Drains: Annoying but Necessary.

Whats the deal with the drains?

The lowly drain must be one of the least appreciated and liked components of the tummy tuck procedure. They are nuisance to deal with early on, they get in the way, they require extra work to take care of and to record the output, and when you can't stand them anymore there is the hesitation or fear of having pulled out.

So are drains necessary following the tummy tuck procedure.

The simple answer is yes. Although there is a tummy tuck technique that does not require drains, lets call it the "French Method" since it got its start in France, the procedure in my opinion takes longer and gives a less powerful result than the tummy tuck techniques that do not require a drain.

The body naturally creates "healing" fluid whenever surgery is performed. When there is a large elevated or undermined area such as in the tummy tuck procedure, the amount of healing fluid is fairly large and there is a large space for it to accumulate if left alone. Some of this fluid will naturally result in scar tissue and/or pseudobursa (see previous post) if not properly managed. To prevent this, we place a drain(s) and use the compression of an abdominal binder to decrease its production, expedited its removal, and allow the abdominal soft-tissue to adhere to the underlying abdominal wall. The vast majority of the tummy tuck procedures including endoscopic, mini, full, extended, reverse, and circumfrential tummy tucks require both a drain and an abdominal binder.

How long is the drain(s) going to stay in?

I always like to answer this question with: "as long as your body needs it and not a day longer". This is an accurate answer since the length of time varies from individual to individual. I prefer to see about less than 25-30 ml of drain output per 24 hours. This usually takes about one week to ten days to achieve.

Doe it hurt to have the drain removed?

Again, it varies on the individual, type of drain, how its placed, etc. I honestly cannot remember the last time a patient did not remark how easy and painless drain removal actually was. I use a flutted or tapered drain, make sure the drain passes easily through the skin during surgery, place numbing medication at the skin site, and usually bring the drain out through the incision or just below it. This not only avoids an additional scar but this area is usually numb in the few weeks following surgery.

In summary, the drain, although annoying at times is necessary to get a great result. We want your tummy to be thin and flat and the extra scar tissue that would build up without a drain is just not acceptable in my opinion.

All the best,

Dr. Remus Repta

What is a Pseudo-bursa?

Recently I have had a few questions about bulging or fullness following tummy tuck. While there are a handful of reasons for fullness to be noticed some time following the tummy tuck procedure I think the presence of pseudobursa is often under reported or underdiagnosed.

So what is a pseudobursa?

Simply put a pseudobursa is a pocket of extra thick scar tissue. Remember those drains that you had after the tummy tuck? They were necessary to prevent a seroma, or collection of "healing" fluid. Despite the use of drains, however, seroma can still ocurr. It is not hard to imagine that some seroma fluid accumulates after the drains are removed. Of course, the majority of the time the body keeps up with absorption of the seroma fluid and any extra fluid that may be under the abdominal soft-tissue is not noticed. The body naturally wants to isolate any free fluid between the abdominal soft tissue and the abdominal wall. The body knows that it does not belong there so it sends in cells to create scar tissue around the fluid. This scar tissue surrounding a fluid pocket is called a pseudobursa. If the wall of the pseudobursa is thin enough then they usually go undetected. Occasionaly a previously undetectable pseudobursa gets infected. When this ocurrs usually there is some tunneling and drainage at the nearest incision, either the lower incision in the midline or the belly button scar. If the pseudobursa contains a lot of fluid or the scar tissue is very thick it can be noticeable as a bulge or fullness.

The most common areas 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. Pseudobursa can also be seen 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.

How do you treat pseudobursa?

Although the pseudobursa can be injected with medicine to scar the two parts together and reduce the overall size, this is usually not that effective. If the pseudobursa is detected either by the development of infection or because it can be felt or seen as a bulge or fullness then it should be removed. The prior incision scar must be used to access the pseudobursa. The scar tissue is then removed, sutures are placed to obliterate the space where the pseudobursa was located, and drains as well as an abdominal binder are used similar to the original tummy tuck procedure. The recovery process is usually much easier than the original tummy tuck procedure with the exception of the drains and the abdominal binder.

