Postoperative scores were lower than preoperative scores, indicating improvement in functional symptoms. These results were statistically significant at both 6 weeks and 6 months for both the International Consultation on Incontinence Questionnaire–Urinary Incontinence and the Oswestry Disability Index, with p < 0.001 in each case. Six patients (2.8 percent) experienced a rise in their International Consultation on Incontinence Questionnaire–Urinary Incontinence score at 6 months, three patients by 1 point (from 4 to 5, from 7 to 8, and from 15 to 16), one patient by 3 points (from 7 to 10), one patient by 4 points (from 0 to 4), and one patient by 6 points (from 10 to 16). Even though the International Consultation on Incontinence Questionnaire–Urinary Incontinence score increased for the amount of leakage and frequency, the 0 to 10 rating scale as to how much the leakage was an issue was static in one case (10), rose by up to 2 points (6 to 8, 0 to 1, and 1 to 2) in three cases, and fell (3 to 2, and 7 to 3) in the remaining two cases. Likewise, the Oswestry Disability Index also improved for nearly all. Three patients (1.4 percent) recorded higher scores at 6 months, two patients by 1 point and one patient by 6 points. One patient had no change from the preoperative score.
The subjective improvement in urinary incontinence was significant (p < 0.001) in the 0 to 10 rating scale as to how much leaking urine interferes with everyday life. Fifty-nine patients had no incontinence preoperatively; of the remaining 155, 66 scored 5 and over on this scale, indicating that 42.5 percent of patients with incontinence rated it a significant concern. At 6 months postoperatively, only four patients (1.8 percent) scored this scale 5 or higher.
A paired t test shows a statistically significant difference in the mean scores across the follow-up for both back pain and incontinence. The t test looks at each individual patient’s score as a paired value before and after surgery. A negative value represents an improvement in the patient’s condition, the higher the more significant. Back pain improved at 6 weeks (−13.14) and again by 6 months (−19.34). Urinary incontinence improved by 6 weeks (−13.94) if it was going to and then it was static at 6 months (−14.49).
Predictors of Back Pain
Regression analysis was performed on the presurgical back pain score against the independent variables age, age range, parity, method of birth, body mass index, diastasis width, and hernia. The statistically significant independent variables in the forward regression model were body mass index over 25 kg/m2 (p = 0.002) and the presence of an umbilical hernia (p = 0.02). Width of diastasis was not a predictor of back pain. The larger the woman, the higher the initial Oswestry Disability Index score. If a hernia is present, she is also more likely to have back pain.
Predictors of Urinary Incontinence
Regression analysis was performed on the presurgical International Consultation on Incontinence Questionnaire–Urinary Incontinence scores against the independent variables age, age range, parity, method of birth, body mass index, diastasis width, and hernia. The statistically significant variables in the forward regression model were age older than 40 years (p = 0.006) and number of vaginal deliveries (p = 0.044). For each decade of age, the score increased by 1.3. Each vaginal delivery increased the score by 1.26. Width of diastasis was not a predictor of urinary incontinence.
Predictors of Change in Oswestry Disability Index and International Consultation on Incontinence Questionnaire–Urinary Incontinence with Patient Demographics
Regression analysis was performed on the change in Oswestry Disability Index and International Consultation on Incontinence Questionnaire–Urinary Incontinence postoperatively against the independent variables age, age range, parity, method of birth, and body mass index. None of the variables was statistically significant in the change of Oswestry Disability Index at 6 weeks or 6 months. The variables age range (p = 0.006) and parity (p = 0.043) were significant in the change in International Consultation on Incontinence Questionnaire at 6 weeks and 6 months. Older patients with a larger age range of children do not improve as well as younger patients who have their children closer together.
Change in Oswestry Disability Index Score by Method of Abdominoplasty
There were no statistically significant differences between procedure types at either follow-up when controlling for the presurgical scores.
Change in International Consultation on Incontinence Questionnaire–Urinary Incontinence Score by Method of Abdominoplasty
High-lateral-tension abdominoplasty was associated with a slightly larger score decrease at 6 weeks, but there was no statistically significant difference between procedure types at 6 months.
Change in Oswestry Disability Index and International Consultation on Incontinence Questionnaire–Urinary Incontinence by Other Surgical Variables
Regression analysis was performed on the change in Oswestry Disability Index and International Consultation on Incontinence Questionnaire–Urinary Incontinence against the independent variables of surgical center, liposuction volume, and weight removed. None of the variables was statistically significant. Liposuction volume was almost significant (p = 0.06) in predicting the change in Oswestry Disability Index score at 6 months, but the effect size was not clinically relevant. For an additional 2000 ml of aspirate above the mean of 800 ml, the score further improved 1 point. None of the surgical variables was statistically significant for the change in International Consultation on Incontinence Questionnaire–Urinary Incontinence score.
