Operation Guide: Sculpt Tummy Tuck Surgery

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Obesity and pregnancy can cause the abdominal skin and muscles to stretch. Sagging abdominal skin often persists, even after the patient has reached a desirable weight.

Tummy tuck surgery (abdominoplasty) is a cosmetic operation that removes excess skin and fat from the abdomen. It also repairs weak or separated abdominal muscles, a condition known as diastasis recti. A tummy tuck is usually performed after weight loss or childbirth once the patient has reached a stable body weight.

In this article, Dr. Bernard Beldholm, FRACS discusses his Sculpt Tummy Tuck technique, which is ideally suited to improving a female patient’s abdomen after pregnancy or moderate weight loss.

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Abdominoplasty history

In the early days of abdominoplasty, surgeons used crude methods to excise lax skin on the midsection. In some cases, the umbilicus was removed entirely — making it obvious that the patient had a tummy tuck to remove loose skin. Due to safety concerns, surgeons also could not perform an abdominoplasty and liposuction concurrently.

Abdominoplasty procedures have come a long way in the last several decades. Thanks to new technology, safer surgical practices, and more research dedicated to the field of abdominal aesthetics, modern tummy tucks can do much more than remove loose skin. Umbilical preservation, of course, has been the standard for many decades. However, today’s surgeons can safely perform a liposuction-assisted abdominoplasty, thereby providing the patient with two benefits in one surgery.

What is a Sculpt Tummy Tuck?

In this article, Dr. Bernard Beldholm describes his Sculpt Tummy Tuck procedure with VASER liposculpture. The benefits of a Sculpt Tummy Tuck are that it eliminates the need for drains and reduces the risk of multiple abdominoplasty complications by minimising dissection. The Sculpt procedure also provides enhanced abdominal definition with VASER fat melting.

While traditional abdominoplasty methods merely tighten abdominal skin and repair the rectus muscles, the Sculpt procedure provides four benefits in one. The Sculpt Tummy Tuck is designed to:

  • Tighten lax abdominal skin
  • Eliminate stubborn fat pockets
  • Repair the rectus abdominis muscles
  • Highlight the existing abdominal musculature and curves

How does a Sculpt Tummy Tuck differ from a traditional abdominoplasty?

The two procedures share a great deal in common. Both are cosmetic skin removal surgeries that tighten sagging skin and repair diastasis recti. Unlike a traditional abdominoplasty, the Sculpt Tummy Tuck has the added benefit of VASER liposculpture, which can be used to artistically shape and sculpt the abdominal region while minimising surgical trauma.

Unlike a routine abdominoplasty, the Sculpt Tummy Tuck provides improved abdominal definition by using VASER to highlight the existing musculature and define the abdominal contours while melting away excess fat using ultrasound technology.

The Sculpt procedure has many benefits compared to other abdominoplasty methods. For example, undermining is minimal, blood flow is preserved, and perforators are spared. Yet one of the biggest benefits of a Sculpt procedure is the fact that drains are not needed.

After a standard abdominoplasty, surgeons routinely use surgical drains. The patient wears the drains for approximately two weeks. Needless to say, drains are cumbersome and uncomfortable for the patient. Additionally, they can be a source of infection.

By omitting drains, the Sculpt procedure makes the patient’s recovery easier, safer, and more comfortable. The patient will not have to worry about cleaning the drains, measuring fluid output, or having the drains removed at a follow-up appointment.

VASER liposculpture does more than liquefy fat

VASER liposculpture is an excellent complement to abdominoplasty procedures. Contrary to popular belief, it is not just for patients who wish to remove fat. While it does liquefy fat so that it can be more easily aspirated, VASER also shapes and contours the abdomen for improved definition.

VASER is precise equipment that selectively targets fat cells. The probe gets very close to the skin surface, offering better refinement than standard liposuction alone. Even a small amount of fat melting can make a difference between a “good” versus “great” abdominoplasty result. The result is a better defined tummy and waist.

Is VASER necessary during a Sculpt Tummy Tuck?

Perhaps the most important reason to perform VASER is that it provides discontinuous dissection. This benefits the patient, even if minimal fat is present. As the VASER probe passes through the tissue, it creates tiny holes. This helps to dissect the tissue, making it tissue dissection during the abdominoplasty procedure easier. Less cutting is required, and the layer where the nerves are present is preserved. It is suggested that discontinuous dissection may lower the risk of abdominoplasty complications, such as numbness and hematoma formation.

