Mesh for abdominoplasty revision? (Photo)

Question

Female, 52, 5'6" 165 lbs. 2 smallchildren by C-section (youngest is 3.5. Had abdominoplasty with plication and lipo in Dec '22. It was looking almost flat for 2 months, then my stomach started to get big again. At 6 months, surgeon said it wasnt swelling and maybe my fascia was weak. She suggested maybe redo with mesh. Now I look almost the same as when i started. Had a hysterctomy and now I'm considering revision of TT, but I want to get it right. PP mesh?

J. Timothy Katzen, MD, FACS · Answer

Thank you for your question regarding mesh for abdominoplasty revision, Practical63480.

Thank you for your history and your pictures. Yes, I would strongly suggest considering the insertion of mesh to correct your weakened abdominal wall 15 months after your tummy tuck. For some reason, your rectus fascia is weak. When correcting the anterior abdominal wall fascia, a very large piece of mesh is used. The mesh typically measures approximately 8“ x 10“. There are many different types of mesh materials, but the most predictable and reliable is made of Prolene. Prolene mesh is a permanent type of mesh that becomes integrated with scar tissue.

The placement of Prolene mesh on the abdominal wall can effectively flatten the profile of a distended abdomen. It creates a strong support structure, preventing further distention and helping maintain the desired contour.

Given your situation, it sounds like mesh could be an excellent solution for your abdominal wall weakness, providing you with a more lasting and stable outcome. I recommend discussing this option with your plastic surgeon to ensure it aligns with your specific needs and to get more details on the procedure.

Good luck. I hope I’ve answered your question regarding the use of mesh in abdominoplasty revision.

Sincerely,

J. Timothy Katzen, MD, FASMBS, FICS

Daniel Barrett, MD · Answer

Dear Practical63480,
generally speaking, mesh can be used in case when you have weak fascia. If you are considering surgery, I would suggest you consult a board-certified plastic surgeon. Only after a thorough examination, you will get more information and recommendations.
Daniel Barrett, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

Ronald J. Edelson, MD · Answer

After a tummy tuck it is not unusual for the muscles to stretch out a bit particularly if you have gained any weight. I don’t think revision is the answer

Connie Hiers, MD, FACS · Answer

Before you go through another surgery, do be checked for food allergies. If you are swelling because of your colon and reaction to certain foods, surgery will not fix that issue.

