Mommy Make-Over
Abdominal Changes with Pregnancy
Loose hanging abdominal skin is one of the most frustrating and persistent problems that both men and women have. It persists no matter how much diet and exercise you do. This is why abdominoplasty continues to enjoy an extremely high level of patient satisfaction. Simply put, there is no other way to get rid of this excess skin.
Why does skin laxity occur? Often it is a combination of things, but at the top of the list is childbirth. During pregnancy the abdominal skin is often stretched beyond its ability to snap back. This leaves loose skin and stretch marks.
The other common reason is simply age. With age, the skin stretches and loses its elastic recoil. Regardless of the reason, abdominoplasty is an extremely effective way to get rid of this excess skin. The key is to make the result as beautiful as possible with the least amount of scarring. When you have your tummy tuck consultation, make sure your plastic surgeon is considering all the options so that your abdominoplasty addresses your specific problems.
I really like the opportunity this section gives me to walk you through my thought process, much as I would if you were actually in my office. It is meant to educate you so that you can speak more clearly with your plastic surgeon and better convey what you are looking for. Keep in mind there a many excellent plastic surgeons who do things slightly different. Still, the underlying principles remain the same.
1) Do the Least Invasive Abdominoplasty Necessary.
There are many advantages to doing the least invasive tummy tuck, as long as the problem areas are corrected. This includes a smaller incision, often less obvious incision, less downtime, and often less cost. Remember, however, it is not wise to try to "get away" with a smaller procedure when a larger one is necessary.
Let's outline the advantages and disadvantages of different types of tummy tucks.
Mini Abdominoplasty (Mini-Tummy Tuck)
The Mini-Tummy Tuck is my favorite version of abdominoplasty and, in my opinion, underutilized. It is the the least invasive abdominoplasty procedure. More importantly, it allows me to place the scar so that it is completely unnoticeable with even the most revealing lingerie. I have perfected the mini- tummy tuck to the point where the incision lies right at the top of the pubic hair and the incision is usually contained within the pelvic bones.
Mini- Abdominoplasty Incision.
Notice how low and short the incision can ideally be positioned.
A significant advantage of the min-abdominoplasty is that there is no incision around the umbilicus. To me and my patients, this is very important as the umbilicus with standard plastic surgery technique is usually the most telltale sign of a tummy tuck.
The best candidate for this procedure typically has redundant skin and an abdominal "pooch" located below the umbilicus. This laxity of the abdominal wall below the umbilicus can be dramatically flattened with a mini-abdominoplasty.
Mini-Abdominoplasty (Mini-Tummy Tuck) with Umbilicus Release
The mini-tummy tuck is ideal when the excess skin is located primarily below the umbilicus. If there is some redundant skin above the belly button, but not enough to perform a standard tummy tuck, a modified mini-tummy tuck with release of the umbilicus may be performed. Here, the umbilicus is released from its cord and is moved down slightly, usually less than an inch. By doing this, the excess skin above the umbilicus is tightened. This nicely changes the appearance of the belly button from horizontal to a more youthful vertical appearance.
The abdominal muscles below the belly button can still be tightened with a mini- tummy tuck. This is more than acceptable as this is where the vast majority of the muscle looseness is located.
The mini-tummy tuck has its limitations. If you lower the belly button too much, it will look unnaturally low. This can only be determined during your consultation with an experienced plastic surgeon.
Standard Abdominoplasty (Standard Tummy Tuck)
The standard abdominoplasty is the most common abdominoplasty. It does an excellent job of eliminating the excess skin and abdominal "pooch" both above and below the umbilicus, especially in women who have given birth. It is necessary when there is a significant amount of excess skin within the upper abdomen. Remember, the determining factor of whether you need a mini- or a standard abdominoplasty is the amount of excess skin above the belly button.
Standard Abdominoplasty Incision.
By definition, the umbilicus has to be transposed in a standard abdominoplasty. This means that the excess abdominal skin is pulled down so far that a new hole must be created in the pulled down skin to accommodate the umbilicus. Remember, the cord of the umbilicus stays attached to the abdominal wall.
