Abdominal surgery is exceedingly common.  General surgery, urology, gynecology, spine surgery, and bariatric surgery all have surgical procedures that require abdominal surgery.  Because of this as well as the complexity of the abdominal wall, abdominal surgical complications are also common and can create both disfigurement as well as ongoing symptoms of pain.  The case below is a video of a patient who developed abdominal pain and disfigurement after multiple abdominal surgeries.  She had developed a pseudo-bursa which caused her abdominal pain and hernia laxity which also caused discomfort.  Secondary to the above issues we decided to proceed with excision of abdominal pseudo-bursa and related scars and repair of ventral hernia without mesh.

Cassandra has left a new comment on your post “Endoscopic Abdominoplasty”:

I am 5 months post full tummy tuck and although my upper abdomen is still intact, my lower abdominal muscles seem to have have way again.

I can for the most part suck the bulge in, but with relaxation or bending over it protrudes again. It seemed to be very flat up until now, w the exception of normal post op swelling.

I did have wound complications just below my belly button which bought me a wound vac for 6 weeks.

My wound has been closed for 2 months now. Any suggestions on what caused this or how to fix it?

I’ve tried to make an appt and they can’t see me for another 3 weeks and I have been told it’s just swollen and it will take a year to go away. This was told to me over the phone.

Any advice is greatly appreciated!!

Dear Cassandra,

Repairing the lower half of the abdominal wall (re-tightening the muscles) can be accomplished alone or in combination with other tummy tuck revision procedures.  At its simplest, the scar from the wound healing issue you discussed can be excised (removed) and access gained to the lower abdominal wall.  Doing so is dependent on the looseness of the skin below your belly button.  The other option is to undergo a full tummy tuck revision.  In doing so the tissues all the way to the rib cage are freed.  This will allow the entire abdominal wall to be tightened appropriately, the scar removed, and the incision lowered.  The other issue you may want to evaluate is the possible presence of a pseudo-bursa.  This can sometimes masquerade as lower abdominal fullness.  If you would like you can contact my office and they can have you email photos and set up a phone consult.

All the best,

Q:   Nana Schultz said…

Plz help have very hard knot from bottom of panniculectomy incision to pubic area on left side..has been oozing pinkish thick fluid..right side isn’t hard or painful. I’m 3 wks post op

A:  Dear Nana Schultz,

Sorry to hear about your healing issue.  There is definitely something occurring with your healing that should be looked at.  Hardness near or at the incision area after a panniculectomy is not uncommon since swelling and healing can create this.  The pain that you are experiencing and the drainage are indicating that something else may be occurring.  It may be that you have some fat necrosis and the body is trying to take care of that.  I would seek follow up with your plastic surgeon to get an idea if you should be doing something else in terms of wound care or if surgical exploration would be beneficial.

All the best,

A tummy tuck can be a powerful plastic surgery procedure. It can provide an incredible amount of improvement in the shape and appearance of an individual’s abdomen and make a significant impact in the confidence and sense of well-being of a person’s body image and self esteem. It is also a big decision and one that should be researched thoroughly.

Although the final result of any tummy tuck procedure is in part related to where each patient starts (amount and quality of loose skin and fat), there are qualities that most great tummy tuck result will have. In the end, you’ll want to have the right tummy tuck done by the right tummy tuck surgeon, at the right time. To help you navigate the consultation process I have listed five of the best tummy tuck result qualities to look for and discuss with your plastic surgeon.

#5 Symmetry and contour

Although there is no perfect symmetry when it comes to any part of the human body there is a level of symmetry that is needed in the abdomen and waist area to make the tummy tuck result appear both natural as well as aesthetically pleasing. Look at before and after photos with a “wide lens” and let the general shape and appearance of the abdomen and waist communicate to you if enough symmetry is present. The sides (flanks) as well the transition of the abdominal tissues from above the incision to below the incision should flow seamlessly. Contour should be smooth without lumps, bumps, indentations, or noticeable transitions.