This study has demonstrated a statistically significant improvement in back pain and urinary incontinence at both 6 weeks and 6 months after abdominoplasty with rectus repair in 214 patients. The data were collected prospectively; nine independent surgeons were involved and six different methods of abdominoplasty were used. No single method of abdominoplasty was more effective at 6 months. The patients undergoing abdominoplasty were the whole presenting population, not specially selected back pain patients, nor were the procedures modified for any extra functional benefit. This study is an observation of the functional improvement following abdominoplasty in normal surgical practice.
There have been reports in the literature of improvement of these functional symptoms after abdominoplasty. Many are case reports, detailing a serendipitous improvement in urinary incontinence following abdominoplasty13,14 or retrospective studies. Solanki et al.15 contacted 46 patients after abdominoplasty. Twenty-seven (59 percent) stated they experienced stress incontinence preoperatively and seven of these patients (26 percent) experienced improvements after surgery. The retrospective review by Carruthers et al.16 of 100 patients who had undergone cosmetic abdominoplasty reported 60 percent of patients with improved symptoms. Vaginal delivery was a predictor of improvement. The closing recommendation was for patients undergoing aesthetic abdominoplasty and incontinence surgery to undergo the abdominoplasty first, as separate incontinence surgery may not be required.
There are case reports, too, of improvement in back pain.17,18 Toranto19,20 and Oneal et al.21 demonstrated this best. Toranto developed the wide abdominal rectus plication abdominoplasty with plication of the rectus from lateral border to lateral border so that the abdominal wall is “drum tight.” The skin flap is closed with no tension. Selected back pain patients underwent the procedure with long-term alleviation of pain in 24 of 25 cases. Oneal used the wide abdominal rectus plication abdominoplasty in eight chronic low-back-pain patients successfully up to 11 years postoperatively. Three of these patients had less plication than the full lateral borders and did just as well. There is no mention of urinary incontinence improvement in these studies.
This study has demonstrated a dramatic improvement in functional symptoms following regular abdominoplasty. The questions to ask are, “What is the mechanism by which this change occurs?” and “Why have we not noticed this before?”
We assume that the improvement in back pain is caused by a restoration of the prepartum condition with plication of the diastasis and removal of excessive skin and fat. All patients underwent plication of the rectus anatomically (i.e., to the midline only).
The postpartum decrease in functional capacity is attributable to a reduction in stability. It is the synergistic action of all the trunk muscles that carries load and function through the lumbopelvic region. Apart from low back pain, postpartum patients often struggle with a lack of “core strength,” finding it difficult to stand on one leg or to get up from a supine position on the floor. They also suffer repetitive musculoskeletal injuries stemming from pelvic instability until the integrity of the abdominal canister is restored.22 As the anterior rectus distance is closed, function increases.23–25 The closure of the diastasis restores fascial tension throughout the abdominal canister, in particular, in the transversus abdominis and internal oblique complex. This restores these muscles to their physiologic length and exerts tension on the lumbodorsal fascia, tightening this broad structure and stabilizing the lumbar spine, even in the absence of erector spinae contraction when the body is in flexion.26 Pelvic stability is restored from above, as the lordosis of the spine is the most important parameter controlling the distribution of forces between the fascia and muscles.27 Abdominoplasty with rectus plication improves posture with a retropositioning of the pelvis and a compensatory advancement of the head and shoulders.28 The lordosis is restored to the prepartum condition along with stability.
This effect can be demonstrated in the preabdominoplasty unstable patient by the wearing of a pelvic belt. Back pain improves, as does posture by the application of an external stabilizer.29 Indeed, if the patient does improve with a belt, an abdominoplasty is likely to effect a permanent improvement.20 Other tests that can be used to assess a patient’s suitability include the abdominal compression test, in which abdominal pressure with lumbar stabilization improves pain19 and straight leg raising is improved by holding the rectus muscles together,22 used by the author.
Abdominoplasty also works to increase intraabdominal pressure. An elevation in intraabdominal pressure acts as a stabilizer of the lumbar spine.30–32 When lifting heavy objects, the diaphragm is tensed for greater mechanical advantage. Intraabdominal pressure is raised when the rectus is plicated, but this elevation in pressure has not been measured other than intraoperatively33 or up to 24 hours afterward.34 These studies were performed to aid in risk assessment of pulmonary complications of abdominoplasty, chiefly deep venous thrombosis/pulmonary embolism. It is not known whether the intraabdominal pressure rise is stable or falls over a few days as symptoms of respiratory distress subside.
