Houston, Texas-based plastic surgeon Christopher K. Patronella, M.D., says it was in the name of patient satisfaction that he modified traditional abdominoplasty in 10 ways to create his anatomy defining progressive tension suture technique. By applying those elements during 1,138 tummy tucks he has performed since 2000, Dr. Patranella reports an overall patient satisfaction of 94% and the professional satisfaction of having patients who emerge with more natural, less plastic-looking outcomes. He published his findings in the November/December 2015 Aesthetic Surgery Journal and shares his approach with Cosmetic Surgery Times.
In This Article:
An Inspired Tummy Tuck Approach
Dr. Patronella, clinical professor of plastic surgery, University of Texas Medical Branch, Galveston, says interviews throughout the years with his patients revealed that many were reluctant to have abdominoplasties because of the artificial looking results they saw among their friends who had the procedure.
“… they’d be reluctant to pursue it because they didn’t want that artificial board-like appearance following surgery. Women wanted the results from abdominoplasty to be more authentic. They wanted it to look more like it looked before they had children,” Dr. Patronella says.
Hearing that over and over led him to refine the tummy tuck. Dr. Patronella says that ideal candidates for the procedure he uses today have body mass indexes (BMIs) between 20 and 35.
“The overly fit patient can be done but I cannot give them the kind of depth of contour that I can in someone who has a little more of a fat pad,” he says.
Dr. Patronella says he is always looking for ways to improve what he does as a plastic surgeon.
“I’m as close as I’ve ever been to creating the ideal authentic tummy tuck,” he says. “It’s rewarding to me because it’s so satisfying to patients.”
10 Tips for Tummy Tucks
This is how Dr. Patronella describes the 10 elements that define his approach to abdominoplasty.
Without exception, women and men want their incision/scar to be low on the abdomen and easily concealed. I have a particular step in preparing for the tummy tuck that aims to keep the incision very low — just at the pubic hairline, extended laterally to a point, on average, about 8 cm below the anterior-superior iliac spine. That is lower than what it has been, traditionally, in the past.
NEXT: Tip 2
When performing an abdominoplasty, our main precaution is to maintain good vascularity to the abdominal flap; therefore, there has been an appropriate emphasis on carefully elevating the flap, to help preserve the blood supply to the remaining skin. Yet, I think it is possible to safely mobilize, or elevate, the abdominal flap with three important technical maneuvers: One is to avoid liposuction of the upper abdominal flap. Two is to preserve the lateral rectus perforators on the upper third of the abdominal flap. Three is to do more discontinuous undermining of the lateral flap, as opposed to direct undermining. It’s important to achieve a thorough mobilization of the flap in order to adequately employ the other technical elements of my approach, which allows for a natural anatomical restoration.
NEXT: Tip 3
3. Repair the fascial separation, but don’t overcorrect.
Most women who request a tummy tuck will have had children, and, in those patients, there is often separation of the medial edges of the rectus muscle that causes an anterior protrusion of the abdominal wall that can’t be corrected with exercise. Historically, a strong, tight repair of the midline fascia was recommended in order to flatten the abdomen. But it is my contention that this can be counterproductive to an anatomically correct abdomen. First, I think an overtightening of the abdominal wall will result in fascial tears and separation of the repair. My technique is to repair what’s obviously separated, but no more than that. Using this approach, I believe I have the best chance at creating the natural concavity of the upper abdomen and a very subtle convexity of the lower abdomen, which is what a toned, attractive female abdomen looks like.
NEXT: Tip 4
4. Thin the fat, especially over the external oblique laterally, but stay below the Scarpa’s fascia.
Traditionally, we’ve been reluctant to thin the fat of the abdomen when we have elevated the flap. I believe we can do this safely, if we limit our thinning to that fat that is present beneath Scarpa’s fascia. Because the blood supply to the elevated flap passes superficial to Scarpa’s fascia, the fat of the flap can be safely thinned deep to the easily identifiable Scarpa’s fascia.
NEXT: Tip 5
5. Consider a modified approach with progressive tension sutures.
The technique of progressive tension sutures was developed and published in 2000 by plastic surgeons Drs. Harlan Pollock and Todd Pollock. The original intent of progressive tension sutures was when the sutures are placed, they will attach to the abdominal flap to the underlying fascia in an advancing method in order to eliminate or at least reduce the space between the fat and the fascia. By eliminating that space, we would reduce the accumulation of inflammatory fluid that could result in seroma formation and its adverse wound healing sequela. I began using that technique because, like many other plastic surgeons, I had tremendous problems with the development of seroma formation after abdominoplasty. Seromas can result in increased wound infection, prolonged healing and potential negative aesthetic ramifications. When a seroma forms, a thicker layer of scar tissue occurs in response, and the possibility of chronic swelling and contour abnormalities of the abdomen can occur. So, I began using progressive tension sutures to reduce the potential for seroma formation but soon modified the technique, so that I could use the sutures, not just to close the space between the fat and fascia, but also to enhance anatomical definition. Specifically, my goal was to enhance the midline valley (linea alba), and the lateral valley (semilunar line), as well as the soft contour depression over the external oblique (external oblique fossa). And when those sutures are placed in a very specific way to enhance those anatomical features, a more authentic abdominal appearance, which has more character and more of a three-dimensional effect as opposed to flat-as-a-board abdomen, can result.
