Dr. Joel Aronowitz — Abdominoplasty and Liposuction Step by Step with Dr. A

 

Dr. Joel Aronowitz

Dr. Joel Aronowitz: Hi everyone, and welcome back to Aronowitz Land. Great to have you here. Today, I’m very excited to show you a tummy tuck, or abdominoplasty. An abdominoplasty is an operation in which we remove skin and fat that’s extra from the lower abdomen. I’m going to introduce you to the patient, show you how we mark the patient, and then the steps involved in the surgery, but you have to promise not to try this at home, and then show you how everything looks after it’s all complete. So, I hope you enjoy it and learn something, and I will see you on the other side of the surgery.

What we’re going to do today is we’re going to go from here all the way around to here. The umbilicus, the belly button, will be about here, roughly.

So, this point will go down to here, and then this point will go all the way down here.

What we’ll do is we’ll make some markings here, so that when we line this up, it lines up a little better. That way, I know this point will go to this point, and this point, or this point, at least fairly close. And then, in order to reduce the sides here, we’ll do a little liposuction up here, and we’ll also thin out the tummy a little bit. Indented here, there are two muscles that run on either side of the midline all the way down to the bone here. And the muscles are shaped sort of like a man’s necktie. They’re thin and flat, and they run up and down, and then they have these inscriptions here that I’m marking, so that when these muscles, there’s another one on this side, the six-pack, because these muscles on either side of the midline have bulged up, and we can actually see them a little bit from the outside, and that’s called a six-pack, for what it’s worth.

What we’re going to do is, because of childbearing, these muscles have separated to the sides. It actually helps to support the back because then the back muscles are not having to work so hard stiffening the back. The stiffness is coming from the front, more so when we work out, or we tighten these muscles, it frequently will help us with back pain, especially lower back pain. It will actually support those muscles in the back, so they’re not having to work so hard. So the two things work together. You can think of it like a ladder that we put out like this, and if one side of the ladder is not supporting its own weight, the other side has to work harder to hold that down and stiffen it up, so the whole ladder doesn’t fall. That’s what’s going on here. That’s why these rectus abdominis muscles, as they’re called, are so important.

Now, the other muscles in the front are layers, and they come into the edge right here of the rectus sheath. And we have one set that’s going like this, and that’s called the external oblique, and we have another set inside of that, that’s going in the opposite direction like this, that’s called the external oblique, and then we have a third layer all the way inside, that’s called the transversalis, and it’s going, of course, transversely, and this layer ends short about right here. So the other layers go, reach all the way down to the bottom of the tummy, so when we go into surgery, we’ll see these layers, this external oblique layer, but we won’t see the internal oblique, and we won’t see the transversalis; we’ll see the external oblique, and then we’ll actually see the muscle. We’ll see the outline of the muscle, we’ll see a sheath, like a sword goes in a sheath, we’ll see a sheath here of white tissue that envelops the rectus abdominis, so we’ll see this external oblique, and we’ll see the outline of this muscle. You’ll see that we tighten that up in the midline to make that stiffer, and then we’ll remove all of this excess, get you back into shape.

So, first step here, is going to be to the umbilical stalks, so here’s the umbilicus, and we want to release it from the abdominal wall, so the umbilicus can stay in one place as we separate this abdominal panacea. You can notice there’s a layer here that’s a little subtle, but you can see this layer right here, separates the, is a fascia layer. You can see this little white line here, for example, and that’s a fascia layer within the, that separates the fat, and the more superficial one is called Camper’s layer, and the more deep one is called Scarpa’s layer. This is the deeper layer, the Scarpa’s layer that I was talking about, and it’s very well delineated in this patient. So, what we’re talking about here is skin, here, subcutaneous fat, and here is that fascial layer. Fascia is just that dense connective tissue, and here you can see vessels going up from the underlying muscle up to the skin, and that’s called a musculocutaneous perforator, and you can see very well there. And if you look closely, you can see the bigger vessel is the vein, and then those smaller vessels are the arteries, and if I cut through it to see, the bleeds darker, and the artery will bleed a redder color, and that’s because obviously, the artery has oxygenated blood.

