Kate Comrie

Good evening, everyone. We're just going to wait a few moments while everyone joins in.

Hello, and good evening. Welcome to our webinar on tummy tuck surgery and liposuction. My name is Kate, and I'm the Clinical Nurse Specialist for Plastics and Cosmetic Surgery here at Benenden Hospital.

I am joined by our presenter, Mr Simon Mackey, who's a Consultant Plastic Surgeon.

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So my background is in the NHS prior to moving into plastic surgery and private setting. So I've got a diploma in adult nursing from the University of Surrey. I've done a mentorship degree. I've also done aesthetics, foundation advance and masterclasses in anti-wrinkle and dermal fillers. In the NHS. I worked in the surgical assessment unit some wards and in A and E at the Royal Surrey County Hospital, and then in Frimley Park hospital.

I moved to the private sector in 2015 and moved into plastic surgery.

I then came to Benenden and became the clinical nurse specialist and helped set up the service. I support our Consultant Plastic Surgeons and patients throughout their journey.

I'm now going to hand you over to Mr Mackey.

Mr Simon Mackey

Hello there, I'm Simon Mackey. I'm a Consultant Plastic and Reconstructive Surgeon.

The sun is just shining across my face there.

I've been actually in plastic surgery. Now for 20 years I did my first plastic surgery job in 2003, and then I've been a consultant at Queen Victoria Hospital in East Grinstead since 2012, and in private practice since then as well, and I trained at what was St. Mary's Hospital Medical School.

It's now a college school of medicine, and I have a wide experience in cosmetic and reconstructive plastic surgery.

So this evening I'm going to talk to you a little bit about abdominoplasty or tummy tuck surgery as it's commonly referred to.

It's one of the commonest procedures actually, that we, as plastic surgeons end up performing for our patients.

And it's one of those procedures plastic surgeons enjoy performing because it's normally got a very high satisfaction rate.

I think a lot of people think of these procedures as being purely cosmetic. But there are lots of functional benefits that you can derive from this surgery as well, and I'll touch on some of those as we go through.

Included in this session, we'll talk a little bit about consultation and assessment a little bit about some of the different types of tummy tucks that are available, and then we'll have a bit of a chat about liposuction as well.

We'll mention hospital stay and recovery, and then at the end there'll be a question-and-answer session.

So, at risk of sounding like Patrick Valance and people during the pandemic Kate's pushing the buttons, so I might have to say, Next slide, please, from time to time, but I'll try and avoid it.

So the GMC. Are very clear with any form of procedure which is deemed to be cosmetic, and they would suggest that we should see you at least twice.

And I think that's very important, because the key thing with any of these procedures is getting to the bottom of the problem and really trying to figure out what it is that is wrong and what's troubling you.

And probably more importantly, I suppose it's then what is the precise procedure that is going to be most suitable for you, and we spend a lot of time talking about expectations and goals.

And what I want to do is try to present a realistic outcome and then achieve that for you. So at the 45-minute primary consultation. I need to find out about you.

So I need to know about your medical background any medications that you might take, because sometimes they can affect your treatment. If you have specialist treatment with other clinicians.

I need to know who's involved with your care, and we might need to ask them for advice, just to make sure that we can tailor your procedure and make it as safe as possible for you.

Blood thinners and cardiac issues and other things are all very important to consider, because this is essentially surgery you don't need to have done so it makes it doubly important I think that we try to stack risks in our favour in your favour and try to make this surgery as safe as possible.

But we'll spend a lot of time discussing your goals. I'll talk about how the condition affects you so very commonly people that present for tummy tuck surgery have had operations on the tummy and might have scars that they don't like.

Lots of ladies, of course, will have had pregnancies and can develop stretch marks which are unsightly, or they really don't like, and you can also stretch the skin. So I often say the skin is a little bit like a plastic bag.

If you stretch it a little bit it will recoil back, but if it's been stretched beyond its elastic limit it can't.

So if you've got excess skin, there's currently nothing in particular that will shrink the skin down. And so that's where really you'd need to think about removing that excess skin. And that's essentially a tummy tuck.

The other thing I do when I examine you I'd look out for things like intertrigo so some people get irritation and inflammation along the fold underneath the tummy tuck tissue.

 It's particularly the case along caesarean scars or hysterectomy scars, and that can be very troubling, particularly in the summer.

I would examine you and feel your tummy and get you to do something called a straight leg, raise to have a look at the integrity of the tummy muscles. The six pack muscles so often with pregnancies or weight, gain weight loss.

The six pack muscles themselves can pull apart, and then you get a bulging of the tummy contents through the gap between them, and that can also contribute to a convex shape to the anterior abdominal wall.

Now, lots of people at the moment are losing weight with a combination of different things. So there's hard work and exercise. There's bariatric surgery.

And there are a whole host of new weight loss, drugs like Ozempic and Monjaro, and a significant proportion of our patients at the moment have lost a significant amount of weight through these sorts of means.

And if you're on one of those medications, really, I need to know, and we need to modify that around the time of your surgery, just to make your general anaesthetic, safer.

But also people who've had bariatric surgery. It's very important that you have your regular blood tests performed.

Because if you're deficient in nutrients or micronutrients, it can significantly impact your ability to heal. So again, as part of the preamble and that initial consultation, I need to explore these things and just make sure that you're as fit and healthy as you can be.

Before any of these operations in an ideal world. You need to be at about your ideal weight when you have the surgery performed. So I think traditionally, people used to regard things like tummy tuck surgery and liposuction as weight loss procedures, and they're really not weight loss procedures.

They are procedures that you can use for finessing and improving the situation for you. Once you've achieved your weight loss, goal, and ideally you then want to maintain, achieve your weight loss, goal, and then maintain that for some before surgery, just to ensure that you're in a stable situation.

You're not still losing weight and potentially nutrient, deficient. Because, again, that can impact your ability to heal.

And then sometimes, when we talk through the different options available.