How does VASER compare to traditional liposuction?

VASER is gentler than standard liposuction. This groundbreaking ultrasonic technology turns solid fat into liquid form. Conversely, traditional liposuction involves manually breaking apart fat in an aggressive back and forth motion. This can be strenuous for the surgeon, particularly during a lengthy abdominoplasty operation. Traditional liposuction also results in more tissue trauma for the patient since high-power suction is needed to remove solid masses of fat, which may increase the risk of hematoma and post-operative discomfort.

With VASER, once the fat is liquefied, gentle suction is all that is needed to remove it. It is reasonable to assume that minimising surgical trauma yields less post-operative bruising and pain for the patient. Therefore, patients treated with VASER might enjoy a more comfortable recovery process than those who are treated with standard liposuction alone.

How to perform a Sculpt Tummy Tuck

This section discusses how Dr. Bernard Beldholm performs a Sculpt Tummy Tuck operation from start to finish.

  • Pre-operative appointment
  • General anaesthesia
  • Local anaesthesia
  • VASER liposculpture
  • Incision and dissection
  • Epigastric tunnel
  • Diastasis recti repair
  • Tissue excision
  • Umbilical shaping
  • Suture selection
  • PICO wound dressings
  • Compression garments

Step 1: Pre-operative appointment

Pre-operative markings are essential to a good cosmetic outcome. Gravity changes everything once the patient lies down on the operating table. Therefore, markings are placed on the skin while the patient is alert and standing upright during the surgical intake visit.

The patient should be made aware that abdominoplasty scars are permanent; Care should be taken to place the incision as discreetly as possible. The patient’s preferred style of swimwear and undergarments can help to inform the placement of incision. Ideally, the abdominoplasty scar will remain as hidden as possible.

Equally important are the symmetry and straightness of the incisions. The goal is to have an even result on both sides once the redundant skin is excised. Dr. Beldholm uses a spirit level to ensure the pre-operative markings are straight and even.

Step 2: Anaesthesia

General anaesthesia is necessary during the Sculpt Tummy Tuck. The patient is fully sedated while lying supine on the operating table. Sterile drapes are placed above and below the body. The abdomen is exposed and sanitized. Once the patient is anaesthetised, intubated, and properly positioned, the Sculpt Tummy Tuck can begin.

Step 3: VASER liposculpture

The first step of the Sculpt Tummy Tuck is abdominal sculpting with VASER liposculpture. VASER is a revolutionary fat melting technology that shapes and sculpts the abdomen by removing localized fat deposits with less tissue trauma than traditional liposuction. This VASER probe targets fat very close to the skin surface for enhanced refinement and definition.

Ring-size selection depends on the extent of adipose tissue that will be removed. A five-ring probe is ideal for removing a large amount of fat in a short amount of time. Bear in mind that using the VASER is a slower process compared to traditional liposuction. This is due to the fact that VASER first melts the fat to a liquid consistency, and then aspirates it with slow, low-power machine-assisted suction.

While it takes a bit more time than standard liposuction, the VASER is advantageous because it is gentler on the tissues. This is thought to lower the risk of certain surgical complications. For surgeons, VASER is less strenuous than aggressive breaking apart the adipose tissue by hand, resulting in less fatigue.

There are three steps to perform VASER liposculpture.

Application of local anaesthetic

First, small incisions are made with the tip of a scalpel, just large enough to insert the cannula. A wetting solution composed of lignocaine and adrenaline is applied to the tissues using a pump and cannula. In the Sculpt Tummy Tuck, Dr. Beldholm prefers to use a generous amount of tumescent fluid. The fluid must be evenly distributed to ensure a smooth result.

Fat melting

Next, protective ports are placed into the insertion points. The VASER probe gets quite hot and can cause the skin to burn. As a note, it is not the heat that melts the fat, but rather the ultrasound energy that is transmitted through the probe.

As an abdominoplasty is a skin reduction procedure, there is less concern about burning the skin so long as the VASER insertion points are located on areas of the skin that will be excised later in the surgery. It is still best practice to employ the use of the protective ports, however.

Sculpt Tummy Tuck Fat Melting

The VASER probe passes through the insertion points and begins to liquefy the adipose tissue. Dr. Beldholm suggests using 80% continuous mode on the VASER. He proceeds to melt the fat until the probe resistance feels similar to a hot knife going through butter.

