When patients come to me about improving the appearance of their abdomen they are often confused about how to proceed. Tummy tuck? Liposuction? Which one is right for me?
The key is in the skin:
If a patient has a bulge of fat, but the overlying skin is tight then liposuction alone will remove the fat and the skin will shrink up nicely. Liposuction just removes fat, not skin. Despite many claims, no form of liposuction really tightens skin well. In fact, to some extent liposuction makes us looser by removing what fills the skin. So, the paradox of liposuction is that it works best on patients who are younger, have tighter skin and smaller fatty areas. To learn more about liposuction options visit the liposuction page here.
1) Tummy Tuck removes fat.
2) Tummy Tuck removes extra loose skin, such as skin that is stretched after pregnancy or weight loss.
3) Tummy Tuck can tighten the muscles of the abdominal wall which have stretched with weight gain and loss and child bearing.
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I hear this frequently and I call it the tummy tuck paradox. Most of my patients are doing everything right. They diet, they exercise and in fact most are quite slender. The paradox is that when these patients do everything right they lose body fat, when they lose body fat the loose skin actually gets looser, not tighter. You can work off fat, but you can’t work off loose skin. The gym won’t help with loose skin.
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Yes, while tummy tuck is most common in post partum women, both men and women undergo tummy tuck particularly after significant weight loss.
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There are actually many kinds of tummy tucks which I will go into below, but the most common type of tummy tucks are the Full tummy tuck or the Mini tummy tuck. Again, the deciding factor here is the amount of extra skin.
In consultation, I perform a pinch test. With the patient sitting and standing, I grasp the skin of the lower abdomen to see how loose it is. If I can grab an entire roll of fat in my hands, from beneath the belly button that patient will do best with a full tummy tuck.
If I can only grasp a small pinch of skin that patient may only need liposuction or a mini tummy tuck.
I also look at the bulging or relaxation of the abdominal wall. If the muscles of the tummy are separated well above the belly button then a full tummy tuck will do better. Full tummy tuck goes much higher with it’s muscle tightening.
Anyone can have a mini tummy tuck, not all patients are loose enough for a full tummy tuck.
There are many variations of tummy tuck that most patients don’t know about:
Full Tummy Tuck:
Removes the most skin and tightens the abdominal wall from top to bottom. Upper abdominal skin is down to the pubic area and a new hole is made for the belly button.
Mini Tummy Tuck:
Removes skin only below the belly button. Sometimes involves muscle tightening from the belly button and below. The belly button is tugged downward but left intact. Often, but not always a shorter scar.
Non muscle tightening Tummy Tuck:
A tummy tuck , mini or full, can be performed without tightening the muscles. The same amount of extra skin can be removed, but the muscles will not be made flatter. Muscle tightening is what causes discomfort after abdominoplasty. Some patients choose not to tighten the muscles. Recovery and return to work is faster. Some patients are not good candidates for muscle tightening.
In a very tall patient the skin above the belly button may not be loose enough to pull all the way down to the pubic area. In this case the belly button can be released from the abdominal wall and pulled down with the skin. It does more skin tightening than a mini tummy tuck, but less than a full. Patients must be chosen carefully because the belly button will be significantly lower.
In a tummy tuck, skin is elevated off the abdominal wall, pulled and stretched down like tighten the sheet on a bed. For some patients, older, heavier, less healthy this may have increased risk of healing problems. A panniculectomy just removes a wedged of skin and fat in the lower abdomen, it does not elevate the abdominal wall skin. The belly button is removed with panniculectomy. Yes, this sound weird, but you don’t need it.
Yes, I made up this name for a tummy tuck that I perform on rare occasion. I’ve never seen anyone describe it elsewhere. Sometimes I will see moderately tall woman with enough skin laxity for a mini tummy tuck, but muscle separation all the way to the top of the abdomen. In this select group of patients, I do a full muscle tightening, with only a mini tummy tuck skin excision. I elevate the skin of the upper abdomen only to tighten the muscles. While there is a scar around the belly button like a full tummy tuck, the belly button is put back in the same place (same hole). In these patients an umbilical float would bring the belly button down too low.
Endoscopic Tummy Tuck:
Sounds cool ? Yes, it does sound cool but I have yet to find a patient for whom it really makes sense. Endoscopic tummy tuck just tightens the abdominal wall muscles, but removes no skin, none at all. It is a very rare patient that has enough muscle separation (diastasis) to make the surgery worthwhile with no extra skin. Cool is not always sensible.
