Depends on what the problem is

Which procedure you choose depends on what is wrong and how it can be fixed. Most women who have had at least two children and two C-sections have several problems: Loose skin, a C-section scar with irregularities, extra fat, loose fascia. If you choose not to fix any of these problems, the unfixed problems will still remain and most likely make you unhappy with your results.

1. Loose skin. If skin is loose, it needs to be removed to achieve a good result. This will involve either a mini-tuck (this removes just a little excess skin just on the lower abdomen) or a full tummy tuck (if lots of extra skin is present). A mini-tuck does nothing for loose skin above the belly button. Some doctors claim that lasers tighten the skin. I have yet to see a study where laser even approaches the results of a tummy tuck.

2. Loose fascia. Fascia is the deep layer covering the muscles. It often bulges in the lower and central abdomen after childbirth. The muscles separate. Loose fascia can be tightened with an "internal corset" with minimal skin excision when skin is not loose (hybrid tummy tuck) or with considerable skin and fat excision (full tummy tuck). Mini tucks do not tighten fascia above the belly button. If skin is removed from below the belly button and the lower abdominal fascia only is tightened, a "mini tuck look" can result, with a flat lower abdomen and an overhanging upper abdomen. If the upper abdominal fascia is bulging, patients may want to consider a hybrid tummy tuck or a full tummy tuck.

3. Fat. Fat can be removed with liposculpture. However, if the overlying skin is loose, liposculpture gives generally poor, uneven, cellulite-like results. Fat removal can be combined with a hybrid tummy tuck or a full abdominoplasty.

4. Scarring and irregularities from C-section. This can be fixed with a scar revision. This can be performed with a mini tuck, a hybrid tummy tuck or a full tummy tuck.

Your doctor should be able to talk about all these procedures with you and allow you to make the choice which suite you best. But please, don't take a shortcut route and be unhappy with your inadequate results.

The basic question with any cosmetic surgery is asking what are the anatomical conditions that make you look the way you look and what do you want to achieve as an end result. It is a relatively simple puzzle of how to get from A to B. The procedure will be determined by answering these questions, not the other way around.

The abdomen is affected by a number of anatomical components: intra-abdominal contents including fat and organ, muscle mass and tone, extra-abdominal fat in many locations and layers, and amount and quality of skin. The C-section scar may help or hinder certain procedures. Liposuction will merely remove fat; skin tightening (i.e. scarring) is unpredictable. Skin excision may help with contour or shape, but is predominantly a determinant of skin tension or texture. Inany situation, when you sit or bend, the skin will become loose. Skin excision may help this situation but will not eliminate it. Muscle tightening might help if your muscles are separated or weak but cannot completely overcome posture and tone issues.

Sit down, or stand, witht your surgeon and carefully discuss what is going to make you happy.  If muscle tightening is not a signifacant part of the final procedure, it is possible to do liposuction and a mini-abdominoplasty under sedation and local anesthesia, but you need to discuss this with your surgeon to see if he is comfortable with that. Surgery such as what you are looking at must be a collaboration between patient and surgeon.

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Tumescent liposuction tightens the skin significantly if the Plastic Surgeon is aggressive with Liposuction. Smart Lipo is just a Hype and there is nothing smart about it.

Considering that you have had two c-sections, there is a high likelihood that you have poor skin elasticity, especially in the lower abdomen. Therefore, doing a mini-tummy tuck along with lipo is a very good idea. Otherwise, you will most likely have some redundant and wrinkled skin in the lower abdomen.

Although all these procedures can be done under local anesthesia, the extent of surgery would be very limited. Meaning that what a doctor can accomplish under general anesthesia is usually more dramatic than under local anesthesia.

The risks of either method are not different as long as you have an anesthesiologist. Often times, patients who are have liposuciton under local aneshtesia don't have an anesthesiologist monitoring them, and this can be a risky thing, especially that during local liposuction patient do also recieve intravenous sedative and other medications.

Choosing between liposuction alone, mini tummy tuck, and full tummy tuck is not difficult. The decision is based on three factors that should be assessed objectively by a board certified surgeon without taking into account biases about price, anesthesia, and length of surgery. Doing a lesser surgery than what is needed because of price or myths about anesthesia actually does a disservice to the patient. 

The decision-making depends on the quality of the skin, the amount of fat within the flap, stretch marks, and the looseness of the midline rectus fascia.

All three of these procedures can be done safely by an experienced and board certified plastic surgeon. Choose a physician who will not compromise on the quality of procedures offered.

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Truly to evaluat the extent of laxity of your abdominal skin, I would need to do an examination.

Some patients with skin laxity of mild to moderate degree, without any element of "hanging skin" or what we term as an "apron or pannus", can benefit tremendously from Smartlipo.  In my operative experience, I have seen very desirable results with Smartlipo alone.  It is best for you to communicate to me a clear picture of what you anticipate as a result with which you will be satisifed.  That can help tremendously in determining if you would be happy with Smartlipo versus a Lower abdominoplasty.  In most instances, the lower abdominoplasty is also combined with abdominal Smartlipo too, however the lower skin removal in the lower abdomen is needed to give a tighter result, in the face of significant skin laxity.  Your comment about the surgeon you saw, indicating to you that there are few patients who are perfect anatomical candidates for just lower abdominoplasty alone is very true.  I have performed  lower abdominoplasty under general anesthesia, but it may be possible to do it under light intravenous anesthesia, with an anesthesiology.  The Smartlipo permits the liposuction procedure to be done under local anesthesia, if only one or two anatomical areas are addressed in one setting.  It may be possible to do abdomen and flanks in certain select cases.  However, the rate - limiting step is the amount of lidocaine (the local anesthetic) that can be safely given to numb the areas being treated.  It is very rewarding however to treat problem areas, such as the abdomen and flanks with a comfortable and effective technique such as Smartlipo, with the patient awake, confident, and comfortable during and after the surgery.  Many women do not want to have the more extended scar (you already have a C-section scar), the drains, the anesthesia, the prolonged recovery and downtime associated wtih a lower or full abdominoplasty.  It is best to have a consultation and openly discuss your expectatons after a complete and thoughtful examination.

Christine Petti, M.D.