Your Questions
Your Questions
Q: Dr. Eppley, I am interested in getting a tummy tuck but don’t know too much about it. What type of tummy tuck do I need? Should I try and lose more weight before? Although with my back injury and being on disability I don’t see any significant weight loss happening. I have attached some pictures of my overhanging stomach for your review.
A: Thank you for sending your pictures. What you have is a large abdominal pannus and thick abdominal tissues. What you would ultimately need is really an abdominal panniculectomy rather than a classic tummy yuck. Your abdominal tissues are too thick an your weight is too high to do accomplish anything more than an extended abdominal panniculectomy. While such a procedure would clearly have great benefit, ideally you should lose a lot more weight to have the better abdominal reshaping procedure. But for many patients weight loss is difficult and an abdominal panniculectomy now is better than nothing at all. That would have to be a decision that only you can make and I think with your back injury that decision has already been made.
You should clearly understand that an abdominal panniculectomy is not the same as a tummy tuck. It is a less refined although larger amount of abdominal tissue removal whose main objective is to eliminate the overhanging abdominal tissues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a tummy tuck later this year. I work out five days a week lifting weights and and eat a high protein based diet. I am 220 pounds and 6’ 2” feet tall.mI am trying to get down to 10 percent body fat and stabilize at 190 pounds. My trainer predicts that we can achieve that in 6 months and that is when I would like to have the tummy tuck surgery. My lower body is all muscle but I have a very fatty upper body. I have significant visceral fat and of course subcutaneous fat below the skin which will be removed during the tummy tuck. My weight has fluctuated a lot in the past which has resulted in a very lax bulging abdominal wall and stretch marks on the skin. I was recommended to have a full tummy tuck with flank liposuction and central abdominal liposuction as well. But I don’t want central abdominal liposuction, I don’t want to risk any healing and circulation complictitons. It can be done later after the tummy tuck. I have attached pictures of my stomach for your review.
A: Thank you for sending your pictures. I would certainly agree that your tummy tuck should wait until you have maximized your weight loss. That is the only way to reduce your visceral fat component of your abdominal protrusion. This will also allow for the most extra skin to be taken during the tummy tuck as well. I would also agree that any abdominal liposuction or etching can be done as a second stage procedure. That is both safer and more effective when done that way.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in the process of reaching my ideal weight and have been researching tummy tuck surgery I have had two children via c section and I have been over weight/obese for many years. I am currently 5’5″ and weigh 227. I have lost 60 pounds so far but I’m wanting to lose another 40-50. I was wondering when I should start the tummy tuck process with a consult? I know I have a ways to go but I wasn’t sure what the requirements are before having a consult. Do I need to reach a certain BMI or be within so many pounds of my ideal weight? Like I said I’m just researching now and trying to plan for the future. I have double rolls of skin/fat around my abdomen and a lot of sagging already. I’m sure part of that will shrink but I also know I need muscle repair too. Thank you so much for your time and any info you can provide!!
A: Congratulations on your weight loss. This is a great question and a very proactive one. As a general rule when there is weight loss needed before a tummy tuck, one should not have the surgery until one is within 10 to 15 lbs of their weight goal. However, when one is undergoing extreme amounts of weight loss (bariatric surgery or otherwise), one may find that there comes a point when the skin rolls and their ongoing persistence (your skin rolls will not shrink much if at all) will cause one to consider where surgery may need sooner rather than later. I would continue with the weight loss until you hit the proverbial wall and no further change in how you look has become apparent. Then it is time to have a tummy tuck, or what is more likely an extended tummy tuck or body lift, consultation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a gastric bypass surgery three years ago to lose weight. I have lost nearly 200 pounds. I am a 50 year-old female. My primary insurance is Medicare and my secondary is Champ VA. i did not have to pay a penny for my gastric bypass. I saw a story on my local news tonight about Cool Sculpting. A procedure that costs $1,500. by a doctor in California. One place locally here has given me a quote of $7,600 tor a tummy tuck, but there is no way I’ll ever be able to save that much money. I have no credit cards. I don’t even have a car or a phone. I cannot afford a monthly payment on a car much less the insurance. Nor can I afford a monthly payment on a phone. My car broke down last year with a cracked engine in January. I rent a car when I need to go out of town. Thank you.
A: When one has lost 200 lbs, the overall circumferential body problem is too much skin. Do not waste your time and money on anything other than a major tummy tuck operation. There is nothing less than a big operation to cut out the extra tissues that will work. You may have luck finding a plastic surgeon who takes Medicare to do your surgery (which is very scarce) or you may be able to have it done in a VA. But other than these unlikely options, being able to do a tummy tuck like you would undoubtably need at just $7,600 is a bargain. Whomever offered to do your surgery at that very low rate for a tummy tuck like you would need was doing you a major favor.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had two abdominal surgeries. The first was a hepatic bypass and the last one was a partial hepatectomy. My last surgery was complicated with infection at the organ level as well as an incisional hernia. The surgeon plans to surgically repair the hernia in May or June of 2016. I am interested in having a tummy tuck at the same time. I am not sure if I am a candidate or not. Would need to know if the two surgeries can be done at the same time.