Fleur de lis Tummy Tuck:
Most people have never heard of this type of tummy tuck. It is mainly used for patients with massive weight loss. A standard tummy tuck pulls out extra skin from top to bottom. Like pulling down a window shade. For most post partum patients this is enough. Massive weight loss patients are not just loose up and down (vertical laxity), they are loose side to side as well (horizontal laxity). A fleur de lis tummy tuck pulls top to bottom as well as side to side. The downside is that it leaves a verticle scar in the middle of the abdomen. Some patients (particularly my younger weight loss patients) would rather not have this scar. In that case a standard full tummy tuck can still make a huge improvement , but these weight loss patient will still have some horizontal laxity.
Extended or Circumferential Tummy tuck:
Some patients have laxity that extends toward the backside, or in some cases all around the trunk. Some surgeons call extending toward the backside an extended tummy tuck. I extend most of my tummy tucks as needed, depending upon the degree of frontal laxity (see “how long will my scar be“). In select cases, usually after massive weigh loss, I will excise skin from the bak and front at the same time. This is known as belt lipectomy.
The answer is yes and no. I commonly perform liposuction of the flank or love handle area as part of my tummy tuck for appropriate candidates (not everyone need it). I feel that contouring this area makes the tummy tuck look better. Because of this any thing I can reach on the flanks with the patient face up is part of the tummy tuck.
Some patients carry their flank fullness all the way around above the buttocks. For these patients I may recommend what I call “Posterior flank” liposuction. This is an area that I can not reach from the front. In these patients we start surgery face down with the posterior flank liposuction. This is considered an additional site of liposuction.
Hip and flank liposuction does not interfere with the blood supply to the abdominal skin that we pull down. Some surgeons will liposuction the upper abdominal skin to thin it. I think this is risky and often unnecessary. Lifting and pulling on the skin changes and stresses its blood supply, liposuctioning this area at the same time is a double stress and can need to healing problems. If I have a patient with fatty fullness in the upper abdomen we discuss staged upper abdominal liposuction after the abdomen has healed. It is a much safer.
This question is really ” tell me about the scar”. No one who sees me ever wants a scar, let alone a long scar. I call the scar a trade off and you have to ask yourself “is it worth it to me?”
For a woman with a sagging bag of loose flesh hanging off the lower abdomen the trade off is usually worthwhile but, never let any plastic surgeon push you to a scar you can’t live with.
As plastic surgeons we are trained to give the best, and best hidden scars we can. We perform multiple layers of closure, with buried nonreactive sutures to minimize the impact of the scar. Unfortunately, even as of this writing in 2014 genetics still plays a large role. More than 20 years into this I have seen patients of all races and color make beautiful fine scars, but I have also seen thicker and wider. Be sure the unpredictability is something you can handle.
So, back to the question: How long will my scar be?
It depends on how loose your skin is. The more I pull down, the further I have to bring the scar to the sides. So in general looser people have longer scars than tighter people. Mini tummy tucks pull down less so usually, but not always, the scars are shorter.
Common thinking :
Patient perspective: OMG ! long scar terrible !!
Doctor perspective : If I had to bring the scar way far back it means I got a lot of skin out of the abdomen.
Common Patient question: Why can’t you shorten the scar ?
Doctor answer: If I pull down the skin and the scar does not go far back enough you will develop a bunching on the sides called a “dog ear”. The treatment for a dog ear is to make the scar longer.
Doctor summary: All of may patients have different length scars depending upon how much laxity I pull down and out. To give the right tummy tuck contour each patient is tailored (and I really mean tailored) individually.
I ask my patients to bring in their favorite, and hopefully timeless, common sense underwear or bathing suit. No thongs, no strings and no laces or frills. Something about an inch and a half wide in the hip that you would like to see yourself in post operatively. Something inexpensive in case I get marker on it.
I plan my incisions low in the bathing suit line because when skin is pulled tight the pubis and the scar can rise. While there could be a taller underwear or bathing suit in your future every effort is made to keep the scar as low as possible. In men I usually plan a more horizontal scar in keeping with the underwear waist band.
P.S. some docs make funny zigs or zags above the pubic area– I don’t get that. For me a gentle line paralleling the lower underwear makes the most sense.
Also: Beware of fashion! 10 years ago everything was high cut hip. Today everything is low, low, low. Pick timeless swimwear or underwear. Fashion changes but scar position does not.
This question is really only relevant to a full tummy tuck. In a full tummy tuck your belly button is left attached to the abdominal wall. The upper abdominal skin is pulled down over the belly button stalk. A new hole is made at the proper location and the stalk is pulled through. So, Its your belly button, but its coming through a new hole. There is a scar around the belly button where it is sewn in. In people with a thicker fatty layer the scar is pulled inward and can be less visible.
My philosophy of belly buttons:
Nothing is as natural as a God given belly button so– Keep it small and unobtrusive.
