The Lap Band and Tummy Tuck are two of the most common surgical procedures for weight loss. The surgery is not just about losing fat and reducing weight, but also about improving the overall health of the patient.
The lap band surgery is a restrictive procedure that limits food intake by creating a small pouch at the top of the stomach. This reduces the amount of food that can be eaten at one time. The tummy tuck, on the other hand, removes excess skin and fat from around your waistline to give you a more toned appearance and improve your posture.
Both procedures have their pros and cons. Let’s take a look at them in more detail:
Lap Band Surgery: Pros And Cons
Pros:
- The band can be adjusted to provide different levels of restriction depending on your needs throughout recovery
- You don’t need to make drastic changes to your diet or exercise regimen because it does not affect how much food you eat or how often you exercise
- It is reversible if you decide later on that you want to lose weight naturally
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Lap Band And Tummy Tuck
Schematic diagram of gastric band and components, whereby the gastric band (B) is placed below the stomach and esophagus (A) and connected by a fill line (C), which traverses through the fascia and muscle at the “site of entry” (D), to eventually terminate subdermally within Scarpa’s layer to the port arm (E) and access port diaphragm (F). Critical structures that will be encountered during an abdominoplasty are highlighted in red.
A majority of patients who undergo LAGB procedures have body mass indices (BMIs) in the 40+ range.4 With eventual weight loss, greater laxity of abdominal skin is inevitable. Overhanging panni and redundant skin can lead to chronic moisture entrapment and eventual repetitive dermatitis and skin breakdown, prompting many patients to pursue further aesthetic procedures, such as abdominoplasty. The fundamental principles of abdominoplasty historically involved excision of excess skin and fat and plication of the rectus abdomini fascia; these remain the standard of care to this day.5,6 Modifications in dissection and use of minimally-invasive techniques have contributed to further refinement of the technique, including blunt undermining and mobilization of the upper abdominal skin flap with liposuction.7,8 Regardless of modality, abdominoplasty remains a common request for many post-massive weight loss (MWL) patients.9 With the increasing popularity of minimally-invasive and reversible bariatric surgery and a greater cultural body consciousness, post-LAGB abdominoplasty is becoming more commonplace. The growth rate of these procedures will likely accelerate further, given new Food and Drug Administration (FDA) data indicating efficacy at even lower BMI.10
At present, there is no protocol, algorithm, or suggested mode of abdominal wall contouring following gastric band placement in the bariatric, general, or cosmetic surgery literature. We find this void in knowledge concerning, as the gastric band port and line can be (and often are) obstructive to successful abdominoplasty if not repositioned appropriately. Furthermore, the potential consequences of inappropriate port or line handling can be catastrophic for viscera and bowel function. Competency in port and line management is therefore critical to the intraoperative and perioperative care of these unique patients. In this Featured Operative Technique article, we present our technique for a simple and safe method of managing the port and apparatus during abdominoplasty, and we present the results of several unique cases from our 20-patient series.
Operative Technique
(A) The fascia and port are pulled immediately following imbrication with interrupted and looped secure sutures, represented as crosshatched lines. (B) The port is “swung” 45° laterally, such that it is approximately 3.5 cm lateral to the midline corset suture. (C) The ideally repositioned port is shown without encroachment or contour defects on the midline corset suture or umbilicus after complete closure. It overlies the sagittal midline of the left rectus abdomini muscle. This provides a stable port base to allow long-term access. No visible mass effect or bulge from the port or connecting tube should be appreciated upon closure.
The port is repositioned at an approximate 45° angle away from the linea alba, to the midline of the rectus abdomini muscle.
The Post-Adjustable Gastric Band AbdominoplastyPlay Video
Currently, no clinical protocols exist for laparoscopic adjustable gastric band (LAGB) apparatus management during abdominoplasty, despite the fact that serious medical complications can accompany post-LAGB cosmetic procedures. In this video accompanying their Featured Operative Technique article, the authors demonstrate their “swing” procedure for rotating the LAGB port.