Now, at the very bottom of the dissection here, there’s another fascia layer, and this one is much denser, and probably more important as well, and that is the anterior abdominal wall fascia. And you can see that glistening white layer right here. This layer is investing or enveloping, if you will, the muscles that we talked about earlier, and as we open this up, and you can see more of the abdominal wall, the anatomy will be more obvious to you. So, this white layer going up and down right here, is the rectus abdominis sheath. So, we have external oblique right here, fusing to the lateral margin of the rectus abdominis here, and inside this white fascia tissue, is the muscle that I was going this way, that gives you the six-pack look. And then, on the other side of the muscle here, is the midline. So here’s the midline, and the midline is a little harder to see right now, because I haven’t fully dissected it, but the midline is right here, and the midline represents where the edges of the muscle fascia are interdigitating, like this, and that’s called a raphe, so they’re interdigitating, like this, that’s occurring right here, where it’s a little denser white, and there’s no muscle right here. So if we cut through here, all the way, will be to the peritoneum, the layer that is inside, it protects the inside of the abdominal cavity, and this is what we’re going to tighten up. So we’re going to basically bring these two edges together like this, we’re going to bring… let’s see… here’s the midline, so we’re going to bring this together like so, and tighten it up a little bit. You can see her waist is getting narrower when I do that because we’re tightening up like a belt, if you will. So, here’s our umbilical stalk, now separated from the abdominal flap. You can see here’s where it came from, and now we’re going to dissect all the way up to the edge of the rib, or the costal margin, and then we’ll be able to tighten up the muscles and remove the excess skin.

So, just to make things easier, we’re going to split this in two. Make this easier, if you put a hand there. So now, the next step is going to be to imbricate, or bring this together. Now, what I’m doing is bringing together the lateral margin of the rectus sheath and trying to get as little muscle caught in my suture as possible because the muscle is not going to help me hold that tight. The fascia will, and my suture will end up just damaging the muscle I get muscle, so you don’t want to… you don’t want to injure the muscle. So I’m just going along the surface here of the sheath. Visually, you can’t see what I can feel, but I’m feeling with the tip of my needle for the fascia, and as I tighten it up here, you can… visually, you can see here’s the one edge, here’s the other edge, the bottom here of this little valley I’m creating. You can see the midline raphé, and then I decided ahead of time how much I’m going to tighten it, so I didn’t really mark it, but sometimes we mark it. So we’re going to tighten it to the degree that we’ve decided.

So, everybody… so here’s the repair we just did, and then, down below, here’s a repair we haven’t done yet. So here’s the midline, here’s the fascia on one side, the fascia on the other side. You can see the right here is the outside edge of the rectus, and you can see it over here as well. And then you remember what muscle this is, coming in obliquely.

So now, we… we elevated the abdominal flap, we have the abdominal fascia below. We did have other layers that we saw under the skin; we had the Camper’s and the Scarpa’s layer, and we pointed those out, and you can kind of see it a little right there. And now, we went ahead and dissected all the way up to the rib, and that’s… that’s called the costal margin, costal just being a fancy name for rib. We saw perforating vessels going from the muscle, musculocutaneous from the muscle to the skin; here we cauterized many of them, and we saved a few. And we saw the rectus sheath here, we saw the external oblique, we saw the midline raphé, we brought the midline together like this, tighter even. We… this is the midline raphé, and then we kind of folded it in like this, and sewed it together. We left the umbilical stalk out, exposed so we can put that back in where she belongs, and now we’re going to thin out the flap a little bit so that the contour is a little nicer before we remove the excess. Basically, the excess is going to be everything below here. You can really see the excess. And so we’re going to thin that out with liposuction, which will not be as exciting to watch, but… so what we’re doing now is to mess… messing means to make turgid, and the way we make something turgid is by putting in fluid under pressure. So in this case, we’re putting a saline solution under some pressure, and that’s going to fill up the spaces between the cells and make the tissue bulge. So the idea with the tumescent solution is to make the subcutaneous fat bulge so that as the cannula goes by, the fat bulges into the cannula orifice and gets… a bolster, gets sort of torn from the surrounding tissue, and therefore there’s less bleeding. And we put drugs in there, in the tumescent solution, to make it less bloody and also less painful for the patient afterward.

You have some Exparel? Yes. Now, as you can imagine, the tightening we did on the tummy is going to be painful after surgery, so we’re going to add a long-acting local anesthetic. This one is called Exparel, and the Exparel is slowly released, so it’ll last several days and give the patient relief from that tighter, that tightness to some degree, and the pain. So we will inject this into the practice sheath, with the idea of anesthetizing some of that, the nerves going to the muscle. So you can see the midline line here, and this is where our umbilicus is going to go. So we want to… so that there’s a nice little depression where the umbilicus is.

