ABDOMINOPLASTY / TUMMY TUCK -
RISKS & LIMITATIONS
Ideally, before coming for a consultation, you should consult with your GP in order to identify any concerns about your fitness to undergo surgery. Please note that your GP will be kept fully informed by correspondence before and after your surgery.
All surgery carries some risks of complications. Some are potentially serious and can harm your health while others are less so. During the consultation before surgery you should work with your surgeon to identify all risk factors and, where possible, correct them. The better prepared you are in getting yourself fully fit before surgery the greater the chance of you coming through surgery safely.
Risk factors before surgery
There may be occasions, where your fitness to undergo surgery gives rise to concern, your surgeon or anaesthetist may advise against surgery. Significant medical conditions include:
Chronic heart diseases – uncontrolled raised blood pressure, angina, previous heart attacks, irregular heart rates and heart valve problems
Chronic lung diseases – bronchitis, unstable asthma
Chronic gastro-intestinal diseases – Crohn’s disease, ulcerative colitis
Chronic neurological and musculo-skeletal diseases – slipped discs, MS
Autoimmune diseases – rheumatoid arthritis
Active treatment for cancer
History of deep vein thrombosis (blood clots)
Chronic psychiatric conditions – severe depression
Significant life changing events - recent bereavement
The prolonged taking of certain drugs for the above and other conditions may predispose to complications:
Aspirin, clopidogrel, warfarin – uncontrolled bleeding, haematoma (collection of blood)
Steroids such as prednisolone in high doses – poor wound healing, infection risks
Other immuno-suppressant drugs – ability to fight infection
Complications during surgery
General anaesthetic risk – You will be seen before surgery by your anaesthetist and you may have to undergo a pre-assessment in order to identify any issues so that they can be sorted before surgery. If you have had previous general anaesthetics before and, especially if there had been a problem, then it is very important that you draw this to the attention of your surgeon and anaesthetist.
When compared with having a local anaesthetic, a general anaesthetic carries an inherent risk. You will be looked after by a consultant anaesthetist, who is a senior doctor. If you are generally fit and well and your anaesthetist has no concerns, then the procedure should be safe. To put things in context, many thousands of patients undergo operations under general anaesthetics safely every day throughout the UK.
Complications in the early post-surgery period
Deep vein thrombosis (DVT) and pulmonary embolism (PE) – Swelling and pain in your calf may indicate the presence of a DVT and if the blood clot in your leg travels to the lungs (PE) you may suddenly become breathless and experience pain on breathing. These complications can make you acutely unwell and very occasionally a massive PE may be fatal. Smoking, the oral contraceptive pill, obesity and prolonged immobility for whatever reasons are some of the pre-disposing factors.
Precautions that will be taken at surgery include the use of TED stockings to be worn until you are fully mobile again. During surgery, where possible, a calf compression device will be fitted and it will serve to keep your circulation going and prevent blood stagnating which is one cause of DVT. After surgery, as soon as you are able, you should practise regular circular movement of your ankle, avoid crossing your leg and you should try to mobilise out of bed by the next day.
If the pre surgery assessment (according to a scale of risks) indicates that a blood thinning agent (a heparin derivative) should be given, this will be administered by injection by the nursing staff after surgery daily until discharge.
After discharge home you should remain mobile and active around the house, avoid prolonged bed rest and you should keep up with your leg exercises. However you should avoid being overactive (e.g. housework, heavy lifting or going for very long walks) too soon as it may cause a problem with your wound healing and could cause a build-up of blood (haematoma) or fluid (seroma) under the skin.
Chest infection – Smoking increases the risk of you developing a chest infection after a general anaesthetic. Stopping smoking before surgery is therefore strongly recommended and after surgery you should practise deep breathing exercises.
If you find yourself having a productive cough then you should contact the hospital as soon as possible for advice in case you need to take antibiotics.
Bleeding and haematoma – Through careful and unhurried surgery the blood loss during surgery should be modest and the need for a blood transfusion should be rare. Occasionally bleeding in the post-operative period can lead to a haematoma and this is manifest as a visible swelling under the skin and pain. If this happens it may be necessary to take you back to the operating theatre so that the clot can be removed and the bleeding points cauterised.
Problems that may develop some days after surgery
Wound infection – Smoking can deprive tissue of oxygen and predispose the wound to infection and it is another good reason for giving up before surgery. Every care will be taken by your surgeon and his team to minimise the risk by gentle handling of tissue and careful suturing. Antibiotic prophylaxis will be given at the start of surgery. Post operatively antibiotic is not given routinely for such clean procedures as this could encourage the development of resistant bugs (e.g. MRSA). It should be reserved for any clinical sign of infection.
Minor infection, indicated by a localised area of redness or discharge, is not serious and relatively simple to treat with regular cleaning and antiseptic dressings. Sometimes a buried suture knot that irritates the wound is responsible and this may either come out by itself or it may be removed by your surgeon. The wound usually settles uneventfully thereafter. Antibiotic is not usually needed.