Below is a photo of a pseudobursa excision.  Extra skin and soft tissue with the underying pseudobursa was removed.  When present on top of the abdominal wall the size of the pseudobursa is actually large and more spread out.  Once it is detached from the surrounding tissue it shrinks up.  This contractile property is likely related to some of the symptoms patients experience when a pseudobursa is present.

Feel free to ask any questions that I may not have covered. Look for an extended tummy tuck post next.

All the best,

Dr. Remus Repta
Phoenix/Scottsdale, AZ

Liposuction and the Tummy Tuck

What is Liposuction?

Liposuction is the process of removing fat by using small cannulas that are inserted through tiny incisions in the skin. It is one of the most powerful discoveries in body contouring. Liposuction goes by many names these days including laser assisted lipo (LAL), ultrasound assisted lipo (UAL), power assisted lipo (PAL), etc. All of these modalities have differences and similarities, the final component, however, is always the use of tiny incisions to access fat underneath the skin.

Is there a role for Liposuction in Tummy Tucks?

Liposuction is an almost indispensible tool for giving the very best results possible for the tummy tuck procedure. Although not every tummy tuck candidate benefits from liposuction during the tummy tuck procedure, I would estimate that 90+ percent do.

How is Liposuction beneficial in Tummy Tucks?

In three different ways:

1) To thin the abdominal soft-tissue apron. Remenber, part of the primary goal of the tummy tuck procedure is to "Thin". Despite the fact that tissue will be removed with the tummy tuck procedure, the remaining tissue may and frequently is still relatively thick from an ideal cosmetic result standpoint. Liposuction can be used to uniformily thin the fat of the abdomen.

2) To contour the areas near the abdomen. The tummy tuck procedure will improve the contour of.......the abdomen. Frequently, the areas of the flank, hips, thighs, and near the bra/breast area may appear in contrast to the now improved tummy tuck contour. Liposuction can be used to contour these areas so that not only does the abdominal contour and silhouette look great, but your whole trunk area looks thinner, uniform, and beautiful.

3) To scultp the abdominal surface. I frequently will emphasize the vertical groove in the middle of the abdomen by using liposuction. This groove is sometimes referred to as the "Champagne Groove". (Google it for a colorful explanation). This is a very important part of the attractiveness of the abdomen, so I strive to create or improve it's appearence.

Are there some patients who are not candidates for Liposuction during their Tummy Tuck?

The short answer is yes. Some patients are higher risk for healing following tummy tuck. Patients who are heavy smokers, certain abdominal scars that may interrupt the blood supply to the abdominal skin and soft-tissue, etc., may not be candidates for the use of liposuction of the abdominal soft-tissue itself. Of course, liposuction can still be used in the areas around the abdomen to improve the overall contour of the trunk, but liposuction of the abdominal soft-tissue itself at the same time of the tummy tuck should be used with caution in this group of patients that present with increased risk of healing issues.

All the best,

Dr. Remus Repta

Bra Line Back Lift

What is the Bra Line Back Lift?
The Bra Line Back Lift is a new procedure that helps correct the soft-tissue rolls and folds of the middle and upper back. There are a large number of women who complain about the presence of these soft-tissue folds. Many express the desire to wear form fitting clothes in the current fashions but hesitate to do so because of the appearance that these back rolls present. Until now, there was relatively little that could be offered to help these patients.The Bra Line Back Lift was co-authored by me and Dr. Hunstad. Scheduled to be published in the October 2008 issue of Plastic and Reconstructive Surgery Journal, the leading journal for the American Society of Plastic Surgery (ASPS), the Bra Line Back Lift procedure was designed to improve the appearance of the upper and middle back by correcting the presence of soft-tissue folds and rolls and allowing a smooth, even-flowing silhouette to be achieved. In recent weeks, there has been increasing media coverage of the procedure. Below are the details of the procedure including ideal candidates, recovery time, and additional information.
Who are candidates for the Bra Line Back lift?
There is actually a wide range of patients that could be good candidates for the Bra Line Back Lift procedure. We have noticed that the most frequent request is from patients that are in their 40’s or 50’s, are in relatively good shape, but because of either aging, excess sun exposure, or secondary to weight fluctuation, they have excess soft-tissue laxity in the upper and middle back that present as rolls and folds. It is important to note that skin and soft-tissue laxity cannot be exercised and therefore cannot be tightened. Liposuction alone has been used to treat these areas but this just improves the presence of fat and it does not correct the laxity of the skin and soft-tissue which is the main problem.
How long does it take and what is the recovery time?
The procedure takes about one hour. It is performed under general anesthesia and as an outpatient procedure. The recovery process is fairly easy as reported by many patients. There is often not a lot of discomfort and beside the restriction of heavy lifting and vigorous activity, the patients are usually allowed to increase their activity level as tolerated. Drains are usually not used and since all of the sutures are internal and dissolved by the body, there is no cumbersome dressing needed and patients are allowed to shower in 24-48 hours.
Are there any scars?
Yes. Scars are always created whenever surgery is performed। The Bra Line Back Lift has the benefit of placing the scar within the borders of the bra strap. In discussing the Bra Line Back lift procedure, I tell my patients that a visible scar will be present, that it will be hidden by the horizontal part of the bra strap, and that in the end, they are choosing between the presence of back rolls or a scar. The benefit of choosing to undergo the Bra Line Back Lift is that with all form fitting clothes, the folds are now gone and a smooth silhouette is present. With the exception of a backless dress or the very tiniest bikini top, the Bra Line Back Lift scar is usually well hidden.

