COSMETIC SURGERY

COSMETIC SURGERY

Patrick McMenamin, MD

785 University Avenue · Sacramento , CA 95825 · (916) 564-8888

Abdominoplasty (Tummy Tuck) is an imperfect solution to a protruding abdomen (weak abdominal muscles) and excessive skin as a result of overstretching during pregnancy or significant weight loss. This condition does not respond well to exercise or diet because it happens as a result of stretching. During the surgery, the abdominal muscles can be tightened and excess skin removed to improve the appearance. However, Abdominoplasty does not treat stretch marks and texture changes in the remaining skin and it leaves you with scars across the low abdomen and belly button that can be unsightly, especially during the early healing phase.

Abdominoplasty is not a substitute for weight loss. This operation works best for patients at or near a normal healthy weight. You may be asked to lose weight prior to the procedure and it will be important to maintain that loss afterward. A good candidate for this procedure will also be in good general health, at an age appropriate for good healing, and a non-smoker (i.e., no smoking for 1 month before and 1 month after the procedure.) All of these factors, and others, will be assessed during your preoperative medical history, physical exam, and preoperative tests.

There are risks to undergoing this surgery as with any surgery and these risks are serious. All of these risks will be discussed with you by the doctor. These risks include bruising, swelling, numbness, infection, allergic reactions, necrosis (skin death), seroma (fluid pocket), hematoma (blood pocket), and deep vein thrombosis (blood clots in the legs which can travel to the lungs.) There are other risks as well and are included in the operative consent form. Treatment for complications, should they occur, will be at an additional expense to you, including, if necessary, hospitalization. Skin irregularity, mottling, or unevenness may result. Scars may need to be revised. Liposuction may be beneficial at a later date to smooth contours and remove residual excess fat in the waist or hips that is not addressed by the abdominoplasty. These treatments, if necessary, will also be at an additional expense to you.

Our office wants to provide you with the very best surgical care. You can help to minimize the risk of complications by carefully following the preoperative and postoperative instructions. The patient is responsible for the following before surgery:

• Please read all the information in this handout. Do not hesitate to telephone to ask any questions that may occur to you after you have left our office.

• Do not take ASPIRIN (Anacin, Bufferin, Excedrin, etc.) or ANTI-INFLAMMATORIES (Advil, Ibuprofen, Naproxen, Motrin, etc.), or any medication containing these drugs for two weeks before and after surgery. These will promote bleeding and bruising. Tylenol (Acetaminophen) is OK for pain/headache. Also, do not take any vitamins, herbal supplements (Ginko Biloba, St. John’s Wort, etc.), diet or energy pills, Vitamin E, Vitamin C, or fish oils for 2 weeks before and after surgery. Also do not take any unprescribed or recreational drugs of any kind. Make sure your doctor knows all of your prescription medications.

• Do not drink any ALCOHOLIC BEVERAGES for two weeks before and after surgery. Alcohol promotes bleeding.

• Do not SMOKE CIGARETTES/Marijuana or “chew” any other tobacco product, for at least four weeks before and after surgery. Tobacco products constrict blood flow to the skin causing delayed healing and higher instances of skin necrosis (skin death.) Second hand smoke is important to avoid also.

• Arrange for help: Arrange to have someone drive you to and from your surgery and to your post operative appointments for the first two weeks. You must also arrange to have someone stay with you for the first 3-4 days or longer, if needed. Child care should be arranged if needed. You should plan on 6 weeks of healing time where you can do no exercise, lifting, or other movements that strain the abdominal area.

• Clothing on the day of surgery: Wear something very loose fitting that is easy to get on and off. A moo-moo type dress is preferable for women or very loose fitting “sweats” for women or men and slip-on shoes.

• Diet before surgery: Do not eat or drink anything (including water) for eight hours prior to your surgery except a sip of water to take the medications given to you by our office and your approved prescription medications.

• Bring warm socks: Because it is cool in our operating room, we recommend warm socks to keep your feet warm. If you tend to get cold hands, mittens can also be worn.

· Preoperative medications: At your preoperative visit, you will be given medications in small white packets to take before and after surgery. You will be asked about all other prescription medications and any over-the-counter medications/vitamins/herbs you currently take. Be prepared to give the name, dose, and reason you are taking prescription medication. You can usually take your normal daily medications (except aspirin or anti-inflammatories). These will be discussed with you by the doctor or by the PA at your pre op appointment.

· Vionex Disinfectant Soap: A vial containing disinfectant soap will be given to you to shower with before you come in for surgery. You only need to use this in the areas of treatment. Do not apply any lotions, creams, talcs, etc., to those areas after you have cleaned your skin.

Before you leave your home, you must take the medication given to you at your preoperative visit according to the directions on the packages. Also, you will shower with the disinfectant soap. Be sure to read the additional instructions on the white “Pre Op Handout” that was given to you at your preoperative visit that outlines the time you need to arrive and other instructions.