He artistically shapes the abdominal contours by melting unwanted fat with the VASER. As the probe passes through the tissue it provides discontinuous dissection, which is beneficial later in the surgery when it is time to perform the tissue resection.

Aspiration

Once the adipose tissue has been liquefied to the consistency of hot butter, it is time to remove it. Machine-assisted suction (liposuction) aspirates the fat, leaving the abdomen noticeably slimmer. The VASER system comes with liposuction cannulas. Dr. Beldholm prefers to use the Candy Cane 4 mm cannula for removal of fat. If the patient is slim, less-aggressive cannulas, such as the Mercedes cannula, may be used. The abdominal skin appears more lax and empty once the underlying fat is removed.

Sculpt Tummy Tuck Fat removal

Step 6: Incision and tissue dissection

Next, he places a horizontal incision low on the abdomen, following the pre-operative markings. The tissue is elevated to reveal the scarpa’s fascia, a tough, white membranous tissue on the anterior abdominal wall. It is located just beneath the Camper’s fascia. Typically, the scarpa’s fascia is easier to locate after performing VASER liposculpture since the probe has already partially dissected the subcutaneous tissue to an extent.

Sculpt Tummy Tuck Tissue dissection

The scarpa’s fascia is the key to superficial dissection. This is what makes a drainless abdominoplasty possible. In the Sculpt Tummy Tuck, Dr. Beldholm avoids dissecting below the scarpa’s fascia, thereby eliminating the need for surgical drains. The strength and density of the fascia makes it capable of supporting a great deal of tension to ensure the sutures remain in place. This provides a taut closure and strong seal without compromising vascularity.

Step 7: Epigastric tunnel

Abdominoplasty methods in the past involved dissection all the way up to the ribs. This is not necessary today. In the Sculpt procedure, Dr. Beldholm dissects up to the level of the umbilicus, and then he creates what is known as an ‘epigastric tunnel’ the rest of the way up to the ribs.

Minimising dissection makes abdominoplasty procedures safer than ever. It preserves blood flow and reduces the risk of nerve damage and other surgical complications that can occur during tummy tuck procedures, such as necrotic tissue.

The VASER liposculpture that took place earlier makes dissection easier. Passing the probe through the tissue has already partially dissected the tissue. Sometimes a bit of tethering is present, which Dr. Beldholm works through using his fingers as needed.

Step 8: Diastasis recti repair

Through the epigastric tunnel, Dr. Beldholm gains access to view the uppermost abdominal muscle layer. If the patient has weakness or separation along the linea alba, which is the membrane that connects the two sides of the rectus abdominis muscles at the midline, it can be corrected during a Sculpt Tummy Tuck.

The repair process is performed in an identical manner to a traditional abdominoplasty. The muscles are plicated together at the midline, thereby restoring strength to the abdomen. If the patient presents with an umbilical or epigastric hernia, it may also be corrected at this stage.

Step 9: Abdominal skin excision

Measuring the extent of loose skin is arguably the most important step of any abdominoplasty procedure. Removing too much skin is a disaster; It makes it impossible to close the incision without a skin graft. A skin graft can disfigure the patient for life.

Remove too little skin, however, and the patient is likely to be dissatisfied with the results of the surgery. After all, the main reason that patients pursue abdominoplasty is to tighten lax abdominal skin.

Sculpt Tummy Tuck Skin tightening and mons lift

It takes skill and experience to determine the correct amount of skin to remove. The goal is to provide adequate skin tightening without making it difficult to close the incision neatly.

Dr. Beldholm finds it helpful to position the operating table on a slight tilt  of approximately 15 degrees. The upper abdominal tissue is then pulled downward. Any skin that overlaps the incision line is marked and resected. Surgical tools are available to measure and mark excess skin. However, he finds it easier to place allis forceps along the lower skin opening. When the upper abdominal skin is pulled downward and over the incision line, the clamps make it easy to feel out precisely where the incision is located.

Any excess skin is marked and excised. It is important not to stray too far from the pre-operative markings. It is essential to trial the resection and double-check all the markings before making any cuts.

Step 10: Umbilical repositioning

If the umbilicus is positioned too low on the abdomen once the excess skin has been removed, repositioning the navel to a more natural position is necessary. Dr. Beldholm creates a circular incision around the navel to free it. This can be challenging, as the tissue surrounding the navel has a tendency to wobble. Hooks may be used so that an assistance can hold the umbilical skin taut as he makes the incision.