Okay, let’s do a little liposuction here. So, I’ll show you how liposuction works. Here’s a little piece of fat, here’s my tube, and you can see how the fat… little globule of fat… is sucked up into the tube, and the tumescent solution just helps because… because it causes the fat to bulge into that orifice of the tube. So here’s our fat… I don’t know if you can see the fat being suctioned, and if we look at that carefully, we’ll see it’s just thousands of little globs of fat that came through the cannula, the way I just showed you.

So we’re taking off the skin and the fat here. And it’s a good question, how much weight are we removing? Probably in the neighborhood of, under, certainly under 10 pounds in this case, and probably in the neighborhood of six to eight pounds, something like that, maybe even a little bit less. It’s less than you think.

So now, I’m going to make a little opening here, to bring my abilities through. So this is the drain, to remove any fluid so it doesn’t accumulate in there… just secure this over your… so it doesn’t fall out. I will take a… your monocryl next.

So now, we’re applying Pre-Neo tape. This is a 3M product that helps to minimize the scar.

And it’s this special meshed tape that is… that is then… it has an adhesive, but then we will glue it in place with a… with a glue, an adhesive similar to… um, Dermabond. It’s a type of super glue. Okay, now they… so this is Dermabond. This is Dermabond, is a cyanoacrylic, and that’s the same as, chemically as, the super glue you’ll use, or in the house, or used industrially, but this is a product that was developed for medical use. So, and it can be used for lacerations, although not a big fan because frequently the incision is not held properly. Scissor, please. And the super glue gets inside the incision and causes, um, a foreign body reaction. So, not always the best thing to super glue it instead of sutures. For the less experienced, the practitioner, the more I think super glue is, um, not good. And, uh, something very basic like sutures is better. There you go. All right, so there you have it. So here’s our specimen. This is the little opening where we took the belly button out. This would be down by the pubis, and this would be up higher. You can see this is the roll that I was holding pre-operatively, and it’s all been removed. This is along the lower part, and then this is what was removed from the upper part toward the ribs. So, here if we look at the specimen, we can see the adipose tissue, small blood vessels here, and we can still make out the layers that I was talking about earlier in the fat layer. So, let’s see here. So here is one layer, the Camper’s layer; it’s more superficial. And then this layer down below, right, is the Scarpa’s layer. So we can remember that because we always ‘camp out,’ and then the Scarpa’s is just the deeper layer there. Okay, so we finished with the tummy tuck. We did some liposuction up here, did some liposuction on the sides, defatted up high, especially in the middle, removed the excess skin, plicated the rectus sheath, and sewed everything up. And now, she’ll have a much flatter tummy without this big, uncomfortable panniculus or apron of skin hanging. So, I hope you enjoyed that. We’ll try to show you some post-op pictures after a while, when she’s healed up a bit. Well, I hope you enjoyed that operation. I hope it wasn’t too graphic for you. In person, it’s actually less graphic than it looks like in the video, believe it or not. But I hope that that was instructive, that you learned a little something about the anatomy, and appreciated it, and found it interesting to see how much we can really do in plastic surgery to the improve the appearance of the lower abdomen and also help functionally. One of the things that’s not really clear from the video is how much this can improve the whole torso of the body. This is tightening the core muscles in the front, and by tightening the front, it actually helps the back a lot. So, a lot of patients who have this operation experience improvement in lower back pain and also, it makes it easier to exercise and do physical activities. So, overall, it improves the health of the patient. The risks of the operation that are serious are breakdown of the wound, infection because if fluid accumulates in that space that I’ve created, you can get a thick scar because the scar is relatively long. One other problem is blood clots, because we’re tightening the abdominal cavity, makes it harder for blood to come from the legs up to the chest. So that’s why activity, leg squeezers, and different things are important to prevent those kind of complications. The formation of blood clots in the legs and then they travel to the lungs and cause big problems. So, DVT’s, or deep vein thrombosis, is a risk of operation that’s a little more than some of the other operations we do. So, we want to take special precautions to prevent that. In general, this is an operation that takes about six weeks to recover from, to really get back to your normal activity. So, it’s not like some of the other operations that I do that the recovery is really quick. This takes a little bit longer and will set back most people a few weeks before they can do regular activities. So, I hope you enjoyed the operation. If you have some ideas for other videos or improvements that I can make, other than to my own appearance, I don’t think that’s going to help, please let me know in the comments below. Meanwhile, I will see you later from Aronowitzland.”

Originally published at https://drjoelaronowitz.medium.com on November 16, 2023.