I believe that the incision around the belly button is the most telltale sign of a tummy tuck. Therefore, it is critical to do everything possible to make it look as if it has not been operated on. The key is to make sure the it is small, recessed, and as natural as possible. This is done by creating a flap inferiorly to hide the incision. In addition, it helps to suture the incision inward to create an "inny" so that the incision is hidden inside.
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| Standard way of placing an incision around the opening for belly button. The incision is made in the shape of simple circle. The incision does not recess inward, therefore, is more apparent. | Modifications can be performed to hide the incision inside and allow the new belly button to be much more attractive and natural appearing. (Courtesy of Dr. Cruise) |
In addition, a properly performed standard abdominoplasty will help create an hourglass waistline. The only thing a standard abdominoplasty will not do well is treat fat deposits in the flank area. This can usually be addressed with liposuction. Liposuction will usually be done at the same time as the tummy tuck. Liposuction of the abdomen at the same time as tummy tuck, however, is more controversial. Many plastic surgeons, including myself, will not aggressively perform liposuction of the abdomen at the same time. This puts a tremendous burden on the abdominal blood supply and can lead to wound healing problems and even skin death. During a tummy tuck, the skin is elevated off the abdominal wall. Now, take this elevated skin and traumatize it further by liposuction. You can see how the effects are cumulative. This does not mean that liposuction cannot be done at the same time. It does need to be done less aggressively. I prefer to do liposuction of the abdomen six weeks after the tummy tuck under local anesthesia. You might think, "Local anesthesia! Liposuction is painful. I don't want to feel pain!"
Normally, this may be true. After a tummy tuck, however, the abdomen is very numb for at least the first 3 months. I like to take advantage of this numbness by doing liposuction comfortably under local anesthesia alone. It is very cost effective as an operating room is not necessary. There is little downtime. In addition, the blood supply is not compromised as the tummy tuck is already healed. As always, other plastic surgeons may handle this issue differently. The important thing is for you to understand abdominal blood supply and safety.
Extended Abdominoplasty (Extended Tummy Tuck)
The extended abdominoplasty is exactly what it sounds like. It is a standard tummy tuck with an incision that extends out laterally over the hips. Sometimes, the incision may need to go toward the back.
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The determining factor is how far the hanging skin goes. The incision must go at least to this level.
As I mentioned above, I try to keep the incision as short as possible. But, when it is necessary, the incision must go as far as the abdominal crease goes. Once again, my goal is to keep this incision as low as possible. This is very important so that the incision is not visible in ordinary pants. The incision, however, has to go higher in an extended tummy tuck compared to a standard tummy tuck. This may make it difficult to wear low-rise jeans, as the incision may possibly be visible when bending over. Normal clothing should be fine.
The amazing thing about the extended abdominoplasty is the dramatic improvement that patients undergo. These patients often feel trapped by the hanging skin around their waist. They tell me that it doesn't even feel like it belongs to them, that it feels like a foreign body. When this hanging skin is removed, they feel as if an emotional as well as a physical weight has been removed.
The extended abdominoplasty gives hope to the patient who is not a candidate for a standard abdominoplasty. Gastric bypass patients frequently fit into this category. The treatment of these patients is especially satisfying to me. They have already been through a very long journey during their surgery and subsequent massive weight loss. Still, they feel trapped and demoralized by this excess hanging skin. Fortunately, procedures such as the extended tummy tuck can get them to a point where they feel comfortable and even excited about their body.
Liposuction with abdominoplasty.
Commonly, the flank is the area that needs liposuction in good candidates for tummy tuck. This is the area that begins above the hips and extends toward the back, right above the buttock. It is important to address this area because it may look more pronounced after a tummy tuck than before. Once the stomach is flat and the excess skin is gone, the flanks become more obvious.