#4 Tummy tuck incision location, shape, and quality

The tummy tuck incision appearance is one of the main concerns for most patients considering a tummy tuck. Examples of bad tummy tuck incisions are easy to find. Great tummy tuck incisions should go unnoticed. Thin, symmetric, low, and high quality should be descriptors of a good incision. As you can see, the length of the incision is not particularly important in terms of incision quality since the incision length is largely dictated by the amount of loose skin present. The incision should match the patients’ body type and clothing preferences.

#3 Shape and appearance of the belly button

The belly button will definitely be the one part of the tummy tuck that cannot be covered when wearing a bikini, so it has to look good. Natural, aesthetically, pleasing, and without any tell tale signs of being operated is key. When evaluating before and after photos take a look at the belly button. If the belly button is aesthetically pleasing, if it looks natural, and if it matches the persons body then it is likely the other details of the tummy tuck design and completion are probably also good.

#2 Tummy tuck shape

Thin, flat, tight, and narrow. These are some of the words that I like to use to discuss an aesthetically pleasing tummy as well as a good tummy tuck result. There is a combination of factors that can come together to accomplish this including liposuction, removal of excess skin, and tightening of the abdominal wall. In the end, a tummy tuck should result in a narrower waist that flows well and is aesthetically pleasing as well as a flat or significantly improved side profile from ribcage to pubic bone. Narrower from the front and flatter from the side–that’s basically the improvement a tummy tuck should provide from the shape standpoint.

#1 Harmony

Everything about the tummy tuck and waist should flow and appear as one. This one encapsulates a little of all of the above. When looking at before and after photos of a tummy tuck everything should just make sense. The result should just tight enough, not too tight and not too loose. The tummy tuck result should provide waist narrowing. Not too narrow and certainly not a boxy shape. The abdomen should compliment the thighs and breasts and should make sense when everything is viewed from afar.

Tummy tuck surgery has one of the highest satisfaction rates of any elective cosmetic procedures. Because of this, tummy tuck surgery continues to be one of the most common plastic surgery procedures. Below are five facts about tummy tuck surgery.

Belly Button

During your tummy tuck surgery, you keep you belly button. That is, in the normal full tummy tuck surgery process, your belly button is not removed. You also don’t get a new belly button. Rather, your belly button is released from the abdominal skin and then brought back out through the skin that is pulled down. Our belly button is like a straw with one opening on the surface of our skin and the other end inside our abdomen. The “straw” is maintained and it’s then brought out through the new skin that now overlies it during the tummy tuck process. What makes one tummy tuck belly button look better than another is how the incision is made initially, how the opening is made when bringing it back out, and how the belly buttoned is sutured back up.

Muscle Repair

People often talk about loose muscles and the need to repair them with a tummy tuck. If you think about it, muscles are designed to flex and extend. Therefore, pregnancy or weight loss will not lead to a change in the muscles themselves. What people often notice is the looseness of their abdominal wall. Since the muscles are wrapped up in connective tissue it’s the connective tissue that is loose and it’s the connective tissue that needs tightening during a tummy tuck procedure. Muscle repair, therefore, is really more like connective tissue repair. Doing so during a tummy tuck will repair rectus diastasis and tighten the abdominal wall.

Fat Redistribution

Many patients ask me if the fat that is removed during a tummy tuck will appear somewhere else on the body after the procedure. The answer to this question is if weight is maintained, no new fat will appear. If weight is gained, the body will distribute that weight evenly based on your genetics like it always did but less will go to the abdomen since there are fewer fat cells there.

Incision location

Some patients think that how low the tummy tuck incision can be placed depends on their body. There is some truth to that, as someone a small amount of skin looseness will have more difficulty in pulling the upper abdominal skin all the way down to the pubic bone. There are modifications that can be done however that can still make this happen. In my practice I always mark the incision super low near the pubic bone and use the techniques that are available to allow the upper abdominal skin to be pulled down and maintain a low abdominal incision.