It might be that I think a particular technique is the most appropriate for you, but you might feel that the particular technique is slightly too much, or you don't like the particular scar.

So we then need to really consider whether or not you could potentially get away with a slightly lesser procedure.

But sometimes, when you're compromising on scars, you really are compromising on outcome. So some of these procedures are much more powerful than others.

And yeah, we just need to assess things and have a chat about the different options so that you can make an informed choice.

At the second consultation, normally we'll spend more time discussing your procedure, the limitations, risks, and complications, and I like to ensure that we've completed a consent form together before the day of your procedure to give you plenty of time to cool off.

Sometimes people wake up in the middle of the night with a load of questions, in which case drop them all down, and I'd much rather try and answer those for you before surgery rather than afterwards.

We're very lucky at Benenden hospital to be supported by Kate and Lexie is our other plastic surgery nurse, who are very knowledgeable, and they can often give much more tailored advice on things like compression garments and wound care postoperatively.

So and then tummy tuck surgery is commonly combined with other procedures as well.

So there are some advantages to combining operations. So long as the recovery period is fairly similar for each of the different operations, then it can mean just one hospital visit, one period out of work, one period of recovery.

But again, we need to just make sure that any combination is sensible and safe. So some patients having massive weight loss procedures.

Maybe they'll benefit from tummy surgery, arms, thighs, breasts, but doing all of those at the same time is not recommended it's dangerous.

We just need to think about sensible combinations for you.

It's a terrible phrase, but it's the mummy makeovers made it onto the slide here. So that was something that was commonly marketed about 10 or 15 years ago.

And it's very, very common to have breast surgery combined with tummy surgery, and again, often effects of pregnancy. So postpartum atrophy of the breast, where you lose volume from the breast, and the breast tissue can descend, is commonly combined with a tummy tuck type procedure, and again, tummy tucks and arm lifts, tummy tucks and thigh lifts are commonly performed procedures, and we can discuss all of those as well.

So I think we can probably progress to the next slide.

So what is a tummy tuck procedure? Well, it's a procedure really designed to improve the shape of the anterior abdominal wall can be used to remove excess, skin excess, stress or stretch marks and to reduce some of the fat from the anterior abdominal wall

In terms of management of the muscles. It's a thing you can try for yourself at home actually, if you lie flat on your bed.

Keep your legs straight with your hand on your tummy, and then just lift your legs up off the bed. If your six pack muscles are pulled apart, you'll often feel a sausagey bulge that can course, from the rib cage down to the pelvis.

And there's some evidence, actually, that if your six pack muscles have split more than four centimetres apart, then, when they're repaired, it can increase your core strength significantly and measurably.

So, some of the common problems that people have with diastasis of the rectus muscles where the rectus muscles are pulled apart can be lower back pain. It can be pelvic instability, and there's some evidence to suggest that pelvic floor function can also be improved if you're able to improve core strength.

So, frequently, people will present with a diastasis of the rectus muscles and dislike the appearance, and as a bonus. Often you get an improvement in core strength.

But with a plastic surgical repair of the rectus muscles. We normally do that from the same transverse incision which lies below the Bikini line.

Some of the more old-fashioned ways used to put a long scar from the hip, from the rib cage down to the pelvis, and you could repair the six pack muscles like that, but it always left you with a very noticeable scar, so us plastic surgeons prefer to do it with a transverse bikini line type incision.

So I think we can probably move on.

So, who can have a tummy tuck. So, again, really you need to be at about your ideal weight

on the day of one of these procedures, what I would aim to do is to take as much skin as I possibly can, while still ensuring that I can close the tummy up a complete disaster to take out so much tissue that you can't close things up.

So as a sort of sensible plastic surgeon, what I would try to be doing is taking as much tissue as I think I can safely get away with for you to get a terrific result.

But actually, if I had to err towards overcorrection or under correction, I would err towards taking slightly less tissue because it's very important we're able to get you healed up after one of these procedures in an ideal world, as with most cosmetic procedures.

Really it's probably best performed once you've completed your family. This is aimed at women in particular, because the effects of pregnancy are significant, and although it's not a complete disaster if you were to get pregnant after some of these surgeries, it can affect your result in the longer term.

So again, if you imagine that the tummy muscles want to stretch apart again, or the tummy needs to expand, to accommodate the developing foetus or the baby. Then you're better off waiting until you've completed your family before having these sorts of procedures.

And common things. In addition to intertrigo, which is that irritation along the fold stretch marks, scars that people discuss are. It's just feeling uncomfortable in clothes. So lots of people come in wearing baggy clothes even in the summer, just because they dislike what they call people describe frequently the tissue in the lower tummy is a pouch.

Or there's a whole host of different words that people use to describe their own tummy. And actually, it's, you know, to me, really, the goal is to try and make you feel more comfortable in your clothing.

If you feel more comfortable being a bikini or out of your clothing as well. Then that's a bonus.

So I think we can probably move on. Okay.

So the standard abdominoplasty takes a piece of loose skin which we call pannus in the medical world, normally going from all the way up from the tummy button all the way down to the Bikini line.

So lots of people have Caesarean scars, and normally, I'd want to be putting the transverse scar below the level of the Caesarean scar.

And this is quite a long scar that courses from the midline all the way out to the pelvis, to the hip bone on each side, and with the standard tummy tuck I have to cut around the tummy button to take out all of that tissue from the lower tummy.

And then, when I've closed the tummy tuck tissues up. I cut a fresh hole for the tummy button to poke through, which gives you a separate scar around the tummy button itself.

So this is the traditional type of tummy tuck scarring that people normally think of when they think of a tummy tuck.

And with this, in order to mobilize the skin from the top of the tummy button so that I can move it down to the Bikini line.