Upon arriving at our facility, you will be greeted and changed into appropriate garments for surgery. The surgeon will use felt tip pens to mark out the areas being treated. (Fig. A) Preoperative photographs will be taken. (Copies of these photos will be given to you.) After one last trip to the bathroom and a step on the scale, you will be escorted to the operating room. While lying on a heated surgical bed, an I.V. will be started and you will be hooked up to a monitor that will regularly check your heart tracing (EKG), blood oxygen level, and blood pressure/pulse. You will be given fluids through your I.V. The anesthesiologist will ask you a few general health questions. He will administer sedative medications as needed for your comfort. For all practical purposes, you will sleep through the procedure. You will NOT be administered a general anesthetic unless that has been prearranged and your surgery is being performed at the hospital or surgery center outside of our office.

After prepping the treatment area with a disinfectant, your skin and abdominal wall will be numbed with a dilute anesthetic solution. A small amount of fat may be removed from the abdomen by suctioning. An incision will be made basically from pelvic bone to pelvic bone. (Fig. A) The skin and fat layer will be elevated away from the muscle layer of the abdomen from the pubic line to approximately the breast line. The navel will be totally released from the elevated tissue. (Fig. B) A strong suture will be used to tighten the musculature of the abdominal wall. (Fig. C) The excessive skin and fat will be cut off from the lower edge. A new navel hole will be made in the skin flap. The navel stump will be brought through the new hole, and the tissue will be sutured to fashion a new navel. (Fig. D) One or two “drains” will be placed at the outer edges of the abdominal incision and the lower abdominal incision will be closed with sutures. Note: This facility does not use staples to close incisions.

After the abdominoplasty incision is closed with suture, steristrips will be placed. Absorptive padding and/or a soft folded towel will be applied under an abdominal compression binder. Compression will help prevent a fluid collection under the skin. The drain tubes will be attached to fluid collection bulbs that will be attached to the binder. Lastly, Jobst anti-embolism stockings will be put on your legs to help prevent blood clots. When it is determined that you are stable for discharge, you will be disconnected from the IV and the patient monitors. Verbal and written instructions on home care will be given to you and your home care person, along with discharge medications and supplies. You may have some level of numbness, tingling, swelling, redness, sharp shooting sensations, pain, and other sensations for weeks to follow. We would expect you to improve dramatically over the first 3-4 weeks and then have gradual improvement from there. It will take a full year to completely heal from this surgery. Fig. E shows an excellent result at one year in an ideal candidate for this surgery. You can expect something less, maybe much less, in your result. There are many variables that determine the final outcome of this surgery. Your surgeon will discuss with you what you can realistically expect.

Most patients have minimal discomfort upon waking because of the local anesthetic and IV pain medication. “Tightness” in the abdominal area is more often described rather than pain. The local anesthetic will wear off in 6 – 8 hours.

Post-surgical nausea and vomiting is uncommon with IV sedation as opposed to general anesthesia.

It is not uncommon to feel drowsy for several hours after the procedure. You must be driven home and made comfortable to rest. A recliner chair works best for sitting and sleeping the first 10 days or so after surgery. Keeping the head elevated above the heart and keeping your torso in a semi-flexed position will help with swelling and comfort. Putting ice packs on the abdomen will help also, but they must be applied over the binder.

It is very important for you to closely follow postoperative instructions to maximize the benefits of surgery and minimize unwanted complications. Ask for clarification by your surgeon or the staff if you do not understand any of the following instructions:

• You can not under any circumstances drive yourself home from surgery or to your follow-up appointments in the first week.

• Activities: Quiet rest is required in the first week after surgery. However, it is very important that you routinely squeeze the muscles in your legs and get up to slowly walk around the house for a few minutes out of every waking hour. This helps to prevent deep vein thrombosis (blood clots) in the legs which can be life threatening.

• Elastic Abdominal Compression Binder: After abdominoplasty surgery, an elastic support binder will be worn to prevent accumulation of fluid under the skin of the abdomen. Patients are required to wear this elastic binder (or later a girdle) continuously for approximately six weeks after surgery. Your surgeon will tell you when you may discontinue wearing it. The binder/girdle should be “comfortably snug.” If you are having tingling or swelling in your extremities, the garment is too snug. If you can easily slide your hand underneath, it is too loose. Wearing the garment helps to decrease swelling sooner and helps to prevent the accumulation of fluid pockets (seromas.) If you develop a fluid pocket, please notify the office. Seromas develop frequently and may require treatment. If a treated area becomes red, tender, and inflamed, notify our office immediately, including weekends.

• Jobst Stockings: Compression (Jobst) stockings must be worn on your legs 24 hours a day after surgery. The compression increases blood circulation in your legs to help prevent blood clots. However, squeezing the muscles of your legs frequently and getting up to walk for a few minutes every hour, is very important, too. If you don’t do those things (wear the stockings, do the squeezing exercises, and walk) you will be at a much greater risk for deep vein thrombosis (blood clots.) If you develop a clot and it goes to your lungs, you could die.