A: The question you ask about a concurrent tummy tuck done at the same time as an abdominal wall reconstruction (hernia repair) is determined based on the consideration of multiple issues. First I would have to see pictures of your abdomen to determine the tissue excess and the location of your current abdominal scars. The location of certain abdominal scars may preclude or at least potentially complicate healing of the tummy tuck incision. Secondly, you would have to be in good medical health (which I would assume you would be for a hernia repair), on no immunosuppression drugs and be a non-smoker. I would need to know more about your medical history. Lastly there is the economics of doing a cosmetic surgery procedure in a hospital. While many patients think that most of the cost of the surgery would be covered by insurance because one is already asleep and having surgery, that is not the case. Hospitals are well aware of what is being done and will hold the patient accountable for the time and costs of the tummy tuck surgery, including OR costs and anesthesia, up front.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in tummy tuck surgery. Can you please tell me the cost of tummy tuck surgery in your practice? Also what is the recovery time from tummy tuck surgery?
A: Thank you for your inquiry. There are eight different types of tummy tucks with differing associated costs. I would need to see some pictures of your abdomen to give you a very specific cost figure. Most women are type 4 so I will have my assistant pass along the cost of that version to you. That may or may not be the type of tummy tuck that you need. There are three different levels of recovery and it depends on what you are defining as your recovery point. (up and about, back to work, working out, final recovery) Since full recovery from a tummy tuck takes a complete eight weeks, I am assuming you are referring to some level of incomplete recovery where you can get at least back to that type of activity. Working backwards then it would six weeks for working out/running, four weeks for any job that has a significant physical components to it, two weeks for a sit down job and seven to ten days to be more up and about.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need diastasis recti muscle repair. I need to see if your office can do a pre determination through my insurance for this procedure. I have chronic low back pain and do not want to continue to take 500-1000 mg of Naproxen for life or Cortisone injections.. I have joined weight watchers and lost 15 lbs and I am not morbidly obese but my back makes my quality of life poor. I cannot jog, run. I cycle 30-60 miles or more a week indoor spinning. I cannot lose my belly since my csection no matter how hard I work out. Can you please help. My back is getting worse and I’m at my wits end. I know that insurance can pay for alot of the procedure but I know I will need abdominoplasty also, but please can you help!
A: Thank you for your inquiry but I am not sure where you are getting information that would indicate that insurance would pay for a diastasis recti muscle repair…as they will not. Insurance only covers two adbominal type procedures for medical reasons…a hernia and in some cases an abdominal panniculectomy. A hernia is not the same as a diastasis of the rectus muscles. A hernia is an actual defect in the abdominal wall where bowel may or may not poke through. A diastasis is a separation of the midline of the vertically oriented rectus muscles but is not an actual defect of the abdominal wall. Most women have a rectus diastasis of various widths from pregnancies. Insurance will cover repair of an abdominal wall defect (hernia) but not for a muscle separation that is not associated with a hernia
In tummy tuck surgery it is common to have a diastasis recti muscle repair with the removal of extra skin and fat. While it is part of almosyt every cosmetic tummy tuck it is not a medically necessary procedure as defined by insurances.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in pubic liposuction. I had a tummy tuck over ten years ago and my pubic area is rather puffy and i would like to get liposuction to remove the fat that completely sticks out on each side of the seam in my pants or it is disgusting in my bathing suit. I have an appointment with another plastic surgeon but I like all that you have said about this after tummy tuck problem so you seem to be experienced in what I am looking for.
A: It is very common after a tummy tuck that residual fullness of the pubic region is seen. This is because the fat content of the pubic region has not changed (tissue thickness) while what lies above it has. Since the narrowest portion of a tummy tuck is usually the scar line this makes the unaltered pubic region more evident after surgery. While many patients think that the pubic fullness is persistent swelling from the tummy tuck, this potential cause can be eliminated once one is six months after their tummy tuck. Pubic liposuction is the solution to the puffy mons and is tremendously effective at reducing its profile and making it flatter.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a full tummy tuck. I believe I would accept the trade off of the scar for the results of the tummy tuck. My loose skin bothers me so much I do not take my shirt off in front of anyone and I will not wear a bathing suit. I find myself covering my stomach with my arm even when I am alone. It would ultimately depend on how high the incision would be and how inconspicuous it would be over time. I have researched hundreds of before and after photos on real self and women with similar “before” photos like my stomach and was very impressed with the results. With my C-section incision, my appendectomy incisions and all the stretch marks from pregnancy I think the incision would be a fair trade. Again, I would want to know where the incision would be and I know that could only be accomplished through an in-person consultation.