He attaches a small piece of a drain to the navel with a 2/0 Silk stitch. The hard plastic bit allows him to feel where the umbilicus is located beneath the skin as it is repositioned.

Next, Dr. Beldholm creates a new hole for the navel. It is important to place the navel in a natural position on the abdomen, similar to where it was prior to surgery. The hole must not be too round. This can result in constriction and bunching, which can eventually lead to the umbilical hole closing up.

Sculpt Tummy Tuck Belly button repositioning

Instead, he creates an oval or slightly irregular shaped hole for the umbilicus, approximately 1.5 cm in diameter. He uses a small triangular incision to create an oval shape, although the exact technique may vary from patient to patient.

Not only does an oval shape reduce bunching, it also tends to look more natural than navels with a round shape. Adding a small hood to the upper portion of the navel opening also helps the umbilicus to appear more natural. He also removes a small cylinder of fat just behind the navel to create a small dip, which is a feature often seen in photographs of swimwear models.

Finally, the umbilical stalk is pulled through the hole. The plastic bit makes it easier to locate the umbilicus. (Note: In post-major weight loss patients, it is sometimes necessary to amputate the umbilical stalk slightly.) The plastic bit is removed. The navel is artistically shaped and carefully sutured in place. Dr. Beldholm spends a significant amount of time shaping the navel during the Sculpt procedure.

Step 11: Sutures

Dr. Beldholm uses four 2-0 PDS sutures and ARTISS tissue spray sealant to close the umbilicus and pull the edges downward into the abdominal cavity to hide the scars. The umbilical incision should be as well hidden as possible so that it cannot be seen by the patient. He applies pressure for two minutes as the tissue sealant dries.

Sculpt Tummy Tuck Closing the layers

Deep permanent sutures are applied to the scarpa’s fascia. Dr. Beldholm uses one Ethibond suture; Tricron sutures may be used instead, but they do have a tendency to spit out afterward. The thick, tough scarpa’s fascia can withstand a large amount of tension. This enables him to create a firm, taut closure with the tightest seal possible.

He then uses V-Loc 180 barbed sutures to close the upper layers, as well as ARTISS tissue sealant. This provides additional support and takes tension off the wound to ensure proper healing. Subcuticular sutures should not be applied too superficially. Dr. Beldholm finds that going a little bit deeper avoids the problem of the sutures spitting out afterward. Tissue glue helps to reduce the risk of seroma by eliminating gaps that may allow fluid to build up.

Step 12: Wound dressings

The Sculpt Tummy Tuck eliminates the need for drains. After the sutures are finalised, Dr. Beldholm applies the wound dressing.

Any sterile bandage that the surgeon prefers is suitable, however he prefers to use PICO negative pressure wound dressings. The PICO System represents the latest advancement in surgical dressings. It does not just cushion and protect the wound. This soft dressing is attached to a battery pack that creates constant, gentle negative pressure on the wound as it heals. According to the manufacturer, negative pressure optimises healing and promotes circulation.

PICO’s soft inner layer is made of absorbent material with AIRLOCKTM technology. This helps to guard against bacterial invaders and keep the wound dry. It is advertised to prevent up to 99.9% of bacteria from reaching the wound.

The downside of the PICO System is that application of the bandage is no simple task. Without proper training, a nurse is not likely to have much success getting it to work. Dr. Beldholm takes the time to place the bandage in the ideal position, which he admits can be a finicky process. While applying the PICO dressing can be time consuming, the results are well worth it. When the PICO dressings are removed, the wound is usually beautifully healed. Dr. Beldholm has observed a substantial difference in the wound healing response by using the PICO system compared to ordinary bandages.

The patient will wear the PICO bandage for approximately seven  to ten days. The dressing is changed once and removed at a post-operative visit.

Step 13: Compression garments

Compression garments are placed on the abdomen before the patient wakes in the recovery room. The purpose of compression garments is to reduce swelling, minimise seroma formation, promote skin retraction, and keep tension off the wound as it heals. The patient should be advised of aftercare instructions, particularly with regard to how tight the compression garment should fit and scar care.

The Sculpt Tummy Tuck is now complete.

For more tips and information about performing a Sculpt Tummy Tuck, as well as related body contouring procedures for patients after weight loss or pregnancy, contact the office of Dr. Bernard Beldholm, FRACS to ask about his one-year surgeon training programme.