The mechanism of improvement in urinary symptoms is the subject of several theories. These range from a reduction of anterior abdominal weight14 to increased strength of the anterior abdominal wall leading to more complete bladder emptying.13 These factors no doubt apply, but it seems likely that retensioning in the elevation of the pubis and Scarpa fascia, contiguous with Colles fascia of the urogenital triangle, acts to lengthen the urethra and improve continence.16 This concept of tension distributed throughout the fascial network to effect change at a distant point is central to the tensegrity theory of biomechanics.35
Our study does have recognized flaws. There is no control group; patients acted as their own controls. It is unlikely they would have improved without intervention. There was also no randomization; all patients underwent the operation the surgeon saw fit. This led to a skewing in the method, as three surgeons contributed 83 percent of the data. All three surgeons prefer a cutaneous closure method under tension, be it high-oblique-tension12 (n = 65), high-lateral-tension11 (n = 72), or progressive-tension sutures used in radical abdominoplasty36 (n = 37). Whether this added tightening contributed to the results is difficult to say. One surgeon submitted three patients, only one of which had improvement from radical abdominoplasty. This was hidden in the weight of numbers. Classification of operation method was also an issue. A high-lateral-tension abdominoplasty is well defined and understood, as is high-oblique-tension abdominoplasty, but what constitutes a standard radical abdominoplasty, a miniabdominoplasty, or a lipoabdominoplasty varies from surgeon to surgeon. A miniabdominoplasty is internationally understood to be a subumbilical plication of the rectus with a minimal skin excision and little if any umbilical movement. In this series, the rectus was plicated fully, to the xiphisternum, along with minimal skin excision and little umbilical movement. Eighty-six percent of patients in this study had liposuction along with skin resection. The amount and aim of the liposuction varies from surgeon to surgeon. Initially, lipoabdominoplasty was a category the surgeon could nominate on the surgical demographics form but, because of the difficulty of defining the operation, from between any liposuction performed to liposuction being the main method of reduction,37 the lipoabdominoplasty patients were incorporated into the radical group. Forty-five of the 70 patients (63 percent) therefore had liposuction in the radical abdominoplasty group. The mean body mass index of patients in whom liposuction was not performed was 22.1 kg/m2, compared with the study mean of 26.3 kg/m2. Sixty-six of the 70 patients in the standard radical group (94 percent) had progressive-tension sutures as part of the closure, increasing tension in the superficial fascial system and limiting dead space.
Significantly, only a tiny number suffered a worsening of their symptoms, and even then only minimally. A deterioration in the Oswestry Disability Index score at 6 weeks could be explained by incomplete recovery from the procedure and was not uncommon, but 98.6 percent improved or returned to their presurgery score at the 6-month survey. One patient had a high score of 62 percent disability entering the study; this patient’s score rose to 94 percent at 6 weeks but returned to 62 percent at 6 months. This illustrates the Oswestry Disability Index’s subjective nature. The patient was supposed to be bedridden but had filled out her 6-week form in the surgeon’s rooms. The follow-up is also short at only 6 months, but the group consensus was that symptoms had stabilized by this time and, if anything, tended to improve further by 1 year. The mean Oswestry Disability Index was below 4 percent at 6 months; thus, there was not a lot of improvement expected to be gained by extending the length of the survey. Anecdotally, patients tended to improve even further by 1 year postoperatively, stabilizing with better exercise habits, social and family activity, and the enhanced self-esteem that comes from greater ability. A deterioration in the International Consultation on Incontinence Questionnaire score at 6 months occurred in six patients (2.8 percent) in the study group. Half of these patients had a mild deterioration of a preexisting incontinence, with only one patient becoming incontinent, with a score increase of 0 to 4. Scores improved in 97.2 percent of the study group by fascial stabilization and pubic elevation kinking the urethra. Abdominoplasty may also create an upset in the delicate urodynamic balance, causing deterioration, but only rarely. The study has not given an insight into the duration of symptoms preoperatively. Abdominoplasty with rectus repair improves the pregnancy-related back pain and urinary incontinence by restoring the abdomen to the prepregnancy state but may not be able to correct a prepregnancy back injury or undefined urodynamic issues.
This prospective multicenter study has demonstrated a significant improvement in low back pain and urinary incontinence following abdominoplasty in 214 patients. No method of abdominoplasty was superior in effecting this change. All patients had closure of a rectus diastasis, and most had a cutaneous closure using tension. By restoring prepartum contour, it is also possible to restore prepartum function.
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