I am slightly concerned about the nipple lift for my breast augmentation. I am not sure what that entails, but it makes me more nervous than the tummy tuck incision. I am most concerned of lost sensation and additional scarring as a result.
A: You have made a key point in understanding the aesthetic trade-offs of many cosmetic procedures, particularly that of a tummy tuck. Each option (keeping your loose abdominal skin vs a tummy tuck) is not perfect and you choose which ‘problem’ you can live with the best. The tummy tuck scar will not end up as low as your c-section scar and will probably end up 1 to 2 inches higher. Also it would be likely that our full tummy tuck scar will end up with a small midline vertical component running just above the horizontal part of the incision. This is sometimes necessary when doing a full tummy tuck to keep the central aspect of the scar low rather than being pulled up in the middle. While many tummy tuck scars do heal well, I don’t think I would ever call them inconspicuous but that is a matter of personal perspective.
The small nipple lift scars are really irrelevant and are not a concern for visibility or nipple sensation. The choice you will have to make is that your nipples may not be centered on your breast mound without them given your existing breast sagging. It is important to understand that implants do not create a lifting effect on the breasts. They merely make breasts bigger and can magnify any existing breast asymmetry or breast sagging.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting some initial information about a tummy tuck and breast lifts. I also sustained an injury to one buttock, leaving a large dent of scar tissue that I would like to have repaired if possible.
A: There are numerous types of tummy tuck surgery (eight to be exact) and breast lifts (four to be exact) so it is impossible for me to say which type of tummy tuck and breast lifts would be best for you. I am also unsure what your buttock deformity looks like although I could imagine. The good thing is that that tissue from the tummy tuck (dermal-fat graft) or fat injections from any liposuction can be used for reconstruction of the buttock indentation. I could provide you with more specifics about these procedures if I knew what you looked like. You could do that by sending in some pictures of your abdomen and breasts. Otherwise I would have to see you in the office to know exactly what you need.
A tummy tuck, breast lifts and buttock fat grafting could all be done in a single operation which would allow for just one recovery. The tummy tuck is usually what requires the most recovery. The recovery from other procedures falls well within that of the tummy tuck recovery period.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want a Brazilian butt lift and tummy tuck. Can I get a combined surgery package and price for these two procedures.
A: The combination of a Brazilian Butt Lift and a tummy tuck can be done together. But that is a tough combination in terms of recovery and discomfort. I have done it and patients do get through it but it will be a lot tougher than you envision. Ideally it is better to harvest all the fat that one can from the abdomen and flanks for the Brazilian Butt Lift and deal with the loose skin in a second surgery. (tummy tuck) Whether the combination or staged approach would be better for you depends on what your abdomen looks like now.
While patients understandably would like to combine these procedures to lower costs and have just one big recovery, that approach can be short sighted. In women that have very large abdomens and a lot of excess abdominal skin, it may be more prudent to stage the two procedures. That way the best result may be obtained for both the Brazilian Butt Lift and the tummy tuck with a lower chance of complications.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is there amount of weight you have to lose to get a tummy tuck… what is the recovery time after tummy tuck surgery?
A: It is always best to lose whatever amount of weight one wants to, if possible, before having a tummy tuck. Once one is within 10 to 15 lbs of their weight goal, then one can have the tummy tuck. Doing a tummy tuck and then losing 20, 30 or 40 lbs after will adversely affect the tummy tuck results creating some additional loose skin. Or at the least making the once taut abdominal skin feel more loose.
Recovery after a tummy tuck depends on how you choose to define recovery. A complete recovery, feeling like you do now, will take 6 to 8 weeks. This is the time when you will feel like you can do anything that you do now and feel comfortable doing it. Some people do return to work, for example, two to three weeks after a tummy tuck. But they are usually struggling to do and only do it because they have to. So recovery could be defined as two or three weeks but I would call it a minimal recovery and an incomplete one at that.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an umbilical hernia and have been told that a general surgeon would be needed for this procedure. In addition to needing a mesh piece placed in the hernia, I would like the resulting belly button to be aesthetically pleasing. I also have a c-section scar with some loose abdominal skin. Can you address all my concerns during a single procedure without an additional general surgeon in the OR at the same time?
