Photo by Kyle Smith on Unsplash
Shape-shifting transformations that take place within the cocoon of an OR, tummy tucks are among the more metamorphic experiences in plastic surgery. But sometimes the striking absence of fat and flesh in an abdominoplasty “after” photo can blind us to the subtler nuances of the procedure—the carefully contrived details that are key to next-level outcomes.
While skin tailoring and muscle tightening have long defined the traditional tummy tuck, plastic surgeons of the past rarely obsessed over the proportions of one’s navel or the discreet contours of the abdomen, our experts say. Over time, this collective inattention to particulars gave rise to today’s telltale signs of the surgery: “a big, round, mouth-looking belly button and a drum-tight tummy—these are dead giveaways of the procedure,” asserts Dr. Jacob Unger, a board-certified plastic surgeon in Nashville.
In recent years, research has illuminated ways to safely enhance the results of a tummy tuck. Surgeons have refined their techniques. They’ve finessed incisions to downplay scars. And the tummy tuck has evolved considerably as a result, “becoming much more of a 360 treatment of the entire torso,” says Dr. Nina Naidu, a board-certified plastic surgeon in New York City.
So next time you’re scanning the before and after photos on a surgeon’s grid or in their gallery, go ahead and marvel at the big-picture results but be sure to note the finer aspects as well— particularly these three, which surgeons insist are the hallmarks of a modern tummy tuck.
A low and inconspicuous scar
“An ideal scar heals as a fine line low in the underwear—usually just above or slightly within the pubic hair,” explains Dr. David Sieber, a board-certified plastic surgeon in San Francisco. The goal, of course, is for it to be out of sight when the patient pulls on a not-too-skimpy pair of underwear or a standard bikini bottom—which is no small feat, considering the average tummy tuck patient is sliced from hip bone to hip bone.
Just how low can surgeons go when making the incision? “Here’s the tricky thing,” says Dr. Naidu: “If you make the incision too low, you risk having trouble closing it or putting too much tension on the pubic region and exposing the clitoral hood, which would not be the most comfortable thing for most patients. There really is a fine line.”
To guide their incisions, surgeons will sometimes have patients bring in what they hope to be able to wear in the future—a particular style of underwear or swimsuit bottom—so they can check its placement against their pre-op markings.
According to Dr. Unger, a well-placed scar is not only hidden but actually accentuates the overall result. “The tummy tuck is a surgery of geometry—it involves tugging, contouring, angles—and by creating that low scar, we change the way the sides look and the way the abdomen itself looks,” he explains. An abdominoplasty scar, he adds, “should also be balanced and symmetric, which is harder [to achieve] than it sounds, since most people’s hips and backs are not perfectly straight and even anatomic landmarks aren’t all that helpful in every case. It truly takes an expert to consistently get as close as possible to symmetric.”
A natural-looking belly button
Surgeons have come to regard the belly button as the pièce de résistance of an artful abdominoplasty.
When your abdominal skin is stretched during surgery and a significant amount carved away, your proportions shift–and your former belly button is lost in the process. Plastic surgeons then create a new opening for your existing umbilical stalk.
“So many papers have been written about how to create an ideal belly button,” says Dr. Melissa Doft, a board-certified plastic surgeon in New York City. “But when there are so many papers written on a single topic, that usually means there is no one perfect method.”
What surgeons can agree on is this: For a belly button to read as if it has always been there, it should be oval in shape; it should be neither too large or too small, nor too high or too low; and its top portion should have a somewhat hooded appearance, “so the umbilicus looks like it’s tucked in a bit more and not just like a circle on the abdomen,” explains Dr. Naidu.
Tacking down the umbilical stalk to the abdominal fascia, or connective tissue covering the muscles, gives the most born-this-way appearance while helping to hide the belly button incision. “That’s the thing that really makes the belly button look most natural,” adds Dr. Sieber—“inverting the scar so that it’s not visible externally.”
Of course, how well an incision heals after surgery is partly dependent on a patient’s biological scarring response. But “we really do pay quite a bit of attention to it, offering laser treatments or injections if the scar winds up a little raised or obvious,” says Dr. Naidu. “Whereas 20 years ago, surgeons were more apt to say, ‘Well, it’s just your belly button—don’t worry about it.’”
A contoured abdomen
“When doing a tummy tuck, you don’t just want to make a flat, featureless abdomen or a straight board—which was the traditional way of doing it,” says Dr. Unger. Not only does an overly tight tummy tend to scar poorly, due to tension, he adds—it also doesn’t look natural. The 2020 standard is softer and more shapely, with subtle curves and depressions. Which is why “liposuction is almost always incorporated into my tummy tucks,” adds Dr. Sieber. “There’s just no other way to get that three-dimensional shape that women want.”
Yet for years, plastic surgeons were warned of the dangers of combining an abdominoplasty with liposuction. “When I was in training, it was absolutely taboo to do that,” notes Dr. Naidu. It was the long-held belief of leaders in the field that when you’re already limiting blood supply during surgery by lifting up the abdominal flap to access muscles and remove skin, it would be unwise to risk disrupting it further by liposuctioning that same expanse of tissue.
“Surgeons were nervous that adding liposuction would cause a decrease in blood flow to the skin and lead to poor wound healing or scarring,” says Dr. Doft. “But there have been many papers recently written that describe how to safely incorporate liposuction with a tuck, so surgeons are now more confident [about performing the two procedures together].”
Today, in addition to removing fat from the hips, flanks, and back during a tummy tuck, many surgeons like to carefully sculpt the area above the belly button to “give that nice little vertical groove that we see in a youthful abdomen,” says Dr. Naidu. Our experts are careful to distinguish this mindful and targeted maneuver—“sucking out fat centrally, to get a more athletic and sexy contour,” as Dr. Unger describes it—from the more extensive etching of a six-pack via high-def lipo, which is potentially more dangerous to do in tandem with a tummy tuck.
Ultimately, notes Dr. Sieber, “our patients want to look and feel great without having others know they had anything done”—and the most meticulous surgeons aim to deliver just that.