“Anonymous said…

Hi I lost weight about 8 years ago and have managed to keep it off , I am wanting tt surgery as my tummy is a little saggy and flabby, I am 32 and a size 10-12 and I am worried about having the muscles stitched because of the pain afterwards and the recovery.My question is does loosing weight at a younger age mean my muscles might not be stretched enough to need stitching”

Dear Anonymous,

Congratulations on the weight loss.  Muscle tightening only needs to be performed when the abdominal wall is loose and both front and side profile improvements would be seen with abdominal wall tightening.  Although there is some additional discomfort with muscle tightening it can be made better with long acting numbing medication such as Exparel which I routinely use.  You and your plastic surgeon can make this decision together.  I would say that it is better to have it done if possibly needed since it will provide a better overall result and going back in and doing so at a later date would cost more both financially and in terms of recovery time.

Anolost weight about 8 years ago and have managed to keep it off , I am wanting tt surgery as my tummy is a little saggy and flabby, I am 32 and a size 10-12 and I am worried about having the muscles stitched because of the pain afterwards and the recovery.My question is does loosing weight at a younger age mean my muscles might not be stretched enough to need stitching

There is a lot of confusion about the various abdominal type hernias that can occur. In this blog post we will review the most common type of abdominal wall hernias, how they most frequently occur, and how they can be repaired.

What is a hernia?

Lets first start by discussing what a hernia is. There are medical definitions of a hernia but we can simply describe it in a way that makes sense for everyone in the real world. A hernia is a weakening in that part of the body. Think of it as a bubble in a car tire. That part of the tire is weaker and the air pressure inside can push out that area more than the rest. This “weakening” can result from the thickness of the tissue getting thinner or it can be from the tissue losing its strength. The second part can be thought of as a new versus an old rubber band. The old rubber band has the same thickness but is not as strong as it used to be and therefore stretches out further with the same amount of force applied.

What is Rectus Diastasis?

Rectus Diastasis: The space between the rectus abdominal muscles, commonly referred to as the six-pack muscles, has increased. This occurs when the connective tissue holding the six-pack muscles near one another stretches and thins. When this occurs, the six-pack muscles drift farther apart from each other because the oblique muscles, the muscles on the side of our abdomen that that go more side to side, pull the six-pack muscles away from each other—each towards its own side. This process essentially results in a mild hernia or bulge in the abdominal wall. This hernia can be called a ventral hernia (more about this next) but since there is no discreet break of the connective tissue it has been labeled rectus diastasis. They are really one and the same, only to a different extent.

What is a Ventral Hernia?

A ventral hernia is an abdominal hernia. The “ventral” part comes from the description of where it occurs. Ventral refers to the front part of the abdomen and makes the assumption that the most “front” part of the abdomen will be in the middle of the abdomen. So, ventral hernia refers to a hernia in the middle of the abdomen along the connective tissue between the six-pack muscles. Sometimes you may hear “ventral incisional hernia”. This is a hernia in the middle of the abdomen from a prior abdominal surgery—hence the “incisional” part.

What is an “outie” belly button?

An “outie” belly button is also known as a belly button hernia. A belly button hernia, in turn, is a weakening of the connective tissue under the belly button. Think of it as rectus diastasis or ventral hernia just under the belly button. When this occurs, fat from inside the abdomen usually pushes up into the belly button stalk and lifts the deep part of the belly button making an “innie” into and “outie”.

So how are these types of hernias repaired?

There are two main ways to repair a hernia.

• Use of some type of product to patch the hernia
• Use of the tissue themselves to repair the weakness

Products that can be used generally fall into either synthetic mesh or natural products such called acellular dermal matrix (ie animal or cadaver skin). This is sometimes done when the tissues are not strong enough to hold their own repair or as additional reinforcement.

Whenever able, the use of the bodys own tissues is preferred. The idea is mush like repairing a rip in a pair of jeans. You can sew the edges together or you can use a patch to plug up the tear.

