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During Abdominoplasty, How Does a Surgeon Estimate How Much to Tighten the Fascia?

Surgeons agree my abdominal fascia needs tightening from breastbone to pubic bone. CT scan shows muscle separation of maybe an inch. Isn't the fascia stretched out vertically as well as horizontally? Guessing 1.5 - 2 inches in both directions, but very little excess skin to pull down. How will tightening the midline help with both dimensions, and how does a surgeon determine how much to tighten? Can fascia be tightened 2 inches if the muscles are only 1 inch apart? (BMI of 17 so no fat.)

Doctor Answers (18)

How Does a Plastic Surgeon Estimate How Much to Tighten the Fascia during a Tummy Tuck (Abdominoplasty)

+2

Regarding: "During Abdominoplasty, How Does a Surgeon Estimate How Much to Tighten the Fascia?
Surgeons agree my abdominal fascia needs tightening from breastbone to pubic bone. CT scan shows muscle separation of maybe an inch. Isn't the fascia stretched out vertically as well as horizontally? Guessing 1.5 - 2 inches in both directions, but very little excess skin to pull down. How will tightening the midline help with both dimensions, and how does a surgeon determine how much to tighten? Can fascia be tightened 2 inches if the muscles are only 1 inch apart? (BMI of 17 so no fat.)"

Fantastic question!  You have the mind of a Plastic surgeon.

How does a pianist know how hard to push on the keys, a violinist how hard to push and pull on the bow, a painter how hard and at what angle to pull a brush? It all comes to "experience". After doing something many times and learning from the results, artists and craftsmen learn that intangible, poorly definable measuring stick we refer to as experience.

The sculpting and contouring of a Tummy Tuck is three dimensional. Plastic surgeons are very individualistic and often do variations of the same operation in following with their beliefs of what would get them the best results.

I believe that pregnancy (single and especially multiple) not only separates the 6 pack (Rectus abdominis) muscles but that it also permanently stretches the other abdominal musculature resulting in the exercise - and diet-resistant "pooch" which all women hate.

To correct it, ALL abdominal muscle wall laxity must be "taken in" and corrected by bringing the muscles to the midline and tightening them further as is required. As you correctly pointed out, the amount of stretch is NOT equal (IE 1 inch along the whole length of the midline). Instead, there is greater separation around the umbilicus and just above it. This must be corrected at the time of the muscle repair by taking wider stitch "bites" in these wider displaced areas.

As your muscles are tightened (and waist is narrowed) more loose skin will be unveiled. As a result a Full Tummy Tuck would be the best operation for you. With only a hint of your hips, I would advise you to also consider having an evaluation of your back and hips. Combining Tummy Tuck with Liposuction of the back and hips can greatly define the buttocks and waist making a Tummy Tuck in someone with your figure potentially exceptional.

Good Luck.

Dr. Peter Aldea


Memphis Plastic Surgeon
5.0 out of 5 stars 62 reviews

Distasis repair determination

+1

The diastasis is examined in the operating room and then tested to see how much tightening can be done when placing sutures.  Each side is measured and marked carefully in the operating room once the appropriate closure is determined.

Steven Wallach, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 17 reviews

Diastasis repair

+1

During pregnancy the tissue between the muscles stretch and not necessarly the muscles. Therefore a good "repair" brings the muscles where they "should be", resp. where they used to be. As you can see it is not a repair of the muscles themselves.

Overcorrection can cause belly discomfort and blood clots as mentioned elsewhere.

Guido P. Gutter MD
Evansville Plastic Surgeon
5.0 out of 5 stars 8 reviews

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Tummy tuck modifications

+1

You raise excellent points that are often argued by skilled surgeons at our meetings. Some surgeons do repair and tighten the muscle in both a vertical AND horizontal directions. Furthermore, most surgeons attempt to restore the anatomy of the abdominal muscles while others will "over-correct". In some instance, a modification of a full tummy tuck can be accomplished with less agressive resection of skin.

Otto Joseph Placik, MD
Chicago Plastic Surgeon
5.0 out of 5 stars 44 reviews

Knowing how much to tighten in a Tummy Tuck

+1

Hi there-

As almost all of the other experts have said, this is an experience dependent decision.

