Tummy Tuck techniques influence blood supply disruption and post operative swelling

I have been looking at Tummy Tuck forums, just to get an idea of how patients perceive the whole experience of surgery of the abdomen, or  abdominoplasty. Two things struck me. The first one was the large number of patients who complain of swelling, both immediately after surgery, and weeks after. The second is that a lot of patients are still getting fluid collections that have to be drained with a needle, sometimes repeatedly.

I think post operative tummy tuck swelling and seromas (fluid pockets) are largely preventable by:

A) surgeon’s choice of abdominoplasty technique: Standard vs. Lockwood

B) post operative compression

In today’s post I would like to discuss the two types of techniques used in the abdominoplasty procedure. The two surgical techniques are illustrated above.

Standard Abdominoplasty Technique

The standard abdominoplasty(tummy tuck) surgical technique is taught in most Plastic Surgery Residency programs. Therefore, this is the procedure that most plastic surgeons perform. This technique gets the job accomplished, but the large area of dissection does disrupt the blood supply, which can lead to fluid build up and seromas.

The diagram above illustrates how the standard abdominoplasty operation lifts the abdominal skin from the pubis all the way to the rib margins, the excess skin is cut, usually at the level of the belly button, and the remaining upper abdominal skin is stretched down to the level of the pubic mound. Since such a large area of skin is being dissected, this results in a large area with blood supply disruption. The area with blood supply disruption is represented on the left by the pink shaded area WITH red x’s. You can see that a large area does have blood blow disruption. The problem with the standard technique is that it cuts off the blood supply coming up from the muscles to the abdominal skin. Secondly, the space that was created by the separation of skin flap from muscle is now an empty space where fluid can build up. This is why drains are so important with this technique– they suck the fluid out as it builds up allowing the skin and muscle layers to stick together again.

Lockwood Technique of Tummy Tuck

The Lockwood technique separates much less tissue and is less disruptive to blood supply. From the belly button to the breast bone it only separates a narrow tunnel. This leaves most of the abdominal skin tethered to the muscle and its blood supply. Thus, you have more blood supply in the general area which is a good thing. The area with blood flow disruption is much smaller in the Lockwood technique compared to the Standard technique.

The fact that the skin stays tethered means that there is less chance for fluid accumulations. The fact that the skin has better blood supply has a lot of positive implications. For example, I can liposuction a lot more before worrying about interfering with blood supply. Secondly, the wound itself heals better because of the better blood flow. Similarly if there are other existing scars in the abdomen, such as an old gall bladder scar, this technique is less likely to interrupt the blood supply. Finally, the increased blood flow allows for more compression so that I can tighten the area better (without fear of interfering with blood flow). Thus, I get a much better aesthetic result in my Tummy Tucks with the Lockwood technique.

The Lockwood technique places much of the wound tightening on a deep layer of tissue called Scarpa’s fascia. Other techniques, such as the standard technique use more tension near the incision area which can causes thick scarring. Since the wound tightness is diverted away from the skin with the Lockwood technique, there is less chance of thick scarring. Likewise, since the Scarpa’s fascia is better anchored to the deeper tissues, there is less chance of the scar settling upwards towards the belly button.

In the early years of my practice I used the standard abdominoplasty technique and patients would sometimes get thicker scarring postoperatively which would necessitate steroid injections and crèmes to reduce the scars. Now that I use only the Lockwood technique, I see patients at 4 months for photographs and I never get requests for scar fading creams.

Pascal, or Drainless Tummy Tuck Technique

There is another technique called the Pascal, or Drainless Tummy Tuck technique where the abdominal skin flap is sutured in quilt like fashion to the abdominal wall to prevent accumulations pockets. While it may be effective in preventing fluid accumulations, it does nothing to improve the blood supply of the abdominal flap, which I feel is so important for the reasons listed above. Thus, I do not use this technique.

The Lockwood technique is a great option for preventing fluid accumulations (seromas), like the Pascal technique, but it accomplishes so much more because of the improved blood supply to the skin flap.

The next element in the prevention of fluid collections is compression, and I’ll talk more about compression in my next post

Ricardo L Rodriguez, MD