Regardless of what method is used, access to the hernia is needed. This is where things become interesting. Large incisions can be used for direct access but they should be avoided unless the incision actually makes the area look better. That is, a large vertical incision can be used to fix a ventral hernia if tissue is also removed and tightened at the same time. Otherwise, smaller incisions hidden in the belly button or in the bikini area are used to repair rectus diastasis, ventral hernias, and “outie” belly buttons (belly button hernia).

The following are some photos of what an endoscopic hernia repair and an umbilical hernia repair look like.

Recently Kylie Jenner (of the Kardashian fame) admitted to getting lip filler injections to give her lips a fuller, poutier appearance.  Although this is not so much of a surprise it did stir some emotions and thoughts about plastic surgery, youth, and the idea of inner beauty and self-growth that I wanted to share with everyone.

First.  Medically speaking, there is no reason why a teenager could not get filler in their lips.  The physical indications as well as the possible side effects are the same as those for an adult.  The bigger question revolves around the delicate balance of self-image, self-esteem, and the importance of these aspects to youth in general.

If filler is deemed “appropriate” in a 16 or 17 year old, where is the line drawn for aesthetic improvements in youth that are still in the process of defining their self image and their inherent self worth. Certain plastic surgery procedures such as otoplasty (correction of prominent ears), breast reconstruction in young women that have the absence of one breast, or the reduction of overly large breasts is largely accepted by both plastic surgeons and most in society. They are seen as correcting something that has developed abnormally and often times severely impacts the mental and emotional well being of young adults that feel they are somehow “abnormal”.

There is a slippery slope of sorts in terms of plastic surgery and youth. I believe it is in the best interest of society in general for the parents, the child, and the plastic surgeon to take a broader approach to these issues and include discussion pertaining to mental well being in the present and in the future, counseling, self esteem/self worth, and the broad impact that plastic surgery decisions can have on these aspects of a person immediately but also in the future to come.

All the best,

Tummy tuck surgery can be a daunting journey to embark on for many. As part of my abdominoplasty practice I feel that providing a place for patients to share their experience and advice would be invaluable. I encourage both current and future tummy tuck patients to ask questions and share their advice. I have and continue to learn from each of my patients. I know that the wealth of knowledge from all of my tummy tuck patients will be a source of comfort and guidance to patients that are considering tummy tuck surgery. I am excited to have an additional means of keeping my patients informed. While my website provides in-depth information on the tummy tuck procedure, my blog is a way for me to connect with my patients on a more personal, candid level. I look forward to sharing information with you and hearing your feedback.

“Hi Dr Repta
I had a TT, w/ muscle repair in Feb 2015 and since then have had to get drained every other month from a seroma above my bellybutton. Now I’m scheduled to do laser lipo to hopefully get the seroma to heal as and close what do you think about this?”

—Jenn

Hello Jenn,

Sorry to hear about your recovery.  A long standing seroma certainly increases the chances of having a pseudo-bursa.  If you feel:

-fullness

-firmness

-tightness

In the area of the seroma this may be an indication of a pseudo-bursa.  I think laser liposuction of other forms of liposuction can remove fat and disrupt scar tissue but obviously it will not result in removal of scar tissue.  I have found in my practice that once the symptoms and diagnosis of pseudo bursa is present only excision of the pseudo bursa results in full relief of symptoms.

I hope this helps.

All the best,

Dr. Remus Repta

Tummy Tuck pseudobursa

Q:  Anonymous said…
Hi Dr. Repta, I had a TT in Jan 2014 no drains. Appx 10mo post op I noticed a vertical bulge appx 4″x1.5″ to the left of my belly button. My surgeon first thought pseudobursa, but further review of pictures said fat deposit above the muscle in that area. My weight has fluctuated appx 5lbs, is it possible that is the contributing factor? How can it be resolved? Surgeon did lipo on hips… rather lumpy. Nervous about having a lumpy stomach as well!

A:  Hello Anonymous.  Although fat deposit can be a possibility the fact that this occurred 10 months after your tummy tuck and the fact that it developed in a linear fashion suggests the possibility of a pseudo-bursa.  CT scans do not always show the presence of a pseudo-bursa.  Without an exam its hard for me to guide you through the process but I would discuss the circumstances of how this developed and the fact that it may still be a pseudo-bursa with your plastic surgeon.  He/she can help discuss and plan out what the best course of action will be going forward.

