In the infrequent cases where revision is needed, however, attaining patient satisfaction depends on careful evaluation to understand the etiology of the presenting complaint and establishing realistic expectations.
Dr. Mangubat says that as with any surgical procedure, prevention is the best treatment for complications of abdominoplasty. A good clinical evaluation, including a thorough history, is important for identifying individuals such as smokers or poorly controlled diabetics who are at risk for necrosis or poor healing.Thorough preoperative counseling is also essential so patients are aware of the sequelae of the surgery and have reasonable expectations for outcomes, he says.
"Postpartum women must realize the surgery will likely not restore their body contour to its prepregnancy state, and all candidates must understand that the surgery involves a relatively long incision that will result in a visible scar," says Dr. Mangubat, who is in private practice at La Belle Vie Cosmetic Surgery Centers, Bellevue and Tukwila, Wash.
"I tell all my patients that it is impossible to remove 20 inches of skin and leave a 1-inch scar, and most understand and accept the incision, knowing they are trading a scar for much better body shape. With proper planning and surgical technique, however, the incision line can be made so that it remains hidden under clothing, and most patients are happy to accept an imperfect cosmetic outcome in lieu of their preoperative appearance," he says.
Use of the lipoabdominoplasty technique is not only safer than traditional abdominoplasty because it preserves the vasculature and nerve supply; it also optimizes the cosmetic outcome because it allows for direct measurement of the amount of skin that can be removed and fine-tuning of the level of the scar. Therefore, it minimizes the potential for patient dissatisfaction due to inadequate skin removal or scar visibility, Dr. Mangubat says.
REASONS FOR REVISION In addition to complaints about residual excess skin and scar location, presence of a thickened, hypertrophic or keloid scar and residual fat are among the most common reasons why patients seek revision after abdominoplasty.
Patients should be evaluated for a history of abnormal scarring prior to the procedure so they can be warned of a risk postoperatively. If a hypertrophic or keloid scar develops after the surgery, it can be addressed with surgical excision followed by frequent intralesional corticosteroid injections to minimize recurrence, Dr. Mangubat says. Radiation therapy may be necessary for scars resistant to intralesional steroids.
Before undertaking scar revision, surgeons must consider whether the patient can be relied upon to return for the ongoing postsurgical care, Dr. Mangubat says.
"Patients who do not comply with the need for corticosteroid injections to minimize recurrence may walk around with an unsightly scar that has your name attached to it," he says.
Complaints about the incision being too high can be addressed with a revisional procedure if there is sufficient skin available to be taken from below. Additional liposuction can be performed if the patient wants more fat removed, and it may even be a solution for a patient who is unhappy because of residual loose skin.
If excisional surgery is needed to remove loose skin, however, patients must be cautioned about the possibility of having a vertical midline scar or that their horizontal scar will lie higher after the revision, Dr. Mangubat says.
Patients must also be advised of the greater risk of complications after revision abdominoplasty, due to the presence of scar tissue and potentially reduced blood supply in the operative field. These factors lead to greater tension that in turn decreases blood flow and promotes scarring, Dr. Mangubat says.
Just as lipoabdominoplasty is preferred in a primary procedure because it maintains the blood supply, however, it is also the technique of choice for revision cases, he says.