A: What you are specifically asking is to have a tummy tuck done with an umbilical hernia repair at the same time. This is not a rare situation for a plastic surgeon to encounter and manage. During an open tummy tuck procedure most umbilical hernias are repaired by using your own natural tissue through midline muscle plication. It would be very uncommon for a plastic surgeon to have to resort to the placement of a synthetic mesh for hernia repair during a tummy tuck. The only concern is the fate of the belly button during an open tummy tuck operation. Many umbilical hernias have disrupted the attachment of the belly button to the abdominal wall. During a full tummy tuck the outer connection of the belly button is removed from the surrounding skin. If the umbilical hernia has also separated the base of the belly button, it may not have adequate blood supply to survive afterwards and be lost. So the objective of obtaining a better looking belly button may be a difficult challenge when a full tummy tuck is done with a concomitant umbilical hernia repair. This does not mean that the two should not be done together, as they should, but one has to appreciate the potential implications for the belly button and its postoperative fate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in umbilicoplasty surgery. My belly button has been this way for about 10 years, ever since the birth of my son. It has been the source of my insecurity and I am so self-conscious about it that I can’t even wear a fitted shirt because it clings to my belly button and creates this weird looking indent. I hate it and fixing it would make me so incredibly relieved and ecstatic. I can’t afford a tummy tuck and even so I would hate to go thru all that just to fix one little thing. I really sincerely hope something can be done.
A: Quite frankly, your belly button concerns are due to the excessive surrounding tissues that are collapsing around it and engulfing it. This is not a belly button problem per se, it is due to excessive abdominal skin and fat. Thus there is no umbilicoplasty surgery that is going to correct it nor would it even be wise to spend any money trying it as it will not solve your concerns. What you need is a fully tummy tuck which will treat the real source of the belly button problem by removing all the excessive tissue and in the process create a new belly button. While you may not be able to afford it now, it is much better that you wait until the day you can and then have the correct operation. That is a far better financial decision as an umbilicoplasty surgery now would be a disappointment and waste of money.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a tummy tuck. My questions are:
1. Cost- do you know if insurance pays for the surgery or is it out of pocket?
2. Hospital stay – how long or outpatient procedure?
3. How long off of work?
4. Cost for an office consultation
A: Thank you for your tummy tuck inquiry. In answer to your questions:
1) Tummy tuck surgery is a cosmetic procedure and is not covered by insurance unless one has a large overlying abdominal pannus that has documented medical symptoms that have undergone unsuccessful non-surgical treatments. To be considered for insurance coverage a predetermination process is necessary.
2) Unless it is a very large abdominal pannus and the patient has other medical issues, tummy tuck surgery is typically an outpatient procedure.
3) How much time one would need off work after a tummy tuck depends on what type of work one does. But as a general statement, two weeks for an office for sit down job and three weeks or more for a very physical occupation.
4) As a cosmetic tummy tuck there is no charge for am office consultation.
Dr. Barry Eppley
Indianapolis, India
Q: Dr. Eppley, I was seeking a natural tummy tuck result. But after looking at the picture you provided to me, I now realize that removing the excess skin/tissue across my abdomen is not going to give me the “natural” look I was hoping for. So my questions are:
- What other procedures do I need which will help to reduce the flank areas and outer thigh areas (lipo, lifts, different abdominal procedure?). I am not interested in the inner thigh at this point, but I would like surgery results closer to the “after” picture than what the one procedure appears to be able to provide.
- By adding these procedures how much additional time or what will the total surgery time be? Given my age, do you consider this extended time to be a concern?
- By adding these procedures what amount of recovery time do I need to plan for. (My daughter is getting married in late June and activities are already planned for mid-June.) Will a mid-April surgery date, if available, give me the necessary recovery time to fully enjoy the wedding activites, anticipating no surgery complications?
- Will I need to plan more time off than just the day of and day after surgery?
A: The concept of a ‘natural’ look after a tummy tuck is open to wide intrepretation and is subject to one’s own perception. But in answer to your specific questions:
- It is important to realize that you are not able to achieve the after picture that you saw. Your body is completely different in many dimensions and no amount of additional liposuction will make those type of changes.
- If there is truly a ‘dangerous’ part of abdominal contouring, it is large volume liposuction that may accompany the procedure. It is one thing to do a little flank liposuction as part of a tummy tuck, but major liposuction places certain patients like yourself at increased risks and exposes yourself to some of the greater risks and problems that you have heard with other people. I would not recommend it for you other than some small contouring liposuction at the back end of the tummy tuck incisions.
- When you think of any significant event that someone wants to attend and be truly 100% fully recovered, the minimum time for the surgery before the event would be 8 weeks.
- I would definitely plan for more than just one day after the surgery to return to work. For computer work at least a few days would be in order.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently learned that I have two ruptured disc in my back and pressure on a nerve. I am wanting to know if I was to get a tummy tuck, liposuction, etc would it help with my back pain?
A: Whether a tummy tuck would provide any relief of our back pain would largely depend on the size of the abdominal overhang. Some tummy tuck/abdominal panniculectomy patients do report that they do have improvements in back pain after the procedure due to the loss of an overhanging abdominal pannus or even lesser amounts of skin and fat excess. But whether a tummy tuck would help you can not be predicted and is certainly not a common improvement that occurs after any abdominal reshaping procedure. Unlike breast reduction surgery which causes musculoskeletal symptom improvement in every patient, back pain improvement from a tummy tuck is far less assured. This is evidenced by the fact that no insurance company will approve tummy tuck surgery on the basis as a treatment for chronic back pain with or without ruptured discs and/or sciatic nerve pain.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a tummy tuck with breast augmentation at the same time. Do you include contouring with tummy tuck? Will I still have all the feelings in my breasts after augmentation. I want to go up one to two sizes. What would the cost of these surgeries.