All the best,

Dr. Remus Repta

Hello Lynda,

Sorry to hear about your DIEP breast reconstruction recovery.  If you have a pseudobursa surgery is likely going to be the most definitive treatment.  Time, massage, and PT may help but in my experience, significant resolution of the symptoms associated with a pseudobursa is often only accomplished by surgical removal.  I do not know if the presence of a pseudobursa would also result in some of the numbness that you have described.  Sometimes, the abdominal closure part of the DIEP flap can result in damage to nerves to the front of the thigh.  Its a little unusual with the typical placement of the incision of a diep flap dissection but it is possible.  Since the abdominal component of your surgery was  part of your breast cancer reconstruction, exploration and repair of whatever is the cause of your abdominal symptoms should be covered by your insurance carrier.  I do not know what type of insurance you have or whether you have out of network benefits, but if needed my office may be able to help you pre-authorize any revision surgery you may need if you choose to do so.

All the best,

Dr. Remus Repta

Q: Anonymous Lynda said…
Dr. Repta,
I had a double mastectomy with immediate combined DIEP/SGAP reconstruction two years ago. After a very active left hip drain was removed six weeks later, the incision developed a seroma that I had drained a couple times, approximately three months following the procedure, but I have always felt a numbness and fullness from my hip incision and down my outer hip/upper leg area, even after my revision surgery. I am confident it is a pseudobursa and it is beginning to pull on my hip joint and is becoming somewhat restrictive, but I dread undergoing another surgery. Will active tissue release or some form of PT that breaks up the scar tissue be effective, or is the only real fix to have it surgically removed?

Understanding the different types of and treatment options for abdominal hernias.

There are many different types of abdominal hernias that can occur. The most common abdominal hernias include:

• Ventral hernia
• Umbilical hernia
• Incisional hernia

Common causes for abdominal hernias include:

• Weight loss
• Pregnancy
• Prior abdominal surgery
• Congenital (born with it)

Ventral Hernia

A ventral hernia is a hernia that occurs in the middle of the abdomen vertically between the rectus abdominus muscles (six pack muscles). The best way to imagine and understand this type of hernia is to envision a long, skinny football shaped weakness oriented vertically (up and down) in the middle of the abdominal wall.

A ventral hernia can be caused by any of the above sources that been listed, but the two most common is pregnancy and prior abdominal surgery. Often, weight gain and weight loss in addition to either surgery or pregnancy also is a factor.

Repair of a ventral hernia can be performed by suturing the muscles back together, or by using some sort of mesh. I prefer to bring the healthy tissues back together as this is truly the only real hernia repair that allows the patient to regain their core strength. Sometimes a ventral hernia can be more subtle, without a definite border to where the hernia starts and stops. This is seen more often after pregnancy and is often called rectus diastasis. Repair of correction of ventral hernia and rectus diastasis is often similar in terms of bringing together the healthy tissue layers. When the hernia is too big to do so, component separation, where the muscle layers are separated, can be performed and/or the use of acellular dermal matrix can be used to reinforce the repair.

Umbilical Hernia

 An umbilical hernia is a hernia or weakness of the abdominal wall near the belly button. This is one of the most common types of hernias to be born with and one of the most common types of hernias to develop as a result of weight gain or pregnancy. Umbilical hernias are commonly referred to as an “outie belly button”.

General surgeons typically like to use mesh plugs to repair the hernias while Plastic Surgeons usually like to repair the hernias but bringing together the healthy borders of the surrounding tissue. An umbilical hernia can be repaired via a small incision around the border of the belly button or via a larger incision if a ventral hernia or a tummy tuck is being performed at the same time.

