Then we have 2 major ways to deal with tummy tuck.
1- traditional abdominoplasty without liposuction of the anterior abdomem ( with back liposuction but not on the anterior wall of the abdomem
2- lipoabdominoplasty , described first by Saldanha in 2004 , that is done first a liposuction of the fat under the anterior abdominal skin associated with liposuction back as well.

How to know exactly what path to follow ?
This is the first most important decision to be made with the patient. And the choice is based upon technical decision on the what need to be corrected

So if the patient present a sagging MUSCLE with a large gap and bulging abdomem , a extensive undermining of the skin and extensive suture of the muscle is required , then a traditional abdominoplasty is needed and no liposuction is done under the skin that will be undermined , because that skin that is elevated to allow us do a large suture of the muscle gap looses its circulation and cannot withstand additional liposuction that may lead to skin loss and necrosis

But if the patient has medium to small muscle gap in her anterior tummy and more fat under the skin , then a Lipoabdominoplasty is indicated , because we would have to do small undermining of the skin and we are able to safely do liposuction in the fat in the whole abdomem without jeopardizing the skin blood circulation
However, the suture of the muscle will be minimal

What usually we see is that doctors today use massively the second option , a lipoabdominoplasty when in some cases there is a need to do a wider undermining to correct the muscle gap, and the patients , when standing up, end with a bulging of the abdomem , that need to be corrected by redoing the whole surgery

In other cases , when patients have large muscle gap and a lot of fat under the anterior wall skin , patients are going to need both procedures done , meaning that they are going to need to do wide undermining and muscle suture to close the gap and liposuction of the skin in the frontal part of her tummy …

How to solve it?
Usually we recommend to the patient to safely do first wide undermine and muscle gap closure and then after 30-45 days a second smaller procedure , under local anesthesia , liposuction of the anterior fat ..and why is that?
As explained before , it is much easier to remove fat in a second procedure , than to redo the whole surgery with undermining and re suturing of the muscle at the second procedure if we do wrongly a lipoabdominoplasty at the first time …

LIPOSUCTION BACK AND WAISTLINE

Patients undergoing tummy tuck usually have different degree of definition of waistline and skin rolls in the back that need to be addressed
So a thorough liposuction of the back helps the surgeon to achieve the ultimate body contouring and even reduce the extension of the scar at the lateral side of the patient , when we remove sagging skin with liposuction alone , which helps the skin to contract and attached without cutting this skin and without extending laterally the scar. Besides we usually use the fat of the back to model the buttock and correct any sagging and to fill the hips to give a curved body

TUMMY TUCK PRE OP PREPARATION

Patients need to be properly prepared for this type of surgery due to more complications observed in abdominoplasty associated with liposuction than other plastic surgeries. We ask patients to correct any health problems like stabilizing her blood sugar, her thyroid , stopping any type of smoking including shisha, for at least 45 days prior to the surgery , and even though we tend to decrease the skin undermining to a minimum to decrease complications that can occur such dehiscence and skin necrosis when patients have these kind of health problems.
Other tests that we ask patients are no usually asked for other practitioners , but given the aggressiveness of muscle suture , we ask patients to do echodoppler of the veins in the lower limbs and legs to avoid stroke or thrombosis after large muscle suture that increases the abdominal pressure. We ask them to do a lung test to be sure that they don’t have any airway problems , as the abdominal pressure on the lungs when patients have to correct large muscle gap during the surgery may increase and lead to restriction in breathing and the lungs expansion. Patients are advised to do breathing exercise after the surgery with the help of a device to avoid any lung problems.