A: Thank you for your inquiry and sending your pictures. You are a good candidate for breast augmentation and most patients will not lose nipple or skin feeling in their breasts after the surgery in the long-term. However, at your current weight and with the amount of intrtaperitoneal abdominal fat that you have you are not an ideal candidate for a tummy tuck based on what I am seeing these pictures. With this amount of abdominal fat, it will be limited as to how much skin and fat can be removed and most certainly your stomach will not be flat and will remain round. (less so but round nonetheless) You would get a better tummy tuck result if you lost some weight first.
There are numerous variables that affect the cost of breast augmentation and tummy tuck surgery. (type of implant, type of tummy tuck, how much liposuction is needed) So I will make some assumptions when I ask my assistant to send along the general costs of both procedures to you on Monday.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had my only child two years ago and since then have lost 50 pounds. Although I am working to lose weight, I am only seeing my tummy continue to sag. As a type 1 diabetic, the saggy skin on my tummy has now gotten to the point I can’t attach my insulin pump. Would a tummy tuck be good for me and will it interfere with my need for insulin through a pump?
A: With a 50 lb weight loss, and the resultant skin overhang that would develop from this amount of abdominal deflation, it is easy to see how a tummy tuck would be beneficial. A tummy tuck will completely get rid of all the tissue looseness/overhang in the abdominal area. While you are at some increased risk due to your type 1 diabetes for some potential postoperative complications (e.g., infection, wound healing issues), a tummy tuck would be immensely helpful and could potentially reduce your insulin requirements. I have performed numerous tummy tucks and other body contouring procedures on diabetics and have not seen these types of complications develop in any significant manner. While you will have to change the location of your insulin pump during the healing phase of the tummy tuck (six weeks), you will be able to use your abdomen again after that recovery period.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a stomach stapling done in June and have lost 56 pounds. I have had a tummy tuck, breast reduction and a brachioplasty ten years ago but have obviously ruined that. But now I’m on a healthy eating plan for life. I’m 64 years old and wondering what you would recommend for my body contouring. I have attached some pictures of how my disgusting body looks now.
A: Since you have all the scars from the prior procedures, you may as well take advantage of their existence and use them for skin and fat removal and overall tightening of the areas for your body contouring surgery. For your abdomen you need a fleur-de-lis extended tummy tuck to get rid of the loose skin in all dimensions. (horizontal and vertical) Thuis would need to extend around the flanks to chase the loose skin/dog ears. You would also benefit by a major breast lift, keeping all your existing breast tissue and lifting and tightening the breast mounds back up onto the chest wall. You can just use the breast scars that you already have. For the arms (which seem to have the least amount of excess and sagging skin) a repeat arm lift would be needed.
Most of these body contouring issues are fairly straightforward. The real question at age 64 is to not overdo any single operation and stress your body too much. While in younger patients I would do all three body contouring procedures together, that would be a lot for you to go through at your age. Thus I would recommend only the extended tummy tuck combined with at the breast lifts. These two procedures target the biggest problems that I see (and what most weight loss patients focus on the most) and would yield the single greatest body change.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to get a tummy tuck, breast lift and aug, as well as some liposuction. I have a vacation in April that I would like to look like a million dollars for!! What is the best time to have this surgery?
A: Your description of plastic surgery to help reverse the effects of pregnancy is a classic one for the well known Mommy Makeover procedure. In reality this is a combination of procedures that focus on the breasts and abdomen/waistline area. Although technically it could be any body contouring procedure that helps to reverse the changes induced by pregnancy.
Given your April vacation target date (and this is later December) and the magnitude of recovery really needed for a full recovery from major body contouring surgery, such as a Mommy Makeover, you need a minimum of eight weeks between surgery and the day you leave for vacation. Ten to twelve weeks for Mommy Makeover recovery is even better. This way you will have complete freedom any residual issues that can linger after surgery during the second month thereafter and be only be thinking about what you are doing on vacation and not what you can’t or don’t feel like doing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, How long should I wait to have a tummy tuck after having a baby. I delivered my baby three months ago and I am now very close to my before pregnancy weight. I am only about 3 lbs from it at this point. The issue is not the weight but the ton of loose skin that I have. I know that I am not going to have any more children so I am ready whenever a doctor says I should do it. I also have a lot of stretch marks which I really don’t like, will a tummy tuck get rid of all of them? Lastly, what type of tummy tuck should I have… a full or mini tuck?