I separate all of the skin off the tummy wall all the way up to the rib cage, and that means that I can mobilize things to close things with as little tension as possible. But while I'm up at the rib cage, it means I can use a special locking stitch. We use a permanent stitch just to

Reattach the six pack muscles back together, and that just helps to stop that midline bulge and flattens the upper tummy off.

So this can be performed. So this is normally performed with dissolving stitches, a glue and a tape dressing.

So with any of these procedures. Normally, you've been in the situation where you should be able to shower from two days after the operation.

I normally recommend that you pat your tapes dry, use a hair dryer in a cool setting, and then put a binder or compression garment back on.

And the compression garment is very important because it supports the six-pack repair because it takes about six weeks or six to 12 weeks for that repair to become as strong as it ever will do.

But it also helps to push the tummy tissue back onto the tummy wall to stop you getting collections of either blood or fluid forming underneath the tummy tissue.

The hospital always provides you with a Velcro fastening garment which normally works very well.

But again, Kate and Lexie can normally discuss other slightly better garments with you. We normally recommend that you purchase those in advance.

Lots of people get on very well with the corset type garments, but others prefer the Bridget Jones sort of magic knickers type garments which I think also work very well.

So I think, moving on, we move to the mini abdominoplasty. So the Mini tummy tuck really is best used for people with a modest amount of excess skin in the lower abdomen only.

So really, I tend to regard it more as almost like a scar revision. So it's most commonly used really for people who have had caesareans or abdominal hysterectomies and have a fan and steel type scar along the bikini line, and you can sometimes be in the annoying situation where some of the skin just folds over the crease causing problems.

So it's not particularly good at removing huge amounts of skin. So again, with a tummy, a traditional standard tummy tuck, you're taking all of that skin out from the tummy button

down to the bikini line.

And that means you're taking out any scars that you've got lying in that area, and you'll also take out any stretch marks that you've got lying below the level of the tummy button, so stretch marks lying above the tummy button or scars lying above the tummy button you can't really remove with a standard or a mini abdominoplasty.

But the advantage of a mini abdominoplasty is that you don't need to cut around the tummy button. So you have a slightly shorter scar lying along the Bikini line, and you don't have the visible scar lying around the tummy button itself.

So if we move on to a slightly more invasive procedure, so fleur de lys abdominoplasties are procedures really that we tend to use for patients who have lost a significant amount of weight, and most hospitals would count massive weight loss.

As being weight loss of four stone or more but it does vary a little bit from side to side, and these procedures really are useful for people who have a transverse excess of tissue, so you can essentially, almost like double breasting a jacket.

You can take out vertical skin excess, and you can also take out some transverse skin excess as well.

And this gives you the fleur de lys type scar on this image, they've not really drawn a tummy button in there. But you normally do try and put the tummy button back in.

I think the tummy button is one of the things that can potentially have healing problems, and that's much more common in the population of patients who have lost a significant amount of weight.

The tummy buff in itself is a scar and when you've gained. You see, people who've lost 12 or 13 stone in weight, and the tummy button then, has been stretched, and it's very long.

So as you try to cut around the tummy button. Sometimes the tummy button won't survive, in which case we can try and make you a fresh tummy button or try and give it the benefit of the doubt, and if it does perish, it does tend to heal and look like a tummy button.

But the fleur de lys abdominoplasty, slightly, less frequently performed, really.

But it does give you this obvious vertical scar, so it normally goes from the top of the ribcage. What we call the sternum or bottom of the rib cage all the way down to the Bikini line, and then along the fold of the abdomen as well.

And again, with this technique you can stitch the six pack muscles back together and try to tighten up the anterior abdominal wall which can improve anterior abdominal wall function.

Okay, and then for some people it might be that you've lost a significant amount of weight.

And you do have a significant amount of loose skin that courses around the anterior abdominal wall into the love handle area or the flanks and towards the back.

So sometimes, in order to close that up without leaving what we call a dog ear, which is a slightly lumpy scar at either end of the tummy tuck, we might need to just extend the tummy tuck around the sides of the anterior abdominal wall and into the flanks.

So we tend to call that an extended abdominoplasty and then, if we go on to the next slide.

For some people who've lost a significant amount of weight, you may have a significant amount of weight or excess skin that courses all the way around to the back, and that can lead to a very saggy bottom.

So actually, sometimes, in order to take up the dog ear, you need to head all the way around you.

In which case, in closing that up, you tend to lift the buttocks up so it's almost like a buttock lift. It used to be called a circumferential body lift, or 360-degree abdominoplasty.

So again, slightly less commonly performed, slightly bigger operation, sometimes depending on the amount of tissue you've got, might actually recommend staging this.

So perhaps tackling the front first and then coming back at a later date to do the back, but it just depends really what is or how it's possible to make this as safe as possible for you whilst trying to obtain the best possible result, but this is less commonly performed.

But probably the most invasive of the tummy tucks.

And then just a picture just to show separation of the six pack muscles.

So again, the fascia, the sort of grisly tissue that joins the six pack muscles together rather like the skin.

If it stretches, it won't necessarily go back so normally, after pregnancies, the muscles do tend to head back with time.

But you can't guarantee it. I've got a few poor patients I've seen over the years with sort of 22-centimeter divarication, and people are often then in the situation where they're being asked are you pregnant.

And it's really upsetting for people. So that's where I think rectus placation is particularly satisfying for a surgeon to perform but also provides a noticeable result. Increasing core strength again, all of those sort of functional improvements that can occur, and that can be very, very powerful technique.

And then I think, if we move on.

So liposuction. So back in the eighties, people used to embark on huge amounts of liposuction, they'd be setting out to use this again as a weight loss tool you'd be trying to perform 18 litre liposuctions and things which are very, very unsafe.

So nowadays, really, liposuction is best regarded as again another adjunct to other surgery. And with this you're really trying to take away stubborn pockets of fat that really just don't improve as you lose weight.

So common sites tend to be the love handles, lower or upper back, rolls sometimes under the arms or the medial thighs, but the issue with liposuction really is. It depends on the elasticity of the skin to be able to work.