NEXT: Tip 6
6. Don’t remove as much skin as possible.
There is a tendency to remove as much skin as possible when performing a tummy tuck. Often, during the traditional procedure, where aggressive skin removal is performed, the patient is placed in a hyper-flexed position, so that the abdominal flap can be repaired to the lower abdominal incision. I think this is counterproductive and leads to an unnatural result of excessive tightening of the abdominal skin. Part of the reason that many plastic surgeons will remove as much skin as possible is so that the defect that is created from releasing the belly button can be removed with the abdominal flap. In my opinion, this can lead to an excessive removal of abdominal skin. It can look very artificial, and it can elevate the pubic area, creating an unattractive appearance of the vaginal area and the vulva. It can also elevate the scar. In my opinion, it is far better to accept that you can only remove as much skin as what is redundant, and close the umbilical skin defect as a short 2 to 3 cm vertical closure, somewhere between the new belly button position and the lower abdominal incision. Plastic surgeons might be reluctant to leave a vertical scar, but, in my experience, after interviewing hundreds of women and asking them whether or not a vertical scar would be more acceptable than a high horizontal scar, I have yet to find a patient who prefers a high horizontal scar. In about 30% of my patients, there will be a vertical scar.
NEXT: Tip 7
7. Don’t ignore the mons area.
It is not uncommon for this important area to be ignored during an abdominoplasty, and it shouldn’t be. During pregnancy, the entire abdominal wall stretches, as does the mons. This area can also be lax, stretched and excessively fatty. Women universally hate a plump mons area. It is my contention that the mons area should be rejuvenated in the same way and to the same tone that we’re rejuvenating the abdominal wall. It should be restored to the same skin tone and tissue thickness above and below the incision. This is named the abdominal-mons-aesthetic unit: equalization of skin tone and equalization of fat thickness, and it should be part of every tummy tuck.
NEXT: Tip 8
8. Remove what is actually redundant by waiting until the end of the procedure.
Traditionally, the redundant abdominal skin is removed as the initial part of the surgical procedure. The laxity is assessed, marked out, and removed. I prefer to elevate the skin flap and advance it with my progressive tension sutures in a very specific way along natural anatomical lines; then, at the conclusion of the procedure, I assess how much is truly redundant. I customize my finishing incision to the exact degree of laxity that remains. In doing so, I don’t remove too much or too little at the start of the procedure but rather what is actually redundant at its conclusion.
NEXT: Tip 9
9. Match skin thickness for upper and lower flaps.
At the incision line, it is not infrequent to see either a contour depression of the scar or a flap thickness that is thicker than the fat thickness that is below the incision line. Inadequate equalization of flap thickness and layered repair of Scarpa’s fascia and deep fat can result in an indentation at the scar. The resulting contour depression occurs when the fat of the abdominal flap is thicker than the fat below the incision. It’s an annoying cosmetic deformity that can be easily prevented by equalizing the fat thickness at the incision line, prior to layered repair at the incision.
NEXT: Tip 10
10. Create a deeply contoured umbilicus.
Often, the new umbilicus created during a tummy tuck is the most obvious sign that surgery has been performed. The scar frequently expands circumferentially, and with it the belly button widens, resulting in an unsightly doughnut ring effect and loss of umbilical depth. It’s a real giveaway in a swimsuit, and the primary reason why many women shy away from doing this procedure. If the belly button is not authentic, the tummy is not authentic. By being attentive to maneuvers that create a deeply contoured umbilicus and keeping the scar on the inside edge of the new belly button, as opposed to stretched outward around the belly button, a less conspicuous surgical appearance can be accomplished. This requires deep attachment of the belly button to the muscle wall during the abdominoplasty and generous thinning of the fat where the belly button is going to be inset into the abdominal flap. Then, it requires advancing the abdominal skin flap down to the base of the belly button, so that the scar becomes internalized. I have developed a technique using four small dermal flaps on the abdominal skin to make this a little easier to do. It allows surgeons to advance the abdominal skin down to the muscle wall, so that a deep inset of the belly button can be achieved.
For more, on Dr. Patronella’s abdominoplasty approach:
Patronella CK. Redefining abdominal anatomy: 10 key elements for restoring form in abdominoplasty. Aesthet Surg J. 2015 Nov;35(8):972-86.