Incisional Hernia

An incisional hernia is a weakness or separation of tissues where there has been a previous incision made. Many abdominal surgeries can result in an incisional hernia. Fortunately, most abdominal surgeries are now performed laparoscopically with small incisions.   Occasionally, and abdominal surgery to remove an infected gallbladder or appendix or to treat problems with the liver, pancreas, or colon is needed. When these types of large incisions are used there is a risk that the tissues will either thin out at the incision site or the incision site tissue pull partially apart. Repair of these incisional hernias usually proceed by using the existing incision and bringing together the healthy borders of the tissue. Incisional hernias are often the type of hernias that can benefit most from the use of mesh or acellular dermal matrix.

I hope this introduction of abdominal hernias helps educate those that are struggling with hernias and wondering how to best go about finding help.

All the best,
Dr. Remus Repta

Hello Icampbell,

Sorry to hear about your tummy tuck recovery.  Some of the recovery issues that you have described is in line with what a pseudo-bursa would be like.  There is the possibility that either asymmetric muscle tightening or asymmetric fat reduction via liposuction or surgery may also be the case.  A CT scan can be helpful in terms of differentiating between the various sources of the bulge.  A detailed exam and history is often what is needed only however.

If you are ever near Scottsdale AZ or if you plan on making a trip out here I would be happy to take a look and see what is likely the case and what treatment would be most likely to give you the best result.

I hope this helps.

All the best,

Dr. Remus Repta

lcampbell has left a new comment on the post “What is a Pseudo-bursa?”:

I had tummy tuck surgery in May 2014 and my upper mid-line on the muscle repair had a funny looking bulge afterward. I had revision in March 2015 and now the bulge is much larger, hard and off centered making me look deformed. My stomach also look sunken in around my belly button. My surgeon states he doesn’t know what is going on but willing to do lipo on the area and transplant fat around my belly button to fill in the sunken in area. But he states that it is aesthetic and not covered as a revision. I’m not willing to pay him again and not confident in his ability to rectify the situation. I have been researching my issue for several years and keep coming back to your post. I believe a pseudo-bursa may be my problem but don’t know where to begin. Any advice will be appreciated.

Hello Cookie,

I am sorry to hear about your tummy tuck results and the issues you have been experiencing.  My suspicion is that you do have a pseudobursa which is as you know a pocket of scar tissue.  It is true that you do not likely have a seroma this far out but a pseduobursa as a result of a seroma is certainly a possibility.  I have not tried steroid injections and I do not believe that it is a wise choice since the steroid injection would likely be placed mainly within the fat layer.  The chance of blindly placing the steroid injection uniformly within the pseudobursa is fairly low if not zero.  Steroid injections within the fat layer will lead to fat atrophy and more scar tissue.  Although it is unfortunate regarding the cost and downtime associated with performing a full tummy tuck revision to remove the pseudobursa and its cause, it is likely to be the only thing that truly addresses the issue.

I hope this helps.

All the best,

Dr. Remus Repta

Q:  Cookie said…
I may well have a pseudobursa. My TT doctor told me it was nothing and to go home and do some situps. It actually is painful to the touch! My daughter broached the subject of steroid injection vs. surgery. Why is this not an option? Likely, if I even considered having my TT doctor remove the pseudobursa, the cost would be the same as the original TT. He also said that it is unlikely after 2 years, it could be just a seroma, although I can literally feel something sloshing around when I put my jogging belt on. Swelling below the belly button above where I used to be able to find my pubic bone is fairly large also. So, in an effort to pull my waist in with a TT, my waist is actually larger! I am quite active, am 5 ft. 3″ and weigh about 126. I am not obese by far. None of this makes sense to me but I am so reluctant to spend the money all over to have to go through the same painful procedure. But, the sensitivity and bulge is driving me crazy. Steroids?

