I had a Tummy Tuck about a year ago. My tummy is functionally satisfactory; the apron is gone but cosmetically less so. My flanks bulge and the surgeon kept my navel, even though it's much darker than the rest of my tummy. Most annoyingly, if I don't hold it, I have this hanging globular abdomen again. Is this normal after Tummy Tuck? I am starting to believe that my surgeon did not attempt any muscle tightening. Am I right?
No Muscle Tightening After Tummy Tuck?
Doctor Answers (12)
Get to the Core of the Issue
During Abdominoplasty, the plastic surgeon often plicates (tightens) the lax abdominal muscle fascia. Diastasis Recti (separation of the rectus abdominus strap muscles which run vertically down the abdomen from ribs to pubis) often results from aging and is especially common after child bearing, particularly with multiple pregnancies. In some cases of mild diastasis, it is unnecessary to plicate the muscles at all.
Nevertheless, even if the midline of the rectus muscle is plicated, there are other factors that may influence the appearance of the abdomen. Even if the fascia is closed so tightly that you can "bounce a quarter off the abdomen", a patient may have poor resting muscle tone that contributes to a lax appearance. Plastic Surgery is not a substitute for a modicum of hard work on the part of the patient.
For my patients, I suggest physical therapy or Pilates as a means of strengthening the core muscles of the abdominal wall, once the initial healing process has been completed.
Muscle work - the surgeon's and yours
As mentioned in the previous well written answers, most abdominoplasty procedures entail muscle tightening as a component of the procedure. Just like everything under stress, the abdominal wall stretches after abdominoplasty, just as the skin relaxes. After an appropriate amount of time for recovery, it then becomes necessary to exercise the abdominal muscles the maintain the results of surgery, not to mention experience the many positive benefits of core muscle strength.
If you are really doubting what has been performed during surgery, request a copy of your operative report, and it will say whether a rectus plication was done.
Take good care of yourself!
Many surgeons refer to "tightening of the muscles". This is in fact never done during a tummy tuck. Rather, the fascia, the tough lining of the muscles, is tightened.
Almost always during a full tummy tuck, the fascia is tightened, unless there is a specific reason not to (i.e. a massive weight loss patient who intends to have children shortly but needed the apron off).
Many patients are under the misconception that if the deep layer (fascia) is teightened, the stomach will be flat. This is not true. It will certainly be flatter, but it may not be flat. The reasons for this are many. If there is a lot of fat inside the abdomen, where the surgery does not reach, this fat is never removed. Only weight loss will remove this "intraabdominal fat". Patients should be especially motivated to reduce this intraabdominal fat: not only does it look bad, but it predisposes to diabetes and heart disease.
Some patients have very lax (loose) fascia that simply cannot be tightened completely. Often, intraabdominal fat presses outward, but sometimes the fascia is just lax. Not everybody is made the same. It is sometimes possible to perform a more aggressive tightening with the used of a mesh, or even resection of the fascia and closure. These procedures are more involved and carry higher risk. They are usually reserved for patients with massive weight loss.
It is the job of the surgeon to make the fascia as tight as it is safely possible. It is the job of the patient to keep their fitness and abdominal muscles strong and tight as well. This can be accomplished by daily crunches and dietary restraint, not easy but very rewarding. A motivated patient can make a good tummy tuck result into a great result. It is the very rare patients who looks great but expends no effort to get there.
If the fascia was for some reason not tightened during surgery (the doctor's oprative note will indicate whether this was done of not), and the abdomen is still bulging, it is possible to redo the tummy tuck and tighten the deep fascia.
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Muscle tightening is not always indicated.
Depending on your anatomy, muscle tightening can actually make your waistline look worse. But this is the exception.
The real issue is that you are dissatisfied. You just need to go back to your surgeon because, very likely, you can be happier with a revision.
Discuss your concerns with your plastic surgeon, as you may need a tummy tuck revision
The comments and points made by the other physicians are spot on as it applies to the abdominal muscle and whether or not the muscle/fascia layer was tightened. I would like to address the second part of your question that is directed to the “flanks” that now “bulge”. This is a common problem that I have seen following a tummy tuck (abdominoplasty) procedure. The bulging flanks are indicative that your plastic surgeon has, indeed, tightened the muscle/fascia layer and excised a hefty portion of fat and skin in the lower abdomen that is beneath your belly button. I can say this because it deals with simple anatomy and basic geometry that is intrinsic to the tummy tuck procedure.
As you are aware the tummy tuck procedure involves tightening the muscle/fascial layer which flattens the anterior abdominal wall. This step causes the flanks to bulge and actually can make them look worse. Additionally, when the fat/skin layer of the abdomen is cut out (excised), it is removed in an oval shape. The middle portion of the excised fat/skin layer which is directly above the pubic area is very tight, whereas, in contrast, the ends of the incision near the flanks are loose. This is why the flanks appear to “bulge” and may have a displeasing appearance.
More than likely your surgeon talked and informed you prior to your tummy tuck procedure about the potential need to perform additional procedures and revisions. Your bulging flanks and “hanging globular abdomen” areas are, most likely, easily treated with liposuction and/or additional fat/skin excision in the lower abdomen. No surgeon has a crystal ball and can exactly predict how the tissue layers will respond.
Your treating plastic surgeon knows you the best…knows your anatomy…and, knows the operation he performed on you. You agreed to his/her surgical plan. I would strongly advise you to go back to your plastic surgeon and discuss your issues with him/her. With any body contouring procedure, additional procedures are likely and do not constitute any wrong doing. I am sure that you will be able to achieve your desired cosmetic outcome.
You might have gained weight after your tummy tuck
I don't know exactly what your surgeon did, but if your abdomen did initially appear tight after surgery, and then it started to bulge gradually, then this could be because of you gaining weight. I have had patients who have not watched their diet afterward and have gained weight. Often times, the added weight accumultes in the intestinal fat or "viseral fat," which causes the abdomen to bulge out.
First, try to lose some weight and then talk to your surgeon.
Diastasis recti usually tightened
Muscle are not tightened during abdominoplasty. This is a misnomer. Actually what is treated is the stretched midline fascia that overlies the muscle and connects in the midline.
Loose skin as well is treated by excising redundant tissue inferiorly at the level of the mons pubis. If the skin is very loose, then perhaps more skin shuld have been removed. However, there should be a little laxity that you appreciate when sitting and that flattens out when you stand.
If it is made too tight, then the scar can significantly stretch and/or during the first week or two after sugery the abdominal flap may not heal properly. Going to the gym after 6-8 weeks to work on your abdominal muscles is usually ok to help strengthen them.
If you don't use it, you lose it!
I don't know whether you had a muscle plication during your tummy tuck, or whether or not you actually needed one. However, one thing I am sure of is that if you don't workout to maintain a healthy weight and tighten the core abdomenal muscle, you will have what you are describing.
Pilates is a great way to work on those abs - so get working!
Ask your surgeon
Belt lipectomy versus tummy tuck
It is difficult to assess your description without the use of a photograph. However, it sounds as if you have significant intra-abdominal fatty deposits as well as circumferential laxity that would better be treated with belt lipectomy. A muscle repair would do little to effect your flanks whether or not it was performed.