Feel free to ask any questions that I might not have covered. Before and after photos can be seen in our office as well as in The Atlas of Abdominoplasty textbook.

All the best,
Dr. Remus Repta

Full (standard) Tummy Tuck

The most frequently performed tummy tuck procedure is the full abdominoplasty technique. The reason for this is two fold: 1) most patients presenting for abdominal contouring or tummy tuck are good candidates for a full abdominoplasty, and 2) the full abdominoplasty is the original tummy tuck technique. It is performed the most frequently during training and it can provide good results for the widest range of patients.

So, what defines a full tummy tuck?

A full tummy tuck or abdominoplasty is best defines by the length of the lower incision as well as the release of the belly button from the abdominal skin and soft-tissue. Of course, most full abdominoplasty procedures also invlove muscle tightening if there is is abdominal wall laxity, and liposuction if there is excess adiposity (fat) in the abdominal soft-tissue and surrounding areas. However, it is the length of the incision and whether or not the belly button is released that trully defines a full abdominoplasty. The length of the incision usually spans the hip bones or ASIS (anterior superior iliac spines). It can be a little shorter or a little longer but not by much. A significantly shorter incision together with a belly button that is not detached from the surrounding skin and soft-tissue better defined as a mini-tummy tuck. Conversely, an incision that is much longer, that goes beyond the hip bones and onto the sides of the hips or flanks is better defined as an extended abdominoplasty (to be discussed in later post). The idea behind this is that an incision that extends onto the hips and flanks requires the patient to be rolled slightly during surgery in order to have access to these areas. Most importantly, however, an incision that goes beyond the hips bone and onto the side of the hips and flanks implies that the patient had significant exess soft-tissue laxity and the question then becomes whether a circumferential abdominoplasty (aks body lift, circumferential belt lipectomy, around the world abdominoplasty). I will discuss the circumferential abdomioplasty in great detail in a later post.

Who is not a good candidate for a full tummy tuck?

The very first answer to this question is anyone that is not healthy enough to undergo a full tummy tuck or any abdominal contouring procedure safely.

There are two groups of patients that are not ideal candidates for a full abdominoplasty. Those that do not have enough excess soft-tissue laxity and those that have two much soft-tissue laxity to benefit from the full tummy tuck. Of course there are some patients that would be better served by endoscopic tummy tuck or mini tummy tuck, as discussed in the previous posts. The other group of patients are those that have significant excess soft-tissue laxity. These patients would not get enough correction by limiting the incision up to the hip bones. If this is done one of two things usually results. The first is that the patient is left with laxity and will not be happy. The scond is that there can be folds of skin and soft-tissue at each end of the incision termed "dog-ears" (to be discussed in greater detail in later posts on complications). The reason for this is similar to pleating when clothing is tailored.

So, is the full tummy tuck a good procedure?

Absolutely. For the proper candidate the full tummy tuck is a great procedure. Procedure s are not inherently good or bad. They are good when performed properly for the appropriate patients and bad when performed poorly for patients that are not good candidates.

Next up. Use of liposuction in tummy tucks.