Q:Blogger sadie meek said…
I had a tummy tuck in sept. 2 days later taken back to theatre for haematoma then week later I got a seroma this was drained for 3 day taken 150 ml fluid.. Then the consulton fixed a drain and bag I had this on for 5 weeks collecting fluid.. It was then removed and few weeks later I got a lump above and around my belly button … I have had 2 scans and 1 ct scan its shows no fluid or hernia … The lump is full and hard and swells more on evening and is very painful to touch … Spoke to my consulton few days ago and he wants to do another scan ..please help this is effecting my everyday living… Also the tummy tuck is the worst I have seen I still have a lot of lose skin when I bend … I am now 5 months post op. Regards Donna

Hello Donna,

It sounds like you have had a rough go at recovery from your tummy tuck procedure.  From what you have described in terms of the hematoma, seroma, and prolonged drain use I am fairly certain that you have a pseudo-bursa.  A CT scan would show it but Radiologists are not used to looking for a pseudo-bursa and to them it may look something similar to scar tissue associated with surgery.  You do not need to have a seroma currently to have a pseudo-bursa.  The pseudo-bursa was formed secondary to the hematoma and seroma and even though those things are gone the pseudo-bursa will remain.

The good news is that this can be treated.  By performing a full tummy tuck revision, the pseudo-bursa can be removed and any revisions of the tummy tuck can be done at the same time to improve and optimize comfort and appearance.

If you would like you can contact my office via this website or via drrepta.com and they can set you up with a phone consult and arrange for you to send photos and possible a copy of the CT scan.

I hope that this helps.

All the best,

Dr. Remus Repta

Hello Sally,

I am sorry to hear about your pseudobursa and your tummy tuck recovery.  I prefer to remove the pseudobursa in its entirety since I feel that any scar tissue left behind can continue to serve as a source of possible pain and/or restriction of activity.  It takes some experience doing so to understand and realize the impact that it has on the patient.  It may be that the partial removal will help you feel better in the long run but I prefer not to take that chance and so I choose to always remove all of it.  At this time you may choose to give it sometime to see how it develops and if your symptoms subside.  Unfortunately, if your symptoms do not improve the only option is to go back in again and remove the remainder.  Doing so will require a full tummy tuck revision or at least thats what I prefer to do since, again, it minimizes the potential to leave something behind that can continue to be a source or discomfort.

I hope this helps.

All the best,

Dr. Remus Repta

QSally Rhodes said…
Dear Dr Repta
3 years ago I had a tt and was very pleased with the look but I started getting discomfort where an original seroma was, after 2 years of investigation a pseudo bursa was found. Last week I had it surgically removed, when I spoke to my ps after he said he’d removed ‘part ‘ of it because that’s all he needed too , then used quilting sutures.
That was 10 days ago and the area of discomfort doesn’t feel any better in fact it feels worse, I am so frightened I am going to have to live with this.
Is removing part of the seroma enough and should I be feeling less discomfort by now ??

Q:Anonymous said…
Dear Dr Repta- You seem to be the only doctor on the net who understands the pseudobursa problem and how to fix it.I had a removal of implants and a pedicle tram flap in July, 2015. (DIEP flap was not done because circulatory system compromised in chest from mantle radiation 30 yrs ago). My umbilicus never completely healed; it always seemed to be “leaking”. In Dec of 2015 infection happened, sent me to the hospital,i was on IV antibiotics for 3 weeks. A large horizontal seroma all along the incision scar was drained. It is now Feb, and belly button is still “leaking” and not healed. The other problem is right below belly button, slightly to the right, above horizontal scar, the large seroma that was seen in hospital ultrasound is now hard and extremely painful. There is a definite ugly bulge and i feel like i’m 5 months pregnant. It sounds like a pseudobursa. My question is: can this be surgically removed even though this isn’t from a tummy tuck but a pedicle tram flap that involved tunneling the muscle/blood vessels up to my chest and putting in mesh? I’m so tired of feeling sick. I would really appreciate your thoughts. Thank you!