• Drains: You will have one or two drainage tubes sutured to each corner of the abdominal incision. A fluid collection bulb will be attached to the tubes. The drains extend up under the skin and serve to pull excess fluid away to help prevent a seroma. When the bulbs are full of fluid or are no longer compressed (squeezed down) to provide suction, you must empty the fluid and recompress the bulbs. The fluid will be red (blood) early after the procedure and will gradually lighten to a pinkish color over several days of time.

• Personal Hygiene and Wound Care: You may sponge bathe with a wash cloth as needed beginning the day after surgery. Keep the water temperature comfortably warm, not hot. Do NOT submerge in water (take a bath) or shower until Dr. McMenamin says it is OK. Keep your wound dressings and binder/stockings dry. Remove the binder and inspect the skin daily. If you observe excessive redness or darkness of the skin or any other alarming changes, contact the doctor immediately. Cover the abdomen with a soft, clean, folded towel and replace the binder comfortably snug as discussed above.

• Reapplying the binder: Position the binder out flat on your bed. Lie down on it on your back with the seam of the binder aligned with your spine. Position the towel over your abdomen from the pubic line to the breast line and allow it to curve around your sides. Have someone help you pull the non-sticky side of the binder over while you hold the towel and then pull the sticky side over top to adhere snugly. The drainage tubes should extend from underneath and the bulbs should be safety pinned to the binder. Underwear should be worn on the outside of the binder so the elastic band won’t dig into the skin.

• Discomfort and Bruising: The numbness from the local anesthetic will begin to wear off about 8 to 12 hours after surgery. Because you have just undergone extensive surgery, expect to have significant discomfort. For most people, the most uncomfortable days are the second or third days after surgery. It may be difficult for you to straighten your back to stand up or to lie down flat. Bending slightly at the waist and bending your knees and keeping your head elevated will help. Bruising and swelling in the areas of treatment as well as in the pubic areas and upper hips/legs is to be expected. The extent varies from person to person. Males should not be alarmed about swelling or bruising extending into the penis.

• Pain medication: You will be given Vicodin (or some similar narcotic) for pain. Because you will have some level of numbness in the first 12 hours, only take Extra Strength Tylenol for pain as directed on the bottle. After that, if you need it, you can take up to two Vicodin in a 4 hour period. ALWAYS take it with a meal so as not to upset your stomach. DO NOT take Aspirin, Ibuprofen, or similar medications for at least 14 days following surgery as they tend to promote bleeding. Also, do not take Tylenol and Vicodin at the same time. Vicodin (and some other pain medications) contains Tylenol and you will over dose on it.

• Do not take Ginko Biloba, Vitamin E, Vitamin C, fish oils, or any other supplement of any kind for two weeks after surgery.

• Do not smoke/chew tobacco products or drink alcoholic beverages for two weeks.

• Do not immerse in water (swim, bathe, hot tub, etc.), take a shower, or wash your hair until you’ve been cleared to by Dr. McMenamin.

• Diet: After surgery, drinking generous amounts of water, fruit juices, or soft drinks will prevent dehydration and help your body to rid itself of the medications used in surgery. Light, bland, low salt meals are recommended the day of surgery with resumption of your normal diet as tolerated. It is very important that you keep your intake of calories up and that you get protein in your diet. Your body needs calories, especially protein, to heal. Eggs, dairy products, fish, and poultry are all good sources of protein. Fiber is very important to maintain regular bowel habits. Whole grains, bran, and fresh fruits and vegetables are good fiber sources.

• Lidocaine Flush: Approximately 12-24 hours after abdominoplasty, some patients develop a mild, inconsequential response to lidocaine. Symptoms include feeling flushed, developing redness in the face, neck, and upper trunk, and feeling a little feverish. For those of you who have ever taken Niacin to help with cholesterol, it is similar to a Niacin flush. This is not something to be concerned about, and it will pass in a matter of hours.

• Follow-up Appointment: You will be given an appointment for follow-up for one to three days after surgery. This will give you an opportunity to ask additional questions you may have. Your appointment time will be on the Preoperative handout and the purple surgery scheduling sheet. Please make every effort to attend all postoperative visits. Follow-up visits are at no charge to you for usual post operative care.

Note: In the initial postoperative period, Dr. McMenamin or one of the office staff members will be calling you everyday to check on your status. Make sure we have your correct phone number(s) and that your phone is accessible (no dial-up internet use) during evening hours. If you do not hear from Dr. McMenamin by 8 p.m., you will have his home phone number to call him.

I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE INSTRUCTIONS. I ALSO STATE I READ AND WRITE ENGLISH, AND I AM NOT UNDER THE INFLUENCE OF ALCOHOL OR DRUGS.