4 days came back as staph infection, my PS placed me on amoxicillin for 14 days which cleared the odor, but the drainage has never slowed, I massage my lower abdomen in the shower twice a day with still extremely large amounts of yellow and clear slimy drainage which seems never ending, we are still packing this wound twice daily and yesterday I noticed a small hole on the opposite side which began draining to. I am so frustrated and feel like this will never end. My stomach is beautiful, I do feel the hard places that feel kinda like marbles that my PS says is fat necrosis, how long should this go one? Are there any other options? Will this small hole open up an join the other to make a huge hole to pack? I see my PS again on Thursday but his answer to everything is "that's not surprising or that happens sometimes " I would like to know in advance what to expect. I am a paramedic with of course a very strenuous job and due to possible contamination with a open wound and blood born pathogens I can't return to work and I have already been off 9 weeks. Any advice or suggestions would be greatly appreciated.
Thank you in advance for any advice

Dr. Remus Repta said...

Hello Anonymous,
Thank you for the question. I apologize for not responding earlier. It sounds like you have an ongoing process going on from your tummy tuck. Continued drainage at this time would indicate delayed healing. It may be beneficial for your plastic surgeon to evaluate the option of going back and evaluate what is going on. Wound healing that is managed conservatively should get progressively better. Any deviation from this should peak our interest that there may be something more going and that surgical exploration may be needed.

Dr Remus Repta

Anonymous said...

I had breast cancer and had a diep to build the breast and tummy tuck my stomach right after just would not stay closed only in the middle I wore wound vac for months and then had a skin graft to close the stomach how can this ugly mess be fixed it looks awful and the scar is very high right below my belly button.

Remus Repta said...

Hello Anonymous,

I have posted a reply to your question at my new blog. The link to the reply is shown below.

http://www.scottsdaletummytuck.com/blog/wp-admin/post.php?post=251&action=edit&message=6

All the best,

Dr. Remus Repta

Anonymous said...

Hi Dr. Repta

I'm 8mo post and my stomach stills looks the same as before without the stretch marks. My ps is telling me that this is the flattest my stomach is going to get so he won't do a revision. He said he only thing that he can do is take the extra skin off from the laxity. I think that he is just saying that because he don't want to do it. My stomach is still big and round. I think that my sutures came loose but he doesn't. He is suppose to be doing scar revision surgery but my stomach still won't be flat. Can I get a ultrasound to see if my muscles are still intact? How would I know if I have a pseudobursa? And how can I convince by ps to do a revision to tighten my muscles again? Thanks?

Remus Repta said...

Hello Anonymous,

I have replied to your question at the following link in my new blog.

http://www.scottsdaletummytuck.com/blog/uncategorized/dr-repta-answers-a-readers-question-about-tummy-tuck-repair/

All the best,

Dr. Remus Repta