So if you were to liposuction a large area of fat out of a 10-year-old, you'd never, ever do that. But if you were, the skin is very elastic. So actually, as the fat came away, the skin would recoil and shrink down, and you could expect a fantastic result.

I think if you did the same thing in a 95-year-old. So the skin's lost elasticity, as you emptied the skin out, you'd actually find that you got more loose skin. And actually it can lead to a very disappointing result.

Most people, most of our patients, are in between the two, and things like stretch marks.

Previous use of steroids. Smoking can all affect the ability of the skin to recoil, so, although it would be nice to use liposuction more frequently. We really need to make an assessment of your skin.

The area that you're thinking of trying to improve and decide whether or not liposuction is appropriate, or whether or not a skin excision is actually required.

But this can be fantastic, and the nice thing about liposuction is, it tends to be slightly smaller incisions commonly.

Can be performed with a local anaesthetic or with a general anaesthetic. Again, it depends on the location and the amount of liposuction that needs to be performed at Benenden Hospital. We've got a Microare, so it's a mechanical suction, assisted liposuction system.

Which is very good. So helps us to remove, in fact, from larger areas. And yeah, you can get some terrific results with it.

The incisions from that tend to heal up with little dissolving stitches, and you might put some little absorbent pads on, because often you get a little bit of ooze of some of the fluid through the wound in the early post-operative period, and again very important with liposuction, that you wear close, fitting compression garments just to try and encourage all of the tunnels that are created when you use the liposuction cannula

just to close up and re-adhere.

So you've got to be quite cautious again with liposuction, you can sometimes get contour regularities frequently actually post surgically, people describe areas of liposuction as being the most uncomfortable part of the procedure.

Which I always find quite interesting because it's normally the area with the smallest incisions. And it's not uncommon to get little areas of fat necrosis so lumpy areas under the skin that take some months to fully soften and settle down.

But it can be a very useful adjunct to other procedures.

Okay, we can move on, I think.

Thanks, Kate.

And then risks and complications. So there are risks and complications, unfortunately, with all of these procedures.

So any operation that has general anaesthetic, there are general anaesthetic risks, and you discuss those with your anaesthetist before the procedure, and all of these will leave scars.

Scars should hopefully soften and flatten off and become pale with time, but they can become a little bit red, raised, lumpy and painful.

Post-operatively from about six weeks we'd normally advise you on how to massage and manage your scars, to try and encourage them to mature and to look as good as possible.

But what we'd normally be trying to do is hide the scars underneath clothing, so try to make the scars as invisible as possible. But anybody that promises scarless healing, I'm afraid, is lying. It doesn't exist.

And there are common things like haematomas, so collections of blood that can form under the skin very rarely with some of these procedures you might need a blood transfusion.

Very occasionally you can get a collection of tissue fluid forming under the skin that might need to be drained off with a needle in the clinic. That can be an annoyance, but if you leave it alone it will normally heal and sort itself out with time

Asymmetries, so it will try and put the tummy button back in the centre. Most people, if you have a good look in the mirror, will find that your tummy button lies slightly off to the right, no idea why.

And it's not uncommon to have some permanent change in sensation. So people who have had things like caesareans and appendicectomies previous scars will often find numb areas around the scars. So I tend to suggest you might need to expect that any of these areas that have been offered on would be number or have altered sensation compared to your preoperative.

But it's not like losing sensation in your hands or your feet or your lips, and your minds are fairly placid, and they accommodate this century change reasonably, swiftly.

Things like blood clots. Again. We often give you a blood thinner while you're in the hospital, and some horrible stockings to wear, and we'll get you mobile and up and about as soon as possible, just to try and reduce the chance of blood clots.

And then infection is something we're always aware of. So with any of these procedures, you'd normally have some prophylactic antibiotics as you go off to sleep.

And then we keep a close eye on things. If you do start getting redness, or the wound becomes hot or starts producing fluid, then we might need to think about starting on some antibiotics.

At Benenden Hospital we've got what they call laminar flow theatres, which is special airflow through the theatres. So really, they do a lot of orthopaedic work and implant-based work. And that's I think the laminar flow really does help to reduce infection rates. So we keep a close eye on all of those

Okay. And then, normally, with these procedures, most of the tummy tucks really would require a one-night stay some of the mini tummy tucks may be day case procedures, smaller areas of liposuction again, you may be able to go home, or often can go home as a day case, and some of those larger massive weight loss type procedures might need to be in for two nights, but overwhelmingly nowadays you'd go home after one night.

Tend to use a large amount of local anaesthetic in all of the wounds, so try to make you as comfortable as possible.

and with most of these procedures we would recommend regular paracetamol for the first few weeks you could consider a non-steroid anti-inflammatory ibuprofen as well, and they'll often give you a weak opioid or opiate.

But actually, those are the medicines to get rid of. First because they make you feel sick. They can make you feel dizzy, and they can give you constipation. And actually, that's one of the things that you really don't want. If you're trying to recover in particular.

I think most people after these procedures would describe tightness as being the thing that slows you down the most. But really, although I don't want you to take to your bed after one of these procedures, because it can increase the risk of things like pressure sores, chest, infections, blood clots.

I want you up and about so mobile. But you really, you want to take it nice and easy for the first week or so often from one to two weeks you can start doing a little bit more walking.

I often have people getting onto an exercise bike from two weeks or so. The wounds depending on the wounds the fastest they'll ever really heal, and you're able to remove all of the dressings is probably about four to six weeks, but I tend to suggest for any of the larger abdominoplasty procedures that you're thinking about a six-to-12-week recovery period.

So I love holidays, I think what you really don't want to do after one of these procedures is, be in the situation where you're trying to get better before a cruise or a long-distance flight.

So really, you're best off, just giving yourself the time to recover fully, and then think about a nice holiday just to unwind and relax.

