I did a tummy tuck today on a patient who lost an incredible amount of weight. She could have used a body lift, where you go 360 degrees around the body to get a buttock lift at the same time. But I didn’t advocate for that. Why? Because her front was much worse than her bottom, and if you do a 360 degree surgery, not only is it a longer surgery, higher surgical risk, and other issues, you cannot tighten the abdomen as much. For anyone with a hanging pannus, or who has had kids, or who has a lot of anterior thigh laxity, you want to maximize the abdominal tuck. So for her I did an extended abdominoplasty. I go waaay around the sides, but not 360. She always has the option if she feels like she needs it to come back to do the backside someday in the future.
What is a Fleur de Lis? This tummy tuck is for those who stretch out their belly in two directions- vertically and horizontally. When we do a tummy tuck in the traditional way, we are tightening the skin horizontally. For most patients this makes a significant difference, the scar hides low on the belly under your underwear, and no further surgery is needed.
But for some patients, particularly major weight loss patients who have lost 100 pounds or more, you likely stretched out your skin a lot in the other direction, and a tummy tuck doesn’t tighten this. Enter the Fleur de Lis, where you have two vectors of scar- one that goes from hip to hip, and one that goes from sternum to pubic area.
So if we think you need that, why don’t we just do it at the start?
This was a study in Aesthetic Surgery Journal September 2024, “Complications and Risks Associated with the Different Types of Abdominoplasties: An Analysis of 55,956 patients.” (Wow! that is a lot of patients.) The study was done using CosmetAssure database, looking at demographics and complications. They identified 7 types of abdominoplasties and looked at complication rates. What did they find?
Results:
- Fleur de Lis had highest complication rate
- Higher risk of post operative complications was seen with: obese, diabetics, male, and BMI less than 18
- 27% had concurrent procedures- breast surgery, liposuction, facial surgery. This did not add major complication risk, but did increase minor complication issues.
- Patients older than 60 had higher complication rates.
- Common complications: hematoma and infection.
- Less common complications but “major”: DVT, PE, and major infection.
They defined the types of tummy tucks into
- Conventional **By far the most common. 40K of the 56K were this.
- Mini (like a C section scar)
- Lipoabdominoplasty– a mini with some liposuction of the abdomen
- Circumferential (body lift, 360 degrees)
- Extended (a long tummy tuck, with a scar that is longer than conventional but not 360)
- Reverse (scar under the breasts)
- Fleur de Lis (a vertical scar from sternum to pubis with a tummy tuck scar)
The most common was the conventional tummy tuck, followed by an extended abdominoplasty. Then were the mini abdominplasty and mini with liposuction of the abdomen. Only 761 did a Fleur de Lis, and 721 did a body lift (360). 148 did a reverse abdominoplasty (DON”T DO THAT! It has terrible issues of scarring and pain. There is a reason we don’t do it.)
Fleur de lis had a 3,8% complication rate
My thoughts?
I like to do an extended tummy tuck, let it heal, and then see if you need the vertical extension. There are many reasons for this. An extended tummy tuck is a huge operation already, and I include liposuction of the flank and pubic area as part of my contouring for the tummy tuck. I frequently am doing abdominoplasties with breast surgery for those with major weight loss or post pregnancies. Your body can’t fight battles on too many fronts- you won’t heal well, so I look at your overall health, your blood level, your age to see if you can do breast surgery with abdominoplasty. What would happen if you try to do too much? It could mean wider scars, higher risk of infection, slower return to feeling okay.
A fleur de lis is cutting up the blood supply to heal the big tummy tuck scar. Anytime you have a T junction, there is increased risk it won’t heal well. That vertical scar is also not one you can hide under a bathing suit or underwear. Do you really need it?
So I like to stagger it if you need the vertical incision of a Fleur de Lis. You “know” you needed it and it is much less risky.
Now I have a study which proves it.
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