A: The typical answer from most plastic surgeons is that the earliest that a tummy tuck should be done after a pregnancy is six months. This gives a woman ample time to lose as much as of their pregnancy weight as possible and to be able to take care of a new babcy before embarking on a need for their own recovery. It is also important to remember that this is an elective procedure so any need to rush the decision for surgery is an emotional one not one of medical necessity.
By using the term, ton of loose skin, this implies that a full tummy tuck is needed for the best result. This form of a tummy tuck is also the most assured way of getting off the maximum number of stretch marks. While it does result in a longer scar, the result is always better than when less tissue is removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Do you do or work with an OB/GYN who will do both the tummy tuck and partial hysterectomy during the same operation.
A: It has been historically common to do a hysterectomy and a tummy tuck at the same time for the obvious convenience of patient recovery and the access that a tummy tuck incision provides for the hysterectomy procedure. I have done it numerous times with various Ob-Gyn surgeons. That is still done today although not quite as commonly due to economic considerations. Now that hospitals are very conscious and diligent about collecting complete fees for the elective tummy tuck portion of the combined procedure (OR and anesthesia costs of which you will be responsible not your insurance) it becomes critical to look at the cost differences of having these procedures done together or separately. Depending upon the facility (hospital) the combined costs may be relatively minor compared to doing them separately or could be thousands of dollars more if done together in a hospital compared to having them staged apart. (tummy tuck done in a private facility)
Having good experience combining these procedures, we do know what that differential can be based on our own private plastic surgery center. I will have my office pass along that cost differential to you so you can see of such a combined procedure makes good economic sense for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a kidney transplant six years ago. My transplant team believes I could have a procedure to diminish the abdominal-flanks area. The side where the kidney is is larger. I weight 195 lbs and am 5’11”. I dislike being lopsided and have exercised (I am in pretty good shape). I was interesting in you because of your experience with a few transplant patients. There are great surgeons where I live but I trust you more.
A: I can see in your picture the protrusion/lop sidedness of the left side. That is the same side as your kidney transplant as can be seen by the location of the oblique abdominal scar. However, the bulge that is sticking out I doubt is where the kidney is. Generally that would be under the incision away from the bulge sitting on top of the abdominal fascia. Thus I do think that the protrusion could be reduced by a combination of liposuction and skin excision. (tummy tuck) The skin excision could extend across the whole abdominal incision as there may be skin excess there as well.
You would be on some level of immunosuppressive medication currently and we compensate for that by giving ‘stress steroid’ dosing at the time of surgery. Any other considerations/needs based on your transplant doctors input is also important.
I would estimate that you would need to be here no more than three to five days based on whether the placement of a surgical drain is needed. (which I would work towards not using.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Do you do the “drainless” tummy tuck surgery? Also, I have an umbilical hernia and am looking to have both procedures done simultaneously. Can this be done on the billing end so that insurance will cover the hernia repair, anesthesia, facility charges, etc and I self-pay the abdominoplasty procedure?
A: Thank you for your inquiry. Let me provide you with some clarification and additional insight in both your tummy tuck questions about a ‘drainless’ technique and the financial implications about doing combined medical necessary and cosmetic abdominal wall procedures.
I have done numerous drainless tummy tucks and there is an understandable appeal to it because of the absence of a drain. But there is more to it than just not putting in a drain. There has to be some additional steps done to close down the internal dead space and seal the wounds to prevent a seroma (fluid collection) after surgery. Drainless tummy tucks can be done by either using internal quilting sutures or a tissue glue prior to closure of the tummy tuck incision. These steps do take additional time (an extra 1/2 hour of operative time) and materials (tissue glues can cost up to $1,000) to do and thus the drainless tummy tuck is going to cost more than one in which a drain is used. A drain is a simple and quick method to manage potential seromas and also keeps the cost down. Thus one has to place a value on how much avoiding the drain is worth. And drainless tummy tucks do not have a complete absence of problematic serums afterwards, there is not a 100% guarantee that you would not get a seroma even with these maneuvers.
In what seems like a straightforward issue historically, the separation of a medical necessary procedure like a hernia repair and a cosmetic procedure like a tummy tuck should be simple. But in today’s health insurance world it is not. The first common erroneous perception is that somehow insurance is going to pay for the operative room and anesthesia charges for the tummy tuck portion of the procedure…and they will not. No facility will allow that to happen anymore so that all charges related to the tummy tuck portion of the combined procedure including operating room, anesthesia and any supplies used must be paid out of pocket and in advance of the procedure. While ‘sliding’ the operating room and anesthesia costs of the cosmetic portion of the procedure onto insurance was common practice 10 to 20 years ago, that is no longer permitted and is actually illegal today.