Clinical Results and Case Illustrations
We have treated a total of 20 patients (N = 20) with this technique at the time of writing. Patients were excluded from our study if they had uncontrolled hypertension, hyperemesis, diabetes, and/or active skin infection(s). All patients have been followed for 2 years postoperatively to monitor subsequent gastric band function, as well as perioperative and long-term surgical complications. All patients in our series currently have fully functional LAGB devices, along with normal-appearing and well-contoured abdomens. No cases of seroma have been observed. None of the patients has required any revision of the LAGB instrumentation. Noteworthy is 1 case of an abdominoplasty complication in which minor superficial necrosis of the skin at the lower incision occurred (Figure 4) and 1 unrelated port site infection remote from the abdominoplasty.
Caudal-to-cranial laparoscopic view of the gastric band line (A) adhesed (B) to the base of the right hepatic lobe (C). The left hepatic lobe (D) is freed of adhesions (anterior abdominal wall and small bowel adhesions not pictured here).
The original fascial defect at the site of entry was reduced with a flanking, interrupted 2-0 Prolene suture passed from the abdominal side under laparoscopic visualization. This allowed free movement of the connecting tube but prevented herniation of the port into the abdomen. The port was then pivoted 45° laterally and advanced to the left median rectus muscle belly. Three interrupted 2-0 Prolene sutures were placed to affix the capsule to the fascia at the 3-, 6- and 9-o’clock positions relative to the port. No leak from the band or stomach was appreciated. Peritoneal cultures and biopsies of the adhesions were sent to pathology. Prophylactic intravenous third-generation cephalosporin treatment was empirically extended for an additional 10 days. The patient’s final cultures were negative for organisms, and the pathology was consistent with dense fibrous adhesions.
Case 2: Port Obstruction of Umbilicus Closure
A 48-year-old Caucasian woman presented after a 78-lb weight loss after having undergone LAGB surgery 1 year prior. The patient had developed a large, overhanging pannus and a chronically irritating panniculitis. We performed an abdominoplasty, and the original bariatric surgeon was made available for intraoperative consultation during that time. Preoperative planning and previous fluoroscopy evaluation for LAGB fills revealed a gastric band port located in the left mid-quadrant, lateral to the midclavicular line. During dissection of the abdominal flap, great care was taken by the surgeon to directly hold and guard the port with the nondominant hand. With electrical cautery, a lateral-to-medial and caudad-to-cephalad approach was used to raise the abdominal flap on the left side of the abdomen. With careful and meticulous dissection, the port was found to be encapsulated within Scarpa’s fascia at the level of the umbilicus. Dissection around the port and connecting tube was performed, so as not to breach the surrounding capsule.
Medial to left lateral view of ideal dissection around the port capsule. The instrument points to the umbilicus, illustrating how close the preexisting connecting tube (white arrow) and port (black arrow) may be, as in this case, where they were just 1 cm lateral to the umbilical stalk.
The laparoscopic adjustable gastric band (LAGB) port “swing” method is shown. (A) Initial position prior to surgery. (B) The port is pulled medially after fascial plication. (C) A minimum 45° lateral pivot is required to allow normal closure and cosmesis.
The management of the post-LAGB abdominoplasty patient must begin with clear communication between the plastic and bariatric surgeons. At bare minimum, the plastic surgeon should inform the bariatric or general surgeon of the surgery date to ensure his or her availability for port or tubing repairs or complete port-site revision if normal closure is impeded by the port in any way. Either the bariatric or plastic surgeon should also have a port repair kit readily available during the time of surgery. Preoperative band fill volume is also a critical communication item, in that the ideal fill volume is highly individualized and represents the culmination of multiple fillings and meticulous adjustments at least every 2 to 4 weeks for an entire year. If the device is potentially damaged or requires extensive revision, accurately refilling the band intraoperatively to a known “safe” level will minimize unwanted emergent adjustments immediately following surgery and maintain bariatric function. It is important to note that as little as a 0.5-mL discrepancy can have a profound effect, as even 0.5 mL of overfilling can cause significant inflammation and swelling to the muscularis and mucosa of the stricture point. We have observed that in some LAGB patients, overfilling by as little as 0.5 mL can result in complete obstruction.