Mats Hagstrom, MD (license on probation) · Answer

This post was dictated.
I apologize in advance for any grammatical errors.
Understanding the outcome , of this procedure isn’t that difficult.
Let me try to simplify for you.
There are four tissue variables that determine what the abdomen looks like.
This is true whether someone has had surgery or not.
In other words, there are four different reasons why someone’s Abdomen can look at the way it does.
The fourth tissue variables that determine what the abdomen looks like are the following.
1) abdominal skin laxity typically due to previous pregnancies or significant weight loss.
2) excess subcutaneous fat.
3) muscle separation from previous pregnancy.
4) excess visceral for intra-abdominal fat.
to make an assessment regarding the outcome of your procedure let’s just go through each of the tissue variables in order.
Skin laxity can be differentiated by simply pulling on the skin until it’s tight.
If that improves the contour, then that is how much skin laxity is contributing.
In your case skin laxity is probably not contributing in any significant way because you’ve had any excess skin removed with your previous procedure.
 to assess the thickness of your subcutaneous fat layer gently press against your skin with one finger until you feel the underlying muscle wall.
This requires a very light touch and I’m guessing the thickness of your subcutaneous fat layer around your mid abdomen is probably about 3/4 of an inch. 
Over your oblique muscles it’s probably a little thinner being probably about a quarter inch.
Over your ribs it’s probably about half an inch.
Muscle separation causes the abdominal wall to bulge.Let’s first define what a flat abdominal wall is so we have a reference of when the abdomen is bulging and when it’s not.
A tight flat abdominal wall should create a “bee line” between the sternum and the pubic bone in an upright standing position.
Excess visceral fat causes the abdominal wall to bulge and the appearance of muscle separation and excess visceral fat, is very similar.
Many people will have both if they’ve had previous pregnancies and have not, had a tummy tuck.(like you in your preoperative picture)
Differentiating between muscle, separation, and excess visceral fat is not all that difficult, but may not be intuitive to all people.
One way to do this is to lay on your back.
If an individual has muscle separation, and no excess visceral fat, then the abdomen should go completely flat, when laying on your back. It should drop slightly below the beeline between your sternum and pubic bone.
If the abdomen does not go completely flat, or even slightly concave, when laying on your back, then excess visceral, fat is most likely a contributing variable, and in your case is most likely THE contributing variable. 
Another way to differentiate between muscle separation, and excess visceral fat is to take your non-dominant hand and press your abdomen flat until it makes a beeline between your sternum and pubic bone.
If this does not require much pressure and you can easily do it with your non-dominant hand and hold it for a while then Muscle separation may be the problem. If it takes a significant amount of pressure and pressing your abdomen, flat makes your abdomen feel like it’s full and makes it difficult to take a deep breath then visceral fat is the problem. 
Having excess , visceral fat, that was not properly assessed before having a tummy tuck is by far the most common reason patient’s complain of a bulging abdomen after a full tummy tuck.
Failure of muscle tightening is rarely the problem.
Individuals who have excess visceral fat do not have the potential of having a flat abdomen from a tummy tuck until they’ve lost sufficient weight first.
That tissue has to go somewhere and it’s either going to push against your diaphragm and or the front of your abdominal wall. In reality it does both.Without weight loss, you don’t have the potential for having a flat abdomen.
Ideally, you should’ve been told this during your consultation.
You still have the potential for having a completely flat abdomen just like after your surgery.
It is going to require losing weight and weight loss is the only way to get there.
You don’t need a revision and you don’t need reinforcement with mesh.
 What you need is to lose 10 pounds.
I suggest you get on a weight loss plan and drop 5 pounds at a time.
At each weight loss interval take a new set of pictures of your abdomen to see what it looks like.
You can then dial in exactly what weight you need to be at to get an abdomen that is consistent with what you want.
There’s no possible way surgery is going to overcome excess visceral fat in individuals who have it.
Your preoperative pictures is classic for an individual who has both muscle separation and excess visceral fat.
Had your surgeon press your abdomen flat during an examination at your consultation she would’ve been able to tell that it takes a significant amount of pressure to press your abdomen flat and this should have alerted her that you have excess visceral fat that needs to be managed before you’re a good candidate for surgery.
In the end, there are always four tissue variables that need to be assessed in regards to an aesthetic assessment for someone’s abdomen.
Understanding which tissue layers are causing, the problem helps define which procedure is going to give the best outcome.
Unfortunately, excess visceral fat cannot be treated surgically and can only be managed through weight loss.
A tummy tuck primarily treats, abdominal skill, laxity, and muscle separation.
Excess subcutaneous fat can be reduced with liposuction or weight loss.
Excess visceral fat can only be reduced through weight loss.
You don’t have to be obese to have excess visceral fat.
It is a genetic predetermined condition that some people have.
It’s slightly more prominent among men, but can be found in both men and women.
I’m guessing you always had a slight bulge to your abdomen, and this was made worse if you gained weight Pre-pregnancy.
I suggest you avoid the temptation of having revision surgery.
It’s possible your surgeon was insufficient in muscle tightening, but this is rarely the case for individuals having bulging of their abdomen after a full tummy tuck.
The fact that your abdomen was flat early after the procedure indicates that muscle tightening was done sufficiently.
 Your abdominal wall simply cannot hold up to the pressure of the excess visceral fat overtime and the abdomen will eventually bulge unless weight loss is accomplished first or after the procedure 
Best,
Mats Hagstrom, MD

Mesh for abdominoplasty revision? (Photo)

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