Another important thing just thinking about recovery is smoking and nicotine use so smoking for any of these procedures is bad news, and it's the nicotine unfortunately, that seems to have the effect on the vascular system and wound healing.

So for any of these really would be suggesting that you're off cigarettes for at least six weeks before surgery, and then you want to stop off any smoking until you're nicely healed.

And vaping really, you want a good two or three weeks before the procedure, ideally, with no nicotine on board, and then again try and keep off until you're nicely healed.

But yeah, there you go. And again, with any of these offers. You tend to be quite stooped initially. So people often are after quite rigid criteria for what they can do and when. But it's everybody's very different. So I'd normally be suggesting again, up and out of bed the day after the procedure.

Showering from two days. Driving is often two to three weeks. So you have to be safely in control of your vehicle and able to perform an emergency. Stop before you drive, and you've got to be just really honest with yourself.

That seems to be the one thing that the insurance companies, the DVLA, the police, are all agreed on. So you've got to be safe and sure of a vehicle able to perform an emergency stop.

And then, from about six weeks onwards, people often start building up activities significantly.

But I'd normally suggest things like planking or sit ups and crunches and things.

You probably want to be giving yourself a good three months or so before you get back into targeted abdominal exercises like those just to give the muscles the best possible chance of knitting back together without pulling apart again.

And it can be a little bit uncomfortable. So again, so long as you're sensible, you listen to your body, you can basically tailor up your activity as you feel comfortable.

And yeah, if you if you feel you've overdone it a bit, you probably have, and you can just let back off a particular activity for a week or so, and then you could gradually introduce it again.

And travel. So we do tend to recommend any long-distance flight, and that really includes flights of over four hours.

You should try to give yourself a good six weeks before surgery and after surgery, before embarking on those longer distance flights, just because it can increase the risk of venous thromboembolic disease. So blood clots in the legs. DVTs that can travel up to your lungs. PEs. And that's potentially very serious. Adverse outcome following a procedure.

But seems to be reasonably uncommon. So but we just we keep a close eye on that.

And then your final results really starts to take shape from the moment you wake up. But often things become more swollen over the next few weeks, and somewhere between about six and 12 weeks. Really, the swelling resolves, and normally by 12 weeks we've got a good idea about your final result.

The scars themselves, any scar really takes about a year or so to fully mature. So you're going to have to be quite invested in scar management.

I generally recommend that you massage your scars for a good five minutes twice a day following this surgery from about six weeks or so, and much as the various manufacturers of the creams and things would have us believe otherwise.

I think the evidence seems to suggest that actually, it's the pressure of the massage using the product as a lubricant. That makes the biggest difference. So if you like, Aveeno or bio-oil or coconut oil, or just whatever your skin likes, is the thing to use for scar massage.

And again, it's the pressure of the massage that helps to encourage the scars, to go through that red, lumpy phase and to become soft and flat and pale a bit more swiftly.

Kate I think we're moving on right. So I'm going to hand over to Kate.

But hopefully, that's a bit of a snapshot of tummy tuck surgery, liposuction, and some of the things to consider with this type of surgery.

Kate Comrie

Thank you so much. Always very interesting.

So we are going to take some questions. So I think, actually, we address this at the beginning. But just in case the person wasn't able to hear, how long should you be at your optimum weight or size before considering a tummy tuck?

Mr Simon Mackey

Was that do you say? How long should you be at your optimal weight size?

So ideally so for massive weight loss. So people who have had bariatric surgery or lost more than four stone or so in weight.

They tend to recommend that you have plateaued and maintained your weight for about six months. If you're still actively losing weight, then you can imagine you're in a catabolic state.

Your body's still breaking, breaking fat away. And actually, what you really want to do is to be in a sort of a steady state, or even slightly anabolic when you have your procedure performed.

So the metabolic requirement to heal any of these wounds, because you can imagine you've got your long scar on the outside.

You've got your long scars inside as well. It's quite high, and it's not uncommon to feel fairly wiped out and exhausted because your energy requirements increase after this type of surgery.

So it's very important that you're well-nourished in advance of the procedure. So people take multivitamins and need to concentrate on good quality, protein and eating all of those green, colourful leafy foods and things that we should be eating just to make sure you get all of the micronutrients in.

But so yeah, so about six months. But we get lots of people who want to just lose half a stone before surgery, and will lose the half a stone, and we might see them a few weeks before the procedure.

I think that's absolutely fine as well. But yeah, after significant weight loss good six months.

Kate Comrie

Thank you.

Can you get a better result from healing and also a look from a tummy tuck if you have exercised and built up some muscle in the stomach area prior to surgery?

Mr Simon Mackey

So it would be nice to think so, but it probably doesn't make a huge difference. But I think if you're physically nice and fit before the procedure.

So there's a lot of talk about prehabilitation nowadays. So really, just trying to optimize things before surgery. And just again just try and stack risks as much in your favour as possible.

So one of the things is, you need to have a BMI really, that's below 35 before really considering any of these procedures.

And that's because we know from lots of audits that as your BMI increases when you hit a BMI of 35, there seems to be an inflection point, and there's a significant increase in wound healing problems, wound healing delay and those sorts of issues.

So again, BMI is a fairly crude tool. But they say normal BMI is between about 20-25, 25 to 30 is overweight, 35, and above is, you start getting into all sorts of type, one type, two obesity, and they keep changing the nomenclature.

But really, you definitely want to have a BMI below 35, and ideally closer to 25-30. When you have this sort of surgery performed.

Kate Comrie

Lovely. Thank you.

This person doesn't have any weight loss issues, but they're interested in a tummy tuck with some liposuction to help with previous abdominal surgery and ugly tight scars through a chubby abdomen. Bless them. So they're just wondering if that's suitable?

Mr Simon Mackey

Sounds like it sounds like it is so again, the scars that you can remove normally the ones from the tummy button down to the bikini line and most abdominal procedures. The scars are in that area.