A:  Hello Anonymous,

I am sorry to hear about your breast reconstruction healing issues following TRAM flap.  From what you have described it does sound like you have a pseudobursa.  There are many factors that may have contributed to this but I suspect that a combination of permanent sutures and the mesh are either part of the cause or at least involved in the pseudobursa formation.  Although I do not have all of the details of your history and physical exam I cannot imagine what full correction would not be possible.  Full and complete correction would likely involve revision of the “tummy tuck” portion of the TRAM flap procedure where the abdominal soft tissue is elevated and the pseudo-bursa removed.  Additional contouring of the abdomen at that time may also be possible.  Depending on the insurance that you have, I may be able to have this covered under your insurance as part of complications related to your breast reconstruction TRAM flap procedure.  Feel free to contact my office, 855 Dr Repta (377 3782) or via Scottsdaletummytuck.com to arrange a phone consultation with photos.  We could then go from there.

All the best,

Dr. Remus Repta

Tummy tuck surgery is commonly done after weight loss or after pregnancy.  Significant weight loss often results in loose abdominal skin that has lost its ability to bounce back following the reduction in weight.

There are three different types of weight loss related tummy tuck procedures:

• Complete weight loss: normal weight tummy tuck
• Incomplete weight loss: plus size tummy tuck
• Incomplete weight loss: overweight tummy tuck

Normal weigth tummy tuck

For complete weight loss/normal weight tummy tuck patients, a tummy tuck is designed primarily to remove excess skin, tighten the abdominal wall laxity, and rejuvenate the shape of the belly button.  Some liposuction is almost always helpful as well since the tummy tuck shaping will benefit by being blended into the waist . This is especially beneficial around the waistline.

Plus size tummy tuck

The incomplete weight loss/plus size tummy tuck patient is someone who still has perhaps 5-35 pounds to lose, depending on their body height and type.  These patients are often told to lose the weight first and then come back for a tummy tuck.  Although being at your ideal weight is preferable for most body contouring procedures, a plus size tummy tuck has an added advantage. It allows the plastic surgeon, if he has that understanding, to reshape the residual fat present to allow (at times) an even better tummy tuck result than a complete weight loss/normal weight tummy tuck patient.

Overweight tummy tuck

For the last category, we have the incomplete weight loss/overweight tummy tuck patient.  This patient is one who is 35lbs or greater from their ideal weight depending on their body height and body type.  This category of tummy tuck patient can often be divided again into three separate categories:

• Those who can loose enough weight to be plus size
• Those who cannot loose any more weight but are still a candidate for a tummy tuck
• Those who cannot loose any more weight and are not a good tummy tuck candidate

The last category are patients who are significantly overweight in the obese or morbidly obese BMI range, as well as those patients who have a significant amount of intra-abdominal fat.  This last category of patients should seek medical or surgical weight loss help or find a diet and excessive regimen that works for them to be able to at least lose enough weight to get into the category where a tummy tuck is possible.

The second catchword above, the patients who cannot lose any more weight and are overweight tummy tuck patient candidates, often benefit from proper and judicious use of liposuction before and/or during the tummy tuck procedure.  Although even these patients can achieve great tummy tuck results, some discussion about the limitations of these types of tummy tuck procedures is recommended to allow for proper expectations.

I hope this discussion of plus size and overweight tummy tuck procedures was helpful.

All the best,

Dr. Remus Repta

Q: I specifically asked for c-section to be removed while performing tummy tuck, one of the reasons I had this surgery and apparently I was ignored. Tummy tuck incision was placed higher than requested and c-section was not removed. Never have heard about having a tummy tuck and the c-section not being removed . Does not make sense. What do you think? Got 2nd opinions and was notified that procedure needs to be redone. So much money to get fixed.

A: Hello Sally,

I am sorry to hear about your disappointment with your tummy tuck result.  Yes, the C-section scar is commonly removed.  I can only speculate as to why it was not removed as part of your tummy tuck.  My suspicion is that your surgeon may have been weary of having enough skin to get the original belly button location out.  When faced with this situation I recommend that the incision still be placed as low as possible and the original belly button location simply closed as a small vertical incision.  This can still be done with your tummy tuck revision.  In fact, doing so will be needed in order to bring your current tummy tuck scar as low as possible and in the process removing the original C-section scar.

Wish you the best of luck and a quick recovery should you choose to undergo a tummy tuck revision.

All the best,

Dr. Remus Repta