I believe that smaller belly buttons are less noticed on the beach. If a patient makes a thicker scar a smaller scar is less noticeable, and lastly, a small belly button can be easily made bigger, but it is very hard to make a big belly button smaller.
When skin is elevated, tugged on and then put back down, There is a normal amount of oozing until the skin sticks to the abdominal wall. If this fluid accumulates it can become infected. A drain is a tube attached to a bulb that sucks out this fluid. I do leave a drain. Usually one. I generally bring it out through the right hip incision. Some docs bring the drain out thorough the pubis, but I see no need to make an additional scar.
Some plastic surgeons sew the skin down so that it heals more quickly to the abdominal wall and they do not leave a drain. I too sew the skin down. I think it helps, but I still place a drain as a safety precaution. It usually comes out at the first or second postop visit.
A pain pump is essentially a balloon filled with local anesthetic that drizzles the anesthetic under the skin via small tubes placed internally at the time of surgery. The tubes are removed 3-5 days after surgery. While I will place a pump on occasion if requested I generally prefer not to add additional tubes penetrating the skin. For the majority of my patients I use a long acting local anesthetic injected in the tummy while the patients are asleep.
For a full tummy tuck with muscle tightening the average patient takes off about two weeks. Even so, its’ nice to have a third week and not need it rather than the other way around. Unfortunately, there is no absolute standard. Some patients recover more quickly and others more slowly. Whenever muscles are tightened whether full or mini tummy tuck there is always discomfort.
No, see types of tummy tuck above. It is the muscle tightening that causes the most discomfort. Even so, most people who are candidates choose the muscle tightening to maximally flatten the abdominal wall.
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How flat will I be?
Your body, a living tissue, is smarter than your doctor. Your tissues respond to tension and will relax if there is too much. I believe there are two factors that contribute to how flat you will stay.
1) The strength of your tissues.
We bring the abdominal wall muscles back together in a tummy tuck, but we are not really sewing the muscles. We are sewing a strong layer of tissue that surrounds the muscle known as fascia. The stronger the fascia, the better it holds. Large or multiple pregnancies can weaken the fascia.
2) The weight you carry inside your belly.
Dolly Parton once said ” you can’t put 10 pounds of potatoes in a five pound bag”. While she was referring to a different part of her anatomy, the same is true for the abdomen.
A slender person, less abdominal weight, is likely to stay flattest. Mid weight patients will tend to see more relaxation, but find an improvement, and full figured patients my ultimately stretch back to where they were. In all cases patients and their bodies will find their best abdominal wall equilibrium.
I use this term when I discuss Mini tummy tuck with select patients. In mini tummy tuck, which does not allow tightening of the upper abdomen, the goal is to remove extra skin and make the top and the bottom of the abdomen match.
In mini tummy tuck if I have a patient has a smooth abdominal wall contour I do not tighten the lower abdominal muscle. I just remove excess skin. In this case tightening the muscles would make the lower abdomen flatter then the top–“half flat”
In a mini tummy tuck patients’ abdominal wall is bulging below the belly button I will do only enough muscle tightening so that the curve of the top and bottom abdomen match in order to avoid the “half flat” belly.
Tummy tuck surgery does not make people thin, it makes them more streamlined. While yes, it takes away some skin and fat, the weight loss is not as much as you would think. Our organs and muscles are dense and heavy, fat is not, even though it contributes to our weight. It is always best to be at the weight you wish to be at before surgery, a healthy and stable weight that can be maintained. If you loose a significant amount of weight after surgery your skin will get looser again and you could even need a second tummy tuck.
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Am I a candidate for a tummy tuck?
To be a candidate for tummy tuck, other than having a loose tummy, you have to be healthy and at a reasonable weight. Some patients with well controlled medical disorders can still be candidates. Each patient is evaluated individually to minimize risk and hopefully maximize benefit.
You don’t have to be rail thin to have a tummy tuck, but you should be at a reasonable realistic weight before surgery. The heavier we are, the higher the risks of surgery. If you are dieting do so with a safe and good plan before surgery and have time at a stable weight before surgery. If you are loosing weight until the day of surgery you wont have proper nutrition to heal well. Come in and let me set you on the right pre operative path if you need help.
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What are the risks of a tummy tuck?
I go over all the risks of abdominoplasty ( tummy tuck) surgery in great detail in my consults. Consults are followed up with a consent form that has everything laid out in all its scary detail. I educate patients about tummy tuck and its risks and yet I have spent my career trying to minimize them. The only way to avoid the risks of surgery is not to have it. I don’t say that lightly, but is this is right for you please know that I am dedicated to providing the safest experience I can.
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How do I schedule a consultation?
If you would like to meet with me please contact my assistant Pei (pronounced pay) using the contact form or the phone numbers listed on the site.