The initial patient workup should also include nutritional clearance, although unlike gastric bypass or other diverting surgeries, LAGB carries a low risk of long-term nutritional deficiency. On rare occasions, some patients will present with hypokalemia and poor protein intake secondary to chronic emesis or inability to tolerate thick textured foods. For this reason, albumin and potassium levels should be evaluated at least 1 month prior to surgery and corrected by the nutritionist as needed. A suggested preoperative worksheet containing these and other critical points of information for this specialized abdominoplasty procedure is provided in Appendix 1, A reference list of our suggested clinical protocol is available in Appendix
There is considerable controversy as to whether the gastric band should be deflated immediately prior to surgery. Some advocate doing so in an attempt to decrease the risk of reflux during intubation and postoperative hyperemesis,13 whereas others caution against this practice for risk of potential refeeding edema or decreased band efficacy.14 In our practice, patients are maintained at their current level of band fill if their weight and dietary intake are stable and they present without nutritional deficits, reflux, or hyperemesis. If the patient has a history of hyperemesis or active reflux, we remove no more than 1 mL from the band, 1 week prior to surgery. In this way, there is minimal risk of band migration or refeeding syndrome.
This 47-year-old woman demonstrates port scar migration. (A) The port scar (white arrow) is superior to center of the port (black arrow) 7 days after the original laparoscopic adjustable gastric band (LAGB) procedure. (B) The same patient is shown after 50-lb weight loss, 2 months after the LAGB surgery. The port scar (white arrow) and the port (black arrow) are at the same level. Firm scar tissue (red arrow) inferior to the port scar was palpably mistaken for the port and traumatized several times by failed attempts to access the “port.” The true port location (black arrow) was actually cephalad to the port scar (white arrow). (C) The patient is shown 5 months after LAGB and an additional 25-lb weight loss, at which point the scar (white arrow) was below the port.
This 44-year-old woman also had port scar migration. (A) The port scar (white arrow) is superior to the center of the port (black arrow) at 4 weeks following the laparoscopic adjustable gastric band (LAGB) procedure. (B) After a 67-lb weight loss, 5 months after LAGB surgery, the port scar (white arrow) is above the port (black arrow).
This 55-year-old woman had port scar migration, despite prior abdominoplasty. (A) The patient is shown 3 years after abdominoplasty and immediately before the laparoscopic adjustable gastric band (LAGB) procedure. (B) The same patient 1 month after LAGB and a 10-lb weight loss. The port scar (white arrow) still lies above the port (black arrow). (C) After an additional 40-lb weight loss, 7 months post-LAGB, the scar (white arrow) migrated down to the port (black arrow).
Commonly occurring gastric band port placements. (A) Left paramedian placement, which is the most common current (and manufacturer-recommended) placement. Placement above the xyphisternum (B) and below the xyphisternum (C).
Because of these variables, we recommend at minimum a flat plate and lateral abdominal film with a marker at the left lateral aspect of the assumed port scar to show the location of the port and connecting tube site of entry.15 This film should be posted intraoperatively to help guide the surgical dissection. We also recommend dissecting the capsule of the port completely to the base of the connecting tube site of entry into the abdomen; without knowing this location, it is impossible to safely place any corset or tension sutures. In rare cases in which thick and copious scar tissue has developed, we also use intraoperative ultrasound (a 7-MHz flat probe in a sterile cover) to guide safe dissection.
The necessity of intravenous antibiotic prophylaxis and postoperative antibiotics cannot be emphasized enough, as metastatic infection and splenoportal thrombosis can occur in the absence of perioperative antibiotics.16 In our practice, we usually administer intravenous third-generation cephalosporins for both surgical prophylaxis (2 g, 30 minutes prior to surgery) and additional postoperative outpatient intravenous antibiotic therapy (2 g every 24 hours for 5 days). A “no-touch” infection control policy is also advised when dealing with LAGB material intraoperatively. This can be maintained by carefully dissecting around the prefascial port and tubing, leaving it within an intact native capsule whenever possible. This strategy serves 3 important functions: prevention of direct contamination into the apparatus and abdominal cavity, mitigation of seroma formation, and prevention of excessive tension.