So yes, and actually, really, I think abdominoplasty surgery is best used in people who are trying to remove excess skin.

So it sounds like you're probably an ideal candidate. Whether or not live production would be useful for you, I don't know, but we'd have to take a look at you.

I think again, lots of people come in asking for tummy tuck type procedures.

And actually they end up the patients have got lots of visceral fat, so visceral fat is the fat that's around the organs, so within the tummy cavity itself and you can't get to that fat with tummy tuck surgery or with liposuction so often for people with a lot of visceral fat.

Actually, what you need to be exploring is weight loss and again possibly going through your GP to see whether you're eligible for any of these newer weight loss jabs or bariatric type procedures.

But again, we've had lots of people lose enormous amounts of weight with things like slim fast and weight watchers and eating the rainbow, doing this Tim Spector type thing and intermittent fasting. But again, sadly, I'm not a weight loss expert, but yes. S

o I think this question was about loose skin. So yes, loose skin and scars definitely a candidate.

Kate Comrie

See this person has had successful knee surgery, but they've noticed that along the length of the site of the surgery the scar has completely disappeared in some places but seems to have widened marginally in other places.

Is that likely to happen if they have a tummy tuck also?

Mr Simon Mackey

So it could do so.

People often come in with a very beautifully healed caesarean scar, say, and actually, if you imagine with a caesarean, you've got a patient or a lady with a big tummy with a baby inside, you make an incision.

So basically, just a cut to get down to take the baby out, and then you close the scar up under no tension at all. And, in fact, because the baby's gone, there's a nice there's lots of laxity, so there's no tension on the scar.

So I think what you're describing at your knee replacement scar. I think it was a knee replacement, you said, but is a long scar that heads over the knee, joint itself and the odd points as you flex and extend the knee, you get more tension placed across the scar.

So one of the reasons that people can develop hypertrophic scars which are scars that are permanently a bit redder or lumpier or can stretch is tension.

So with a tummy tuck, of course, rather than an incision, you're taking out as much tissue as you dare, and then you're closing the tissue under tension.

So there is a risk of developing a stretch scar, or a slightly hypertrophic scar.

But again, with massage and moisturisation, we can normally still achieve a very good result. Very occasionally people might benefit from things like steroid injections, literally into the scar, just to damp down an over exuberant, inflammatory response which can cause some of that lumpiness.

But again, I sometimes see people who just have a problematic what they see as a problematic scar from other surgery, and it's actually a stretch scar.

But the stretch scars can often, although they're slightly wider than you'd ideally like, as long as they're flat and they're pale, they can still look very good, so there is some variation.

When I finish any of these procedures off, I always try to make the scar look as good as I possibly can.

But again, when you're stitching, you're sometimes stitching a longer scar to a shorter scar, and in order to try to close that up without a lumpy dog ear at either end. You sometimes have to purse, string that longer, edge in to the scar, so it can sometimes look a little bit creased or wrinkled initially, but it does improve with time.

Kate Comrie

How long does surgery take on average?

Mr Simon Mackey

So, depending on the procedure, I tend to say about two to three hours. So a mini tummy tuck might take an hour or 90 minutes or so a standard tummy tuck with a plication will be around two and a half hours or so.

An extended abdominoplasty might take three hours. Some of the fleur de lys, and the circumferential can take four hours or so, or the circumferential can take four or five hours, but most people about two to three hours.

Kate Comrie

Lovely. Thank you.

We did touch on BMI. But is there a maximum BMI that you consider for tummy tuck surgery?

So this person's lost six stone well done, but still in the overweight category. However, they're quite happy with their appearance generally they just have an amount left which is all carried around the abdomen.

Mr Simon Mackey

Loose skin. So yeah, again, it's a fairly crude thing. But most plastic surgeons, both units would say, a BMI of 35 really is the upper limit.

And it's basically just because for whatever reason, there does seem to be a significant increase in complications with a BMI of greater than 35.

So in an ideal world you would definitely try to drop your BMI to below 35 before proceeding.

Kate Comrie

Thank you.

What is the morbidity rate for these surgeries where there is no comorbidity conditions? So this person has watched too much Grey's anatomy and is terrified of having elective surgery.

Mr Simon Mackey

Yeah. So again, I think as we touched on it, surgery, you don't need to have done. This isn't a lifesaving operation. It's improved lifestyle and can improve function in other ways.

So we have to be very open to any of these things.

 So I would say, probably about 30% of people have some sort of area of delayed healing might need a little bit of additional dressing treatment.

Things like seromas. It's about one in 20 might get a seroma, which is a collection of fluid which might need to be drained off in the clinic.

Things like superficial infections. I think often things like inflammation we over treat as infections. So it's probably about 10% of people might have a superficial infection. I might be being a bit pessimistic.

Things like DVT or PEs with tummy tucks. It's in the region of about one in 2,000 is my understanding.

Blood clots in the legs might be slightly more common. But mortality is. You've asked about morbidity rather than mortality, so I'm sure there is a mortality rate thankfully in my experience, and the experience of my immediate colleagues who have seen anything like that.

I think there are. If you go back through. I can't remember the name of the TV shows but botched those sorts of things.

They will show some disasters, and I think there are some unfortunate cases with, I think, normally non-plastic surgeons performing liposuction, perforating the bowel.

And so you need to know what you're doing, I think. But again we just try to stack the risks in our favour, make things as safe as possible.

Kate Comrie

Thank you.

Next question is, does this permanently change your body, i.e. Does fat form differently after the operation if you were to put on weight. Does the left fat average out after?

Mr Simon Mackey

So it depends. So actually, if you line up a hundred people and they all gained three or four stone again, everybody tends to put on their fat in slightly different places.

So some people it will be the tummy. Some people, it might be inside the tummy cavity, or it might be the bottom. So everybody's very slightly different.