While there is no question that a hernia repair and a tummy tuck should be done together, and this is common practice, you have to look carefully at the cost issues to see what works in your best financial interest. Your insurance is going to require in almost all cases (with the exception of Anthem and a few other private carriers) that your hernia repair be done in a hospital or a hospital-owned facility. Such a facility may or may not have reasonable cosmetic fee usage costs. They will in most cases be higher than a private non-hospital owned surgical facility. Depending upon the difference in cosmetic costs between the two types of facilities will determine whether the combined hernia repair-tummy tuck is done through insurance using their required facility or whether it is just better to pay all of pocket for both procedures. (I have certainly seen that be the case many times) Each patient and what insurance carrier they have has to be considered on an individual basis.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in having a tummy tuck but do have a bit of a twist with my medical history. I have rheumatoid arthritis and have been on Xeljanz 10mg twice a day to control my symptoms. It has controlled them fairly well and I am not keen on potentially going off of it to have surgery. Can I have a tummy tuck while on this medication?
A: Xeljanz, known generically as Tofacitinib, is a recently approved drug (2012) for the treatment of rheumatoid arthritis. It works as an inhibitor of the enzyme janus kinase 3 (JAK3) which interferes ultimately with DNA transcription in the cell nucleus. It helps in arthritis because it inhibits production of inflammatory mediators in joint tissue. As an inhibitor of the inflammatory process, the drug is known to increase the risk of opportunistic infections such as tuberculosis, cancers and lymphomas.
But as it relates to surgery, the key questions are does it present an increased risk of infection or in any way impede wound healing?This would be particularly relevant in a large healing wound like that of a tummy tuck. There is no specific information in the medical literature that addresses the specific effect on wound healing of the Xeljanz medication. This is likely because it is relatively new although almost all anti-rheumatoid drugs, with the exception of corticosteroids, have a similar void of specific information on their effects on postoperative wound healing.
What I can find is from the newsletter Drug Safety Quarterly Fall 2013 issue which has an article entitled ‘Wound Healing and Anti-Rheumatic Drugs’ authored by Drs. Goodman et al from NYU. From it I quote…
‘Healthy wound healing proceeds through an inflammatory phase, followed by wound remodeling and finally re-epithelialization of the skin edges. These are the normal sequential stages of wound healing. Patients with rheumatoid arthritis (RA) are often on multiple medications to control their symptoms. These medications may include analgesic, anti-inflammatory, biologic or synthetic disease-modifying antirheumatic drugs. (DMARDs) With the exception of methotrexate, there are very few controlled studies that have evaluated the effects of these medications on wound healing and infection risk after surgery.’
‘…with the exception of methotrexate, there is a lack of data regarding optimal practice for perioperative management of antirheumatic treatment in RA patients undergoing surgery. Existing data, however, indicates that methotrexate may be continued throughout the perioperative period for otherwise healthy individuals. For the other anti-rheumatic drugs, while continuing medication may hamper wound healing and predispose to infections, discontinuation may lead to disease flare, which increases the need for corticosteroids or other medications that may also increase the risk for inadequate wound healing and infection to regain disease control. Moreover, there is no consensus among the various rheumatic disease societies regarding optimal practice. Although there are clear effects of anti-rheumatic therapy on wound healing and clear infection risk, the role of RA inflammatory activity on wound healing, infection, and rehabilitation should also be considered. For surgeries such as the implantation of a prosthetic joint, where surgical site infection carries significant morbidity, current practice favors a conservative approach.’
This summary comes from an institution that is performing joint replacements in orthopedic surgery. So these types of patients have significant functional and pain issues related to joint dysfunction. So accepting whatever increased wound healing or infection risk may be worth the trade-off for the benefits. Tummy tuck surgery is much more elective and those unquantified risks must be considered even more carefully.
This is a good discussion you should have with your rheumatologist. He/she probably will not be as understanding about tummy tuck surgery as the need for a joint replacement. But in the end you should follow their advice. The only thing we know for sure is that you are at some increased risk of potential wound healing problems or infection if choosing tummy tuck surgery while on Xeljanz but the magnitude of that risk is unknown.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am researching tummy tuck surgery and trying to see what can be done for me. I have attached pictures to help you see my severe abdominal overhang problem. I would like your professional opinion on which course of action would be best.
A: It is important to realize that there are different kinds of tummy tuck surgeries depending on the nature of the abdominal problem. While traditionally divided into a mini and full tummy tuck, that historic classification by today’s methods is too simplistic. I divide tummy tuck surgery into six different types and levels which vary based on the amount of tissue removed, the location and extend of the incisions and whether liposuction plays an additive role in improving the result.