All the best,

Dr. Remus Repta

Endoscopic Abdominoplasty

Endoscopic abdominoplatsy: It's high-tech, it's slick, and it only requires tiny incisions. The downside: Only a select group of tummy tuck patients are ideal candidates.

Endoscopic abdominoplasty can be thought of as minimally invasive tummy tuck procedure. To understand the usefulness of this procedure you may refer to the earlier posts made on this blog regarding the basic goal of all tummy tuck procedures. As you may remember, the main goals are generally to thin, tighten, and flatten the abdominal contour. We'll, there are some patients that really obtain the majority of the tummy tuck benefit from the flattening or muscle plication part of the tummy tuck procedure. In order to accomplish this the soft-tissue on top of the abdominal muscles and fascia (see myofascial plication in the Muscle Tightening post) are elevated to allow access for muscle tightening to occur. Using traditional methods, in order for this to occur, an appropriately long incision near waistline is needed to provide enough space to visualize the soft-tissue elevation and muscle tightening process. When the muscle tightening process is complete the extra soft-tissue laxity is removed and the incision is closed. For most tummy tuck patients this lower waistline incision is needed in order to allow removal of the excess soft-tissue laxity withouth creating folds of tissue at the sides often referred to as "dog-ears". For individuals who have very little excess soft-tissue laxity, however, that still require abdominal muscle plication (myofascial plication) the length of this waistline incision is a big price to pay just to allow muscle plication to occur. It is for these specific group of tummy tuck patients that endoscopic abdominoplasty is a great tummy tuck technique.

The basic details of the procedure are as follows. Most patients still benefit from some for of liposuction of the abdomen. This is usually performed first in a thorough and even manner. Following this, a very small incision perhaps only 2-3 inches long is made within the hairbearing portion of the pubic hair. This incision, once healed is essentially imperceptible and of course completly hidden by even the smallest of bikini bottoms. A second incision is made within the belly button. Through these two incision and with the use of a tiny camera and special instruments, the soft-tissue is elevated from the underling abdominal wall and muscle thightening is performed. In this manner, a patient with laxity of the abdominal wall, frequently seen after pregnancy, can regain the shape and contour of their abdomen without the need for any visible scars. Within a month or two, these patients can be poolside in a tiny bikini with a well toned abdomen making everyone wonder how they regained their body so fast and so well after having a child. :)

All the best,

Dr. Remus Repta

Muscle Tightening

What is muscle tightening?

There is a fair amount of confusion about the process of "muscle tightening" during the tummy tuck procedure। The key to understanding this process is understanding the anatomy of the abdominal wall। The basic idea is that the muscles of the abdominal wall are all covered or enclosed in a thick tissue cover called fascia. This fascia, in part, maintains the general position of the abdominal muscles to one another, especially the "six-pack" muscles in the midline.
With age, pregnancy, and weight fluctuation, the abdominal wall (muscles and fascia) stretch to accomodate these changes. As you may imagine, the muscles have an easier time returing to their previous size and shape. The fascia, however, may remain streched since it does not have the same contractile properties of muscles. This results in a persistent roundness of the abdominal wall which presents as a fullness or "pooch" especially on side profile.
The process of abdominal wall tightening is really the process of abdominal wall fascia tightening। This is why I prefer the term "myofascial plication". It best describes the process of tightening the abdominal wall. When performing a tummy tuck, during the process of myofascial plication, I plicate of tightent the fascial covering of the abdominal wall and by doing so the abdominal wall muscles are returned to their youthful, pre-pregnancy/weight gain position. This process can be better visualized as tailoring the fabric of a dress or pants to better fit the body. The extra cloth is hemmed or plicated so that it matches and follows the contour of the body, allowing a boxy or oversized shaped to be molded to the underlying silhouette.

To tighten or not to tighten: Is muscle tigtening (myofascial plication) always needed?

The short answer is no. Muscle tightening is a very important part of the tummy tuck procedure. It allows the side and front profile to be improved, making the abdomen look flat from the side and hour-glass from the front. Some patients may simply have excess skin and soft-tissue without laxity in the abdominal wall. These patients may not need or benefit from muscle tightening. My experience is that most people who are candidates for a tummy tuck are also good candidates for muscle tightening. Of course, this is based on the needs, goals, and desires of each individual. I simply give my recommendation as if it were my body and explain the pros and cons of muscle tightening, and allow the patient to make the final decision. The downside of muscle tightening is some extra discomfort and a bit longer recovery process to get back to full speed. I have found that 99% of patients choose to undergo muscle tightening when it is explained.