So if you're somebody whose primary site for laying down fat was the tummy tissue and if the tummy tissue has been removed you can imagine that it might be your secondary site. That is the site that is more prone to putting on weight. If you then put on weight again.

So in an ideal world again, you'd be at about your ideal weight when you have one of these procedures performed, and then hopefully, it would incentivise you to try and maintain that weight just to try and maintain the best possible result following surgery.

But that tissue that's been removed has then gone. So if that was your primary site for storing fat, then yes, that would have gone.

So, yes, if you if you put on weight, you could put on weight elsewhere, but it would tend to be your sort of secondary site that you tend to put it on.

Kate Comrie

Thank you.

I've heard that the sorry I've heard that the incision sites made for liposuction can leak after they have healed. Is this true?

Mr Simon Mackey

Shouldn't leak after they've healed. So in the early post-operative period, some of the so to do the liposuction, we inject a solution of saline, so salty water, and some adrenaline and some local anaesthetic, and that produces a tumescence.

It spreads the fat cells apart, and it just makes it much easier for the fat to be removed with the liposuction cannula.

So we tend to use some dissolving stitches which are fairly loosely closed. Actually some steeps, and then an absorbent pad dressing, and most of that fluid is then reabsorbed, or any of the fluid that hasn't been liposuctioned, is then reabsorbed into the tissues through the lymphatic system of things.

But yeah, sometimes it will leak out in the early postoperative period, but once it's healed it shouldn't leak unless you've got an issue with a scar itself.

I don't know if you're speaking from experience or just asking, but if you have a little bit of over granulation or something, a problem with the scar.

Then it might be beneficial just to take a look at the scar and just see if anything can be done to encourage it to settle down, but it shouldn't leak in the longer term.

Kate Comrie

Thank you.

Now, this person's daughter is getting married in August 2026, congratulations, and they still have some weight to lose.

So not yet at the point of having it done now, what would be the minimum timeframe between operation and wedding to allow for all the swelling, etc to resolve so they can fully enjoy the day?

Mr Simon Mackey

So you're being very sensible. You're thinking about things in advance so like people who are forward thinking don't like people doing things at the last minute.

So that's very sensible. I would be thinking you want to give yourself at least three months to fully settle so probably a little bit longer than that, because you want to get fitted for nice clothes and things.

So I'd be thinking four months or so that sort of timeframe.

Kate Comrie

Thank you.

Mr Simon Mackey

three months is the sort of absolute minimum. I think.

Kate Comrie

How long before you can drive?

Mr Simon Mackey

About two to three weeks.

So I've got to say I've done lots of these procedures for people who have had things like hysterectomies or caesarean sections, and overwhelmingly everybody's told me that the caesarean or hysterectomy was much more painful than the tummy tuck surgery.

So normally by two to three weeks most people are driving. I'm sure some people are driving a little bit earlier.

And again, some people take a little bit longer, but as long as you're safe in control of the vehicle, you can perform an emergency stop. You're okay.

And I think most people are driving automatics nowadays. So yeah, two or three weeks. Normally.

Kate Comrie

Yay, do you have any before and after photos that you can share?

Mr Simon Mackey

We do normally would show them to you during the clinic appointment. And it's important, I think, just to make sure it's the correct form of abdominoplasty for you.

So I think there's so much information out in the Google sphere or the Chat GPT land, or whatever or Instagram.

That it can become a little bit, mind boggling and baffling. So we prefer just to show you some images directly. And again, most of my patients are fairly discreet, and would say, they don't particularly want to have their images splashed all over the place.

So yes, we're very happy to show you some images.

Kate Comrie

Thank you.

This person's a train driver. Interesting. How long would they need to be off work for approximately?

Mr Simon Mackey

So it's probably it's you're probably in the region of about three weeks or so.

But it's one of those procedures so often if you've got a ventral hernia, so if you've got a rectus divarication to repair as well, it can slow you down a little bit more.

But many employers would really regard that as a hernia type repair. So it's not uncommon to be out of action with a hernia for about four to six weeks.

So again, probably I've been on the Bluebell railway and things, but I think the steam trains are probably slightly heavier to drive than a modern train.

So it might be that actually, the thing that limits you is being able to drive to get to work more than anything else. But I think once you're, I imagine, once you're at work, it's all or nothing.

So I think you're probably thinking about three or four weeks. Really.

Kate Comrie

Thank you, and you combine liposuction, tummy tuck and breast uplift in one operation?

Mr Simon Mackey

You can, you can, and sometimes, because you suction fat away. You can sometimes think about fat transfer just to augment the breast as well, which is fairly commonly performed.

So yes, that's a fairly common combination of procedures.

Kate Comrie

Lovely, and is it possible to have tummy tuck and liposuction with a diastasis?

Mr Simon Mackey

Yes, definitely, so very commonly performed. Combination of procedures.

Kate Comrie

I think this is two questions, amalgamated one. What age is a tummy tuck not suitable for? And I think the question is, can you operate a tummy tuck on an older woman?

Mr Simon Mackey

You can, I think, so long as you're safe for a general anaesthetic.

And you're mobile and you're fit and healthy. Then there's no particular upper limit. I think the oldest lady I've performed. One of these four is 78.

Youngest is early twenties following massive weight loss.

So that's the sort of the range, but there's no upper limit, I think, so long as you're fit and healthy, it's like most of these procedures, you could consider having it done.

But again, we'll be honest with you. So if you've got medical issues, then I might have to say, Look, don't, don't have this done.

But yeah, if you're fit and healthy, there's no upper limit, really.

Kate Comrie

Thank you. A bit of a complex question here. How much fat and skin do you take?

Mr Simon Mackey

It can depend. Really. So if it's a mini tummy tuck, it might be 50 grams, 100 grams I think yeah.

So some of the massive weight loss procedures. Some of the post bariatric procedures that we've done have been kilos sort of 10-12 kilos, so it can be. It can be quite a large amount.

