Abdominal Wall Reconstruction (AWR)

General information:

Abdominal wall reconstruction refers to a set of surgical procedures, used in combination that can address some or all of the following problems:

1. Excess skin in the lower (and/or upper) abdomen
2. Excess skin and fat in the lower (and/or upper) abdomen
3. Poor abdominal scarring
4. Stretch marks
5. Separation (divarication) of the rectus abdominis muscle
6. A single or multiple hernia
7. An untidy belly button (umbilicus)

The procedures are sometimes called ‘tummy tucks’ but the spectrum of surgeries that this relates to is wide. It includes:

1. Pfannensteil scar revision
2. Mini-abdominoplasty
3. Floating abdominoplasty
4. Full abdominoplasty
5. Lipo-abdominoplasty
6. Fleur-de-lis abdominoplasty

The surgeries are almost always performed under general anaesthesia and the surgical time varies depending on complexity. This can range from 1 to 5 hours. Most patients remain 1 night in hospital. Scar revisions and mini-abdominoplasties can be performed as day case surgeries.

Some terminology:

Mini-abdominoplasty: This is when the excess skin and fat above the underwear line is removed to improve the abdominal contour, particularly obvious when sitting and when standing. The benefit is only seen below the umbilicus. This access can be used for problematic scars and small infra-umbilical hernias.

Floating abdominoplasty: This is when the excess skin and fat above the underwear line is removed to improve the abdominal contour. The operation also improves the skin above the umbilicus. No scar is needed around the belly button and it is usually displaced 1-2cm inferiorly if at all. This access can be used to fix small paeri-umbilical hernias or a divarication of the recti

Full abdominoplasty: This is when all the skin and fat beneath your belly button is removed. The umbilicus is repositioned and the rectus muscles are usually tightened at the same time.

Reeves-stoppa repair: This is the mainstay of abdominal wall hernia repair where the rectus abdominis muscle and its enveloping fascia is reinforced by placing a mesh or acellular dermal matrix behind the muscle, and then the posterior and anterior layers are repaired. This in effect creates a three-layered repair.

Component separation: This is the largest of the abdominal wall operations we perform and involves separating the abdominal muscles back into their constituent layers. This allows for the releasing laterally of the abdominal muscles and then re-approximation in the midline. It always involves the placing of mesh or some foreign material to strengthen the repair and tends to be reserved for very complex hernias.

Pre-operative preparation:

In preparing – both physically and mentally – for your surgery, it is worth considering the below points:
• As a general rule, the healthier you are prior to surgery, the quicker you will recover. This involves sensible eating and regular exercise.
• Smoking can affect skin quality and wound healing, it compounds the risks of any general anaesthesia, particularly if surgery is lengthy and most importantly organ function can be irreversibly damaged. Giving up is strongly advised. If this is not possible, refrain from smoking for the two weeks prior to surgery and the first six weeks after.
• Think about childcare (if applicable), with particular reference to your mobility afterwards.
• You may have some choice over the location of your recuperation to facilitate assistance from friends and family or attendance to appointments, which you can discuss with Chris.
• Avoid undertaking major surgery when life is too complex, or immediately prior to a life event, such as a wedding.
• With surgery after massive weight loss, a stable weight that you are happy with is essential to achieve good results that last.
• It is good practice prior to abdominal wall reconstruction to ensure your bowel habit is soft and you are not suffering from constipation. Laxatives and prunes can help, as can fybogel and senokot dietary supplements.

Following your initial consultation, I always advise a second consultation with your main care-giver (planned for during the recovery period) in attendance, as they often have a different set of questions to you. I would normally undertake clinical photography at either of the pre-operative consultations

Early post-operative recovery

Some pain is inevitable after surgery. Long acting local anaesthetic can be used to reduce this. Sometimes, when patients are staying more than one night, Chris also uses pain-busting in-dwelling catheter systems that infuse the area for a more prolonged period with local anaesthetic. Combination pain relief is imperative for the first two weeks. This can slowly be weaned off.

The scar is usually positioned beneath the underwear line from hip to hip (between anterior superior ileac spines). Occasionally a vertical scar is also necessary in the lower midline of the abdomen. There may also be a scar around the new belly button, depending on which operation has been performed.

There are small risks of infection and bleeding, like with any surgery. These are fortunately rare and are usually treatable with simple interventions.

Abdominal seromas are more common, and I advise the use of a compression garment. This is useful for 3 months and patients often find it reassuringly supportive for longer. The heat whilst wearing one in the summer months occasionally causes difficulty in compliance. I would advise buying two, so that one can be being washed whilst the other is being worn. For the immediate post-operative period, a black garment with multiple zip access, to allow access for personal hygiene is preferred.

Physical post-operative recovery

We advise no heavy lifting for six weeks. We would classify this as anything heavier than around 10kg in weight. By the end of the second week, most patients will be able to lift a full kettle. By six weeks, you should feel nearly normal and be doing all your activities of daily life relatively unimpeded, except for exercise and lifting.

Doctors often get asked about driving. There’s no fixed time period to return to doing this. For most patients it’s around the two-week mark, but you have to be safe to perform an emergency stop and have to ensure your insurance company is satisfied with your level of recovery and gives you the all-clear to return to driving.

The recovery period is governed by the size and nature of the abdominal wall problem being addressed. This mostly effects mobility and comfort. A large improvement in physical recovery usually occurs over the first two-week period with 85% activity regained by 6 weeks.
Most patients can light lift (a full kettle) and drive by two weeks. Recuperation very much resembles the cartoon: ‘evolution of man’ with full upright standing by 6 weeks (or sometimes earlier). In this scenario, lifting small children should be restricted to ‘when-seated only’ for 6 weeks, thus not engaging the core musculature in extension.

Following the first 6 weeks, gradual introduction of heavy lifting and gym work is recommended. Physiotherapy supervision and/or low impact core exercise are advised in the initial phase.

Sexual activity can be reintroduced, as comfort allows and at your discretion, but be advised that no significant physical exertion or stressing of the abdominal wall should take place for the first six weeks.

Cosmetic recovery

The cosmetic result will not be fully evident for at least three months, once all the soft tissue swelling has resolved. Small asymmetries are inevitable as the body is inherently asymmetric and occasionally surgery unmasks asymmetries or makes them more obvious. Scar maturation occurs during the first year following surgery. Your genetics determine ultimate scarring but several manipulations combine to help the end result. Usually after 9-12 months the result is clear. A separate scar management leaflet will be given to you.

Lastly, I will ask my anaesthetist to liaise with you over the telephone so that they can answer any questions you may have about the anaesthetic. You may also need a pre-operative assessment prior to the surgery with blood tests and bacteriology swabs.