All the best,

Dr. Remus Repta

Mini Tummy Tuck

What is a mini tummy tuck?

The best description of a mini tummy tuck is that it has a shorter horizontal scar at the waistline without the need for a scar around the belly button. There is some variation to the other components of the mini tummy tuck procedure. This includes whether the abdominal wall is plicated/tighten and whether the stalk of the umbilicus is detached or left alone.

Often, the mini tummy tuck is performed by dissection of the soft-tissue up to the level of the belly button. The excess soft-tissue is removed, but there is no muscle tightening performed and the belly button stalk is usually left undisturbed. The decision of which components of the mini tummy tuck are performed should be based on the needs and goals of the patient.

Who is a candidate for the mini tummy tuck?

The ideal candidate for a mini tummy tuck is someone that is close to their normal body weight and who have some, but not a significant amount of excess skin and soft-tissue laxity. In essence, the mini tummy tuck patient does not have enough abdominal laxity that will safely allow resection of the excess skin and soft-tissue from the initial waistline incision up to and including the location of the belly button. A standard or full tummy tuck in these patients would create a vertical scar in the midline of the abdomen between the new location of the belly button and the location of the final waistline scar.

How long is the scar?

There is some flexibility in how long the scar of a mini tummy tuck can be. Although the exact length may vary, the ends of the scar should not go beyond the first prominent point of the pelvic bone. This point is referred to as the anterior superior iliac spine (ASIS). Any tummy tuck scar that extends beyond these points implies that the laxity of the abdominal soft-tissue were more than moderate and the patient may be a decent candidate for a standard full abdominoplasty.

What are the pros and cons of the mini tummy tuck?

The mini tummy tuck procedure is designed for patients that have some laxity of the abdominal soft-tissue but not enough to allow a full abdominoplasty to be performed. The pros are that the total length of the scar is shorter and the need for a scar around the belly button is avoided. The recovery time, cost, and the other variables may be quite similar since some surgeons, myself included, perform most of the other components of a standard tummy tuck if deemed beneficial to the overall result. These may include liposuction of the abdomen, hips, flank, and mons area as well tightening of the abdominal muscles. To do so, the belly button can be detached to allow access to the entire length of the abdominal muscles and then reattached at the completion of the case.

The cons are seen only when the mini tuck is used for patients that are not ideal candidates. These include patients with significant laxity, poor skin that may have stretch marks up to or beyond the belly button, and a belly button size, shape, and position that would benefit from rejuvenation. The mini tummy tuck is simply not designed to accomplish all of this.


We have mentioned, and will be discussing abdominal muscle tightening with many of the other tummy tuck procedures. In order to better understand this process a post specifically on abdominal muscle tightening or myofascial plication will be made in the next few days. Stay tuned.

All the best,

Dr. Remus Repta

Before we discuss specific tummy tuck techniques

In order to understand the pros and cons of each different tummy tuck technique, we have to understand what a tummy tuck or abdominoplasty procedure is designed to accomplish.

Although the needs of each individual may be different, the final optimal outcome of all abdominal contouring procedures is very similar. These include:

1) Removal of excess skin and fat
2) Tightening of the abdominal wall
3) Rejuvenating the appearance of the belly button or umbilicus
4) Improving the overall contour and silhouette of mid-drift
5) And finally, doing all this with scars that are thin and well concealed by swimwear, undergarments, and summer wear.

As one of the leaders in body contouring has told me, "the goal is to thin, tighten, and flatten".

The different tummy tuck techniques that exist are selected based with the above goals in mind and tailored to the individual needs of the patient. Since the unique characteristics of a 30 yo females body which for example has had two kids defers from that of a patient who has experienced significant weight loss, the tummy technique that will best be able to accomplish the above goals will naturally be dramatically different as well.

We will start later this week with mini abdominoplasty and progressively advance to more extensive tummy tuck techniques.

All the best,

Dr. Remus Repta