Most people are probably somewhere between about one and three kilos, I'd be thinking, and we tend to weigh the tissue as it comes off, tend to photograph it with a ruler.

So you can if you want to. You can have a little look and see quite how much has come away. But yeah, so it's but it's loose skin that's been removed.

So 3kg of loose skin is actually quite a lot of tissue to take away.

Kate Comrie

Thank you.

This person has an amazingly. They have lost six and a half stone, and they've been left with a lot of skin in the lower abdomen and the pubic area.

Would a standard tummy tuck help with this, and is there a time limit between the first and second consultation? Should they need to go away and do more work on the area to get the desired result before surgery? Brilliant question.

Mr Simon Mackey

Okay, so a few, a few things out, well done on the six and a half cent weight loss. That's very good.

So yeah, so one of the other things that is commonly performed at the same time as tummy tuck surgery is a mons lift so often. If you've gained a lot of weight the tummy skin can stretch, but also the skin of the mons pubis can stretch, and as you then lose weight, people come in again.

These aren't my words.

So people describe sort of a ball in a sock, and you can get very lots of sagginess and droop and excess skin in that area which is again doesn't feel terribly feminine.

And so a mons lift is another procedure commonly performed at the same time as the rectus divarication and tummy tuck type procedure, and basically just take as much of that loose skin away as possible. Hitch things up into a new position.

And that's a very, very good thing to do at the same time as a an abdominoplasty procedure.

I've forgotten the second half of the question there, but.

Kate Comrie

Is there a time limit between the first and second consultation? Should they need to go away and do more work to get the desired result before surgery.

Mr Simon Mackey

There's no maximum time limit. I don't think so I think if I if I saw you and then you went away for a few months, just to optimize things that's fine with. Just treat that as the same consultation or same pair of consultations.

But we should really let you have two weeks to cool off after your initial consultation. So it's very important you don't feel pressured into having any of these procedures done, and there are high pressure kind of folk around. So you just need to be a bit cautious.

I think personally, we'll sometimes do a video consultation for follow up or a phone consultation for follow-up. But I think really, you need to be seen in the face to face. Really, you need to examine the tissues and really get a good feel for what's going to be the best procedure.

So I think two face-to-face consultations, to my mind, is the is the minimum.

Kate Comrie

Thank you.

Mr Simon Mackey

Equally. Sometimes there's a variety of different things you could consider. If I need to see you for a third time, then so be it.

But I'd rather, you know, one of my old trainers years ago. You said, if you do the wrong operation perfectly, it's a disaster.

So actually, the most important thing is to get the right operation for you, and then hopefully get as good result as we possibly can.

Kate Comrie

It's definitely tailored. Thank you.

Mr Simon Mackey

Okay.

Kate Comrie

How long does Benenden support you for post-op? Is this part of the package?

Mr Simon Mackey

There is so terms. Conditions are. Wherever you go to there are different terms conditions. I think, Benenden, it's a year, isn't it?

So they tend to price all of these things up everywhere as a package of care, so it will be the surgical fee, the hospital fee, the anaesthetic fee dressings and things tend to be bundled up together as well.

And with most hospitals, same as Benenden. If we need to get you back in for dressings and things. It's all part of your package. If we need to readmit you for something like an infection, think about earlier on or a wound issue. Then, again, it should all be included within your package of care.

But with any of these self-pay services there's always the chance you could accrue additional costs and fees. So you've got to go in eyes open, but we do tend to. They tend to bundle things up as a package of care, just to make it much more straightforward and transparent for everybody.

Commonest sorts of things people might need to think about changing are dog ear. So we keep. It's a terrible phrase. I don't like the phrase dog ear.

But anyway, everybody knows in plastic surgery what a dog ear is. But I still say, if you imagine a piece of flat foam, and you cut a circle out of it, and then close the edges of the foam together. You would get a big dog ear forming at each side.

And if I'm taking a mole out of the skin, I tend to take it out as an ellipse, because you can cheat the edges of the wounds together and try and avoid a dog ear and a tummy tuck really is like a big lips, so you could normally cheat everything in nicely.

But sometimes if you get a little dog ear at one end of the scar, and it could take about a year for the dog ears to fully improve.

But you sometimes might need to have that nipped out as a quick local anaesthetic procedure. And again, the hospital normally just bundle that into your package of care.

Say, man.

Kate Comrie

Last question. I possibly need to have a hiatus hernia repaired this year, but I also want a tummy tuck done. How long would I need to leave between the two procedures?

Mr Simon Mackey

So I would say, just make sure you're nicely recovered from your hiatus hernia. I get the hiatus hernia repair done first I think, and then, really, it's as soon as you feel you're ready. So probably recommend seeing you once you've fully recovered. So probably from about three months post-op.

And then with the planning things, it might be another three months or so until you're ready to go anyway, so it might be in the region of about six months.

But you just need to make sure you're nicely recovered from your first operation before embarking on another one.

Kate Comrie

Thank you very much.

Right, thank you. I'm sorry if we didn't answer all your questions. If you provided your name, we can answer your questions via email.

And the last slide. So as a thank you for joining this session, we are offering 50% of your treatment consultation, a callback from your dedicated private patient's advisor, an email with a recording of, I beg your pardon, an email with a recording treatment, information and loyalty reward points and updates on news and future events.

So we would be grateful if you could complete the survey at the end of this session to help us shape future events.

If you would like to discuss or book your consultation, our private patients team can take your call until 8.30pm tonight, or between 8am and 6pm Monday to Friday, using the number on the screen.

We currently have an, I beg your pardon, we currently have appointments with Mr Mackey and myself available for the 29th of April.

We do have some upcoming events on a range of topics, including breast surgery, and you can sign up to any of those via our website.

On behalf of Mr Mackey and the expert teams here at Benenden Hospital, I'd like to say, thank you for joining us, and we hope to hear from you soon.

Thank you very much. Take care, bye, bye.

Mr Simon Mackey

Thank you for coming.