Significant infection may be present if you become unwell with a temperature, there is severe and increasing pain that is not controlled by painkillers, if you notice spreading redness in the tissue around the wound or there is discharge of blood or pus. One very rare variant is a rapidly spreading wound infection is called necrotising fasciitis or “flesh eating bugs” which can make you seriously ill with significant damage to the skin. Patients with diabetes or chronic immunity suppression are at increased risk. If seen and treated promptly with antibiotics the infection can be rapidly brought under control. On the other hand if there is considerable delay between you feeling unwell with the above symptoms and the start of treatment then the infection may become overwhelming with significant damage to the skin, wound breakdown and at its worse can make you very ill. The key message is - if you experience symptoms which causes you concern then you must call the hospital immediately, day or night, so that you can be seen right away and antibiotic treatment started without delay. That way the infection can be rapidly brought under control and the damage to tissue limited.
Skin necrosis and delayed wound healing – The skin below the new belly button is under the greatest tension and may suffer to the point that it does not survive and forms a scab. This is the reason why you are advised to bend slightly at the waist to ease the tension in that area of the wound when you first get up and walk the day after surgery and you should gradually straighten up over the course of the first week after surgery. Smokers are at particularly high risk of this problem as the blood supply is further compromised.
Treatment is usually by dressings to keep the wound clean of infection and the wound will take a few extra weeks to heal. The subsequent scarring will be more prominent.
Fluid collection under the skin (seroma) – During the post-operative period the skin normally sticks back down to the underlying muscle. The use of the pressure garment helps this process and it is important to wear the garment constantly. However if there is too much movement too soon (e.g. going out for long walks, getting back to work early) then a seroma may form causing a swelling under the abdominal skin. This may require the fluid to be drained, an outpatient procedure that may need to be repeated every few days until it is resolved. There is also a small risk of the seroma getting infected.
Recently I have used a new wound repair suture V-Loc (Covedien) to internally quilt the skin down to the muscle and my experience seems to indicate that it is effective in preventing seroma and may lessen the need to use drains after surgery. (See video of the procedure)
Longer term effects
Scar - Scars are inevitable as a result of surgery and the position and extent of the scaring will be pointed out to you during the consultation. You must be clear about that and accept there will be scars although your surgeon will do his best to make the scars as neat as possible and hide them, usually below the bikini line.
Once the wounds heal the scars will initially be pink fine lines. Gradually, over one to two years, the colour will fade and when fully matured, they will become pale scars. While the scars are still pink it is advisable to hide them from the sun since the ultra-violet rays may irritate produce dark pigmentation them more noticeable. Once the scars are pale it will not matter if they are exposed to the sun.
Scar stretch - some scars start off as fine lines but then gradually stretch out and become wider and thinner over time.
Hypertrophied scarring – this happens with some scars which gradually get thicker, raised and quite red. They may also be itchy or slightly tender to touch. If troublesome they can be helped with the use of silicone tape, occasionally supplemented by steroid injection to help control the symptoms. Over time, usually about a year, the scar will soften, become pale and flatten.
Keloid scarring – this is an extreme form of scarring which initially behaves like a hypertrophied scar. The difference between the two is that a keloid scar does not soften or flatten with time – on the contrary it continues to grow larger and spread out. There is a genetic and racial predisposition to keloid scarring and it is more common in Afro-Caribbean and some Asian races. If you have any pre-existing keloid scar it may indicate that you are at risk of developing further keloids after your surgery and you should then decide whether to proceed with surgery fully aware of the risks. Treatment can be difficult and may ultimately not be very effective.
Dog ears – At the corners of the scar there may be a raised bit of skin which is commonly called dog ears. Many patients are not bothered by them and with time they often flatten. If they remain prominent and unsightly they can be trimmed off, usually as an outpatient procedure under local anaesthetic. The scar will be made longer as a consequence of trimming the dog ears.
Numbness – As a result of cutting some of the nerves to the skin there is likely to be an area of the abdominal skin above the scar and below the new belly button that feels numb. With time the area of numbness may decrease as some feeling return to the skin. You may experience some stabbing pain as well as a period of “burning” sensitivity to the skin as a prelude to the return of more normal feeling.
Your tolerance of risks of surgery
Before you decide to undergo any surgery you will need to accept that every procedure carries with it a risk of complications. To ignore that possibility could result in you bitterly regretting ever going ahead. It is therefore important that you evaluate your personal tolerance of the risks. If your attitude is that you cannot accept the possibility of anything going wrong, or that you would not be able to cope psychologically with any problem, then my advice is that you should not proceed with surgery.
When performing your surgery I will always take my time to do it with care and try to get the best possible result. However I cannot give you a guarantee that there will never be any complication. What I can promise is that I will do my best to avoid it and if there is a problem after surgery I will do my best to put it right.
Some complications can arise after successful surgery and may be beyond the surgeon’s control. It is important that you work with your surgeon and his team and by adhering to the advice given before and after surgery the risks can be minimised.
Results to expect and the limitations of surgery
Surgery is performed on living tissue and the subsequent healing can produce a certain degree of unpredictability about the outcome. Factors that influence the outcome include persistent swelling, adverse scar behaviour and loss of tissue elasticity. Consequently it is important that to note that no guarantee can be given to achieve a particular result.
What you can expect is a significant improvement to the shape of the abdomen with the removal of the excess skin and fat that hangs from the lower abdomen and an improvement of the muscle tone so that the abdomen is less protuberant. However it may not be possible to remove all pre-existing stretch marks and if there is a very thick layer of fat on the upper abdomen before surgery it may not be safe to thin this down without risking damage to the skin. Most patients are realistic and happy with the improvement achieved. For those who would like a further improvement, liposuction could be performed as a secondary procedure a few months after healing is complete.