Case 1, which is a first-time report of hepatic adhesions, underscores the seriousness of port and tubing management since hepatic bleeding from torn adhesions remains one of the most emergent and difficult forms of surgical hemorrhage to manage. Some surgeons have erroneously tried to obviate this predicament by simply leaving the port and connector tubing within the subcutaneous layer “undisturbed” and retracting the entire abdominal flap during abdominoplasty. This fallacious technique still introduces significant tension on the underlying tubing and band, leading to dangerous “cheese-wiring” or “cheese-grinding” effects on the viscera17 or disconnection of the port from the tubing. A free-floating disconnected tube, although seemingly a benign complication, will not only lead to loss of bariatric function but, if it continues unrecognized over the long term, can also erode and transmigrate through the large18 and small intestines.19 Furthermore, tension on the band itself increases the risk of gastric erosion due to excess compression.20-22 A more recent modification of the LAGB procedure incorporates gastric plication around the band to prevent band slippage.23 Hence, the most recent cohort of LAGB patients are at an even greater risk of fundal erosion or tear in the setting of untoward tension, further mandating a “tension-free” policy.
Conceptual diagram showing the relationship between skin and pre-weight loss scar position, which eventually descends below the fixed port after weight loss (dotted line) to a lower position. This can give the surgeon the false impression the port has migrated cephalad, when in reality it is simply the vertical descensus of the scar and skin.
As noted, in all of our post-LAGB abdominoplasties, which are a now-combined institutional total of 20, all of whom have been followed for at least 2 years, we have not encountered seroma formation. Typically, we place 2 surgical drains at the apex and base of the abdominal flap. The distal Jackson-Pratt drain is placed on the side contralateral to the LAGB apparatus. Both drains are brought out below the transverse incision near the pubic symphysis. We hypothesize that progressive tension sutures, as described in other studies, in addition to flanking tension sutures lateral to the port may contribute to our seroma-free success rates. We also hypothesize that preserving the port-tube capsule may also play a role in seroma prevention, as those patients in whom the capsule was breached or enucleated experienced higher serous fluid drain outputs over a greater length of time. Overall, we have observed that the time to discontinue drains takes longer than a typical abdominoplasty by the order of 1 to 3 days.
We also note that, until the drains are removed and the subcutaneous layer has sealed around the port-tube complex, percutaneous access of the LAGB should be avoided to minimize risk of infection. This may sound contradictory to the standard practice of accessing the port ad lib following primary LAGB placement, but the postabdominoplasty flap is vascularly compromised and the dead space is generous relative to the minimal dissection associated with primary port placement. The post-LAGB abdominoplasty patient is, therefore, at an increased risk of infection and abscess formation. In 1 case not described in this report, a small, superficial skin abscess had formed when the port was cannulated 4 days after abdominoplasty. Port access following abdominoplasty should therefore be reserved only for emergent indications during the first 8 weeks of recovery.
Postoperative follow-up visits were carried out for a minimum 24 months with all patients, as a prolonged latency of symptoms and complications has been noted by others, in a range of 2 years following abdominoplasty.17 As part of routine screening, we survey for abdominal pain, weight gain, port-site cellulitis or infection, delayed wound healing, and inability to draw or flush the port. Although seemingly benign, a persisting port-site infection actually carries the ominous differential of intestinal erosion in one form or another.18 The same holds true for any delayed healing or abnormal discharge.21 A patient experiencing any of these signs or symptoms requires prompt evaluation, preferably in conjunction with a bariatric or general surgeon, commonly with radiographic workup (fluoroscopy and computed tomography scan) to rule out intestinal erosion or port disconnection.
Overall, there are few data on the actual rate at which patients receive abdominoplasty post-LAGB, nor have there been sufficient long-term studies to suggest exact complication rates following post-LAGB abdominoplasty. However, in one of the largest and most recent comprehensive long-term studies on LAGB complications, unpublished findings within the study population suggest that 10% of post-LAGB patients go on to receive aesthetic plastic surgery and that of the patients receiving abdominoplasty, less than 10% experience minor-to-moderate band complications such as transient loss of efficacy (J. Himpens, personal communication, March 23, 2011). Our case series is also consistent with these recent findings in that complications of the band or abdominoplasty are relatively rare events. Despite the rare occurrence, a review of the medical literature shows a clear pattern of catastrophic complications in the absence of appropriate band and port management. Of the 20 total patients who have received post-LAGB abdominoplasty at our institutions, no direct complications of the LAGB were appreciated. Perhaps our lower complication rate and the lack of major complications seen in our population are related to an in situ dissection and tension-free policy, but greater research into this unique issue is highly warranted.