The other area that often needs to be addressed is the abdomen itself. Many tummy tuck patients do not realize that the tummy tuck will not get rid of the excess fat. This is why it is best to get closer to your ideal body weight before considering abdominoplasty. The less fat you have the better your results will be. Typically, I tell patients that they should be within 30 pounds of their ideal body weight. This does not mean that heavier people cannot benefit from the procedure, because they can. The best results are with thinner patients.
As I mentioned above, liposuction of the abdomen at the same time as a tummy tuck increases the chances of wound healing problems. It may even cause skin death. This is because with a tummy tuck, the skin is separated from the underlying abdominal wall. The skin at the bottom is dependent on a blood flow that comes from above. If this area is liposuctioned at the same time, then the blood flow may be jeopardized. For this reason, I do not aggressively perform liposuction at the same time. This is not to say it can't be done. If it is done, you must know the risks. I do routinely, however, perform liposuction of the abdomen with mini-tummy tucks. This is because the blood supply is not compromised as much as with a standard tummy tuck.
Tightening the Abdominal Muscles
Why do we need to tighten the muscles? The most common reason is because the muscles have been stretched and separated by pregnancy. Normally, the rectus abdominus run parallel to themselves from the rib cage to the pubis. During pregnancy, the expanding baby separates these muscles in the midline. During abdominoplasty the muscles can be sutured back to where they should be.
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| Abdomen and Separation of the Muscles after Pregnancy | Restoring Muscles to their Pre-pregnancy Position |
| Click link for demonstration of muscle tightening and tummy tuck procedure. | |
The abdominal muscles below the belly button can also be tightened with a mini- tummy tuck. This is more than acceptable, as this is where the problem is most significant.
Tightening the muscles has the additional benefit of improving the bulge located just below the belly button. It cannot, however, correct bulging do to intraabdominal fat. This can only be corrected with diet and exercise.
Improving the Waistline
An abdominoplasty does a spectacular job of flattening the stomach and getting rid of loose skin. It is not specifically designed to contour the waist. With modifications, however, the waistline can be improved. It is done by purposefully gathering the skin laterally and pulling it inward toward the midline. This gathering can significantly improve the waist, but only on patients within approximately 30 pounds of their ideal body weight. With heavier people the contouring is less effective.
Perhaps the most powerful way to improve the waistline is to have liposuction of the flanks at the same time. Both men and women tend to accumulate fat in this region. By removing this fat not only is the waistline improved, but so is the contour of the buttocks.
Creating a Natural Belly Button
The most telltale sign of a tummy tuck is the incision around the belly button. For this reason, I have spent a great deal of time to develop a way to make the new belly button appear natural. This is important because the lower incision can be easily hidden with almost any clothing. The belly button, on the other hand, is often exposed with sexy or fashionable clothing. A poorly created belly button will prevent you from wearing revealing clothing.
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| Standard way of placing an incision around the opening for the belly button. The incision is made in the shape of simple circle. The incision does not recess inward, and therefore is more apparent. | Modifications can be performed to hide the incision inside and allow the new belly button to be much more attractive and natural appearing. (Courtesy of Dr. Cruise) |
A natural appearing belly button (small, recessed, and as natural as possible) can be accomplished. This should be a priority for your plastic surgeon. The surgeon creates a flap inferiorly to hide the incision and the suture helps to create an "inny" so that the incision is further hidden inside.
Keeping the Incision as Low as Possible
Standard plastic surgery technique does not emphasize the importance of where the incision is located. It makes sense that the lower the incision is, the more hidden it becomes. This is why I like the mini-abdominoplasty so much. It allows me to put the incision much lower than a standard abdominoplasty. Even a standard tummy tuck incision can be kept low with proper technique. You should emphasize to your plastic surgeon your desire to keep the incision as low as possible.
Post-op Abdominoplasty Scar Management
Having worked in a Burn Unit for over 3 years, I understand the importance of scar management. Your plastic surgeon will go over his/her regimen for scar control. It is important to follow this as it will affect the overall result. Some of the information on my post-op regimen is outlined in the after the procedure segment of this web site.