The best advice you could get is to choose a surgeon well... How to go about this?

Please read this:

Armando Soto, MD, FACS
Orlando Plastic Surgeon
5.0 out of 5 stars 104 reviews

Muscle Tightening How Much and Where ?

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Muscles separate in various ways, some down at the bottom, some along their whole legnth.  Some get wider, others get longer.  Rather than just focusing on how tight, as a surgeon I feel its important to have a few goals for the shape in mind.

I generally dont make a tummy straight-line flat,  and I aim for a V-shaped result.  There is a very pretty and natural curve outward from the belly button to the pubic hairline that I think should be created.  Too flat an abdomen here looks boyish to me and besides, curves are in these days.  Also, I prefer a "V" shape for the muscles. My opinion is that this looks toned and youthful and it can be created on all body types...not just long waisted or thin individuals !

World class model Yasmeen Ghouri exhibits both of these features.  Tight is good, but shapely is great.

John LoMonaco, MD, FACS
Houston Plastic Surgeon
5.0 out of 5 stars 174 reviews

Abdominoplasty is an art.

+1

Hi.

Yours are very good questions, and I don't think this answer is very helpful. But it is all in the judgment, skill, perseverance, experience, and good eye of the surgeon. Many little decisions are made during the examination and during surgery which hopefully lead to a great result.

From your picture, you are a very easy patient. I am not sure why a CT scan was done. You have little excess skin or fat, so a short scar approach should be used. The fascia should be tightened side to side only, and the degree of tightening is determined visually and by palpation during surgery. Vertical tightening would actually thicken your waist.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon
5.0 out of 5 stars 9 reviews

Abdominoplasty with fascial tightening, needs experience.

+1

The degree to which a muscle/ fascia tightening in a tummy tuck  is determined is based on experience but the easiest way to determine how tight is that the muscle will only come together as much as it will let you bring it together.

Most of the time the horizontal direction is the only one tightened and only occasionally will the vertical direction need to be tightened. Based on your picture the transverse direction is all that will be needed.

Walter D. Gracia, MD
Arlington Plastic Surgeon
5.0 out of 5 stars 2 reviews

How much can your abdomen be tightened in an abdominoplasty?

+1

Despite the fact that experience is always helpful in every operation, the answer to your question is quite simple.  Your abdomen can be tightened to the degree that your fascia will tolerate. The fascia is weaker or stronger in different individuals and the amount of volume within you abdomen is different in every patient.  If you have a strong fascia and little internal abdominal volume then the tightening can be dramatic, however, with weak fascia and a significant amount of intraabdominal (within the abdomen) fat, you will experience less of a change.  Relating your "surgical success" to the number of inches you've reduced following your surgery will likely leave you disappointed, rather than expecting a positive overall change to your abdominal shape and contour.

Best of luck

Vincent Marin, MD, FACS

La Jolla Plastic Surgeon

Vincent P. Marin, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 26 reviews

Anatomy and experience will determine how much to tighten fascia

+1

Hi,

The rectus muscles have separated and need to be repositioned so they are centralized and not off to the sides. l The vertical dimension is very rarely and issue and I do not believe it is an issue for you given your photo.  During surgery I flex the operating table so it relaxes the abdominal wall significantly; sometimes I will tighten the fascia below the belly button more than the actual separation if there is significant laxity while flexed.  I like to look at the patient sitting to see how much extra skin there is.  If when you sit down there is a roll in the lower abdomen but the upper abdomen is basically OK, then you have very little vertical skin excess, especially above the belly button, and you are an excellent candidate for an abdominal float procedure.  You will not have a scar around the belly button but the excess skin below the belly button is removed and the slight excess skin above the belly button gets stretched out just enough to eliminate the redundancy.  If you have a significant amount of excess skin above the belly button, this is not a good option and you should have a full tummy tuck with scar around the belly button. Hope this helps.  

Tracy M. Pfeifer, MD, MS

Tracy Pfeifer, MD
Manhattan Plastic Surgeon
5.0 out of 5 stars 17 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.