Conclusions
Proper gastric band management during abdominoplasty requires precise knowledge of port and connecting tube entry site into the abdomen, mandatory perioperative antibiotics, avoidance of instrumentation capsule breach during dissection, avoidance of excess tension on port and connector tubing at all times, and repositioning and securing of the port as necessary to allow appropriate closure of the umbilicus. The authors’ technique for LAGB apparatus management, as described in this Featured Operative Technique, has proven safe and effective in a preliminary series of 20 patients.
Can You Have A Tummy Tuck After Lap Band Surgery
Losing weight is a wonderful accomplishment and a positive step toward a healthier life. Bariatric surgery, or weight loss surgery, is chosen by millions of people each year to reduce the size of the stomach and help individuals get back on track with their weight loss goals. After healing from this procedure, however, you may find that excess or sagging skin is preventing you from truly enjoying the benefits of weight loss. Not only that, lingering fatty tissue and weakened abdominal muscles are common issues post-weight loss surgery.
Based in Florham Park, NJ, The Peer Group performs tummy tuck surgery, also called abdominoplasty, to trim away the extra skin and fat while tightening the muscles of the abdominal wall. This gives patients a more contoured body and renewed appearance. Many patients choose a tummy tuck after weight loss surgery for a more aesthetically pleasing look. If you believe abdominoplasty may be the right solution for you, the skilled staff at The Peer Group explain the benefits of this procedure below.
Why should I get a tummy tuck after weight loss?
Major weight loss is a huge accomplishment. But once you’ve reached your weight loss goal, there may be some obstacles still standing in your way. Perhaps you’re not comfortable with the stretched-out or sagging skin on your stomach. Unfortunately, this can’t be cured with diet or exercise alone. Tummy tuck surgery after weight loss provides fine-tuning so you can feel more comfortable in your body in Greater New Jersey.
There are other reasons to consider plastic surgery after weight loss. Those extra pockets of fat could be getting in the way of your new active lifestyle, as your body may not be giving you the freedom of movement you need to perform certain types of exercise. If this is the case, abdominoplasty can give you a more defined midsection so you can continue a healthy workout routine.
What kind of tummy tuck should I get?
While weight loss surgery is an increasingly common solution for those who struggle with obesity, there are some aesthetic concerns to consider. Today there is a range of tummy tuck techniques, each of which addresses specific cosmetic issues on the body. The following explains the techniques used in plastic surgery:
- Full tummy tuck: Suitable for those with a moderate amount of extra skin in their midsection. In this procedure, the incision extends from hip bone to hip bone. Our surgeons tighten the muscles and use advanced liposuction techniques to remove fat. We then reposition the belly button so it appears natural.
- Mini tummy tuck: A smaller incision is made along the lower abdomen. While patients still have some pockets of fat, a mini tummy tuck is not as invasive as a full or extended tummy tuck. The belly button doesn’t need to be modified in this procedure.
- Extended tummy tuck: Patients who require major body contouring after weight loss are best suited for an extended tummy tuck. The incision extends beyond the hips and around the navel. The muscles are tightened, excess skin trimmed, and fat removed through liposuction. The belly button is also positioned in a way that looks completely natural.
In each surgery, every effort is made to minimize the appearance of scars or place them in locations where they will be concealed by underwear or a bathing suit. If you are considering a tummy tuck and body contouring following weight loss surgery, an extended tummy tuck may be your best option. However, we recommend that you schedule an appointment with The Peer Group in Florham Park, NJ, so we can assess the area and make a more personalized recommendation.
Healing from a tummy tuck and body contouring
Surgery is performed under general anesthesia and takes about 2 – 4 hours to complete. The Peer Group in Greater New Jersey has a fully accredited, on-site surgical center that is dedicated to your success. After a tummy tuck and body contouring, one of our friendly and caring professionals will give you a compression garment to promote blood circulation and make you feel more comfortable as you rest at home. It is important to give yourself plenty of time to heal after your procedure. With permission from your plastic surgeon, you should be able to resume exercise in about 6 – 8 weeks.