There is no question you would get tremendous benefit by an extended tummy tuck. (level 5) This is a tummy tuck where the removal of excess tissue wraps around the side of the waistline or encompasses about 300 degrees around the waistline. (it does not cross the midline in the back like a full circumferential body lift does) If you do not chase the excess skin around the waistline (a traditional or level 3/4 tummy tuck stops at the hip bones) you will be left with big dog ears of skin and protruding tissue over the hips. In addition, it is important in any tummy tuck particularly when there is an overhanging abdominal pannus (apron) that a simultaneous pubic lift be done. This is often overlooked because it is hidden underneath the pannus but will become unmasked when the pannus is removed. Thus the excisional pattern of the tummy tuck should incorporate the design of a simultaneous pubic lift in its pattern. I have attached some picture showing a before and after an extended tummy tuck with a pubic lift. Note that the resultant tummy tuck scars wraps almost completely around the waistline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a full tummy tuck three months ago. I opted liposuction with my tummy tuck. I am very pleased with the way the bottom of my abdomen looks, however, I have quite a bit of fat on my upper abdominal. I was under the impression that you would do liposuction on the upper abdominal area during the procedure, however, it wasn’t. Can you advise why? I did pay for the tummy tuck and liposuction. I have researched it quite a bit to make sure I didn’t misunderstand, and it looks like that would be the “norm” if you had a tummy tuck and lipo that it would be done on the upper abdominal area, however, it wasn’t in my case. I look forward to hearing from you.
A: This particular tummy yuck question is not uncommon and there is a very straightforward answer. The concern about fullness in the upper abdominal area is one of the most prevalent after surgery issues after one has had a tummy tuck. One does not have to look too hard on any plastic surgery forums on the internet to see how common this tummy tuck question is.
This question is so common that in every tummy tuck consult I emphasize to patients about this issue and, while liposuction may be done in the flanks and lateral abdominal wall, I do not perform it in the upper abdominal region. Thus, one may be left with an upper abdominal region that may be more protrusive than in the lower area where all of the tissues were cut out if they have any fat thickness in their upper abdomen originally.
It is not the norm in a full tummy tuck to perform full abdominal liposuction on the upper abdominal skin flap. This is avoided by most plastic surgeons because of its devascularizing effect on the skin flap and the risk of causing poor wound healing, central wound dehiscence and even overt tissue necrosis between the new belly button and the incision line. One also does not have to look to hard online to see some disastrous results when upper abdominal liposuction is done with a full tummy tuck. While it may not occur in every such case, one devastating tissue necrosis event can take months to heal and create a permanent abdominal wall deformity.
This makes going for the very flattest total abdominal result possible by widespread use of liposuction at the time of a full tummy tuck a risky manuever. This is one that I will not do out of concern for patient safety and to avoid risks of a postoperative complication. This is why I point this issue out during the initial consultation and emphasize that secondary liposuction may be needed for flattening the upper abdomen six months or more after the procedure when it is safe to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a tummy tuck eight months ago and, although I am happy with most of the results, my belly button afterward has always looked a little funny to me. It looks bloated for lack of a better medical description and bigger than it did before the tummy tuck. It was not a great looking belly button before the surgery but it looks no better now and even looks a little deformed. Can you tell me what is going on and how I can fix it?
A: A ‘bloated’ belly button after a tummy tuck suggests that too much of the umbilical skin is seen on the outside. This usually results from an umbilical stalk that is too long for the thickness of the tissue between the skin and the abdominal wall, pooching outward creating a mushroom or bloated appearance. An umbilicoplasty procedure can be done to shorten the stalk and pull the belly button back inward for an unbloated or more of a funnel effect to create a more natural belly button appearance.
While the creation of the ‘new’ belly button in a tummy tuck is the most minor part of a tummy tuck, it along with the scar line is the most heavily seen feature of the result. Shortening the umbilical stalk, keeping the new opening in the skin small, and removing a funnel of fat between the skin and the abdominal wall all help to create an inward shape or pull to the recreated belly button and allows the scar line to be situated in a more obscure location.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a tummy tuck six months ago but am not happy with the result. My lower stomach area around the incision is flat but my upper stomach below my breasts bulges out. Is this swelling, fat or something else? Why isn’t it flat like my lower stomach?
A: It is not rare after a tummy tuck to have the upper stomach area above the belly button remain than the shape of the stomach below the belly button. This can occur in those patients who have thick fat layer to their stomach initially. Because most plastic surgeons avoid debulking the upper stomach area during a full tummy tuck by extensive lipsouction, and repositioning of the upper abdominal flap downward over the excised area is done to ls close the wound, can create a mismatch in fullness of the tissues above and below the belly button. What you have is not swollen or bloated but the natural thickness of the upper abdominal fat layer which has largely been undisturbed. This is why liposuction of the upper abdominal area six months or more after a tummy tuck can reduce this fullness and put the finishing touches on a tummy tuck effort.
I always make it a point of emphasis in presurgical discussions to point out this exact issue in patients that have naturally convex abdominal shapes and thick fat layers on their abdomen. There are many tummy tucks who can not achieve a completely flat abdomen and this is important to point out beforehand.
Dr. Barry Eppley
Indianapolis, Indiana