Will I be able to achieve a toned and sculpted abdomen with an extended tummy tuck, muscle repair and liposuction? (photos)

Question

Scheduled for ETT with 360 lipo and muscle repair. However, I continue to question how much is visceral fat vs sub fat? I dont expect to be completely flat, but i do expect to have the lower flap removed and a decently toned and sculpted abdomen. Judging by the pictures do you believe this can be achieved or does it appear that i have an abunance of visceral fat? My abdomen bulges, but i always assumed that to be from muscle seperation from my 4 pregnancies, could the bulge be visceral fat?

Donald Groves, MD · Answer

Hello and thank you for your question. From the pictures you have provided, you have some striae (stretchmarks) present throughout your entire abdomen and extending to your flanks and around to your back. This is associated with a moderate/severe amount of excess subcutaneous fat and skin present diffusely throughout your trunk. There are skin folds across your lower abdomen extending to your flanks, and at least on your right mid back. It would be safe to assume that there is also a significant component of internal/visceral fat as well, which would not be correctable with any surgical procedure. Having had 4 kids, you most likely have some degree of diastasis (separation) of your rectus abdominis muscles located centrally in your abdomen (the "6 pack" muscles). Based on all this, you would definitely benefit from an abdominoplasty (tummy tuck- includes muscle repair) and 360 liposuction to best help improve your abdominal/trunk contour.
The difference between a "standard" and "extended" tummy tuck is just how far your incision extends to the side, and this is based on how much excess skin and fat needs to be removed to produce an aesthetic contour. They are essentially the same procedure, so no need to be concerned here. Generally, every surgeon tries to keep their incisions as short as possible so they can be easier hidden, but the goal here is improved body contour at the expense of scars, so this is important to keep in mind throughout the process. Regarding the transverse lower abdominal scar, it should be well hidden within your bikini or underwear, and if you adhere to proper scar care and sun avoidance after surgery, it should eventually heal to be minimally noticeable.
Liposuction is a great adjunct which would definitely provide additional benefit, particularly to the contour of your flanks and back, and can be done at the same time as your tummy tuck procedure for the best possible single operation results. Keep in mind that for you, given that there are stretchmarks and a skin fold present on your back, you likely have lax excess skin on your back which is not addressed with the 360 liposuction. This excess skin can become more noticeable and even appear deflated after liposuction, as it does not have the proper ability to fully recoil after the underlying fat is removed. Therefore, you would likely need another procedure to address your excess back skin at some point in the future, to further improve your overall trunk contour.
With all that said, it is always difficult to provide tentative surgical recommendations, as there is only so much information to be gained from any photos and descriptions provided. You already have a surgeon and reasonable sounding operative plan, which is great- one less thing to worry about! I hope all this helps!
Best wishes,
Dr. Donald Groves
Plastic Surgeon

Daniel Barrett, MD · Answer

Dear mrs.davis19,
based on your photos, you look like a good candidate for a TT. Full tummy tuck should tighten your abdominal muscles and remove the excess skin. Flanks liposuction would give you a better shape. I would suggest you to consult a board-certified plastic surgeon because only after a thorough examination you will get more information and recommendations.
Daniel Barrett, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

Leila Kasrai, MD, FRCSC · Answer

It is difficult to give you an opinion without an in-person assessment. However, it does appear that your mid-section protrudes somewhat, indicating that visceral fat is a concern. It would be a good idea to show a wish pic to your surgeon to determine whether your goal is achievable.

Gary M. Horndeski, MD · Answer

You appear to have a large amount of internal visceral fat. This will not result in a toned look even with liposuction and tummy tuck. I recommend you begin with liposuction, wear an abdominal binder for several months and begin a low fat diet and do abdominal core exercises such as sit-ups, planks and pilates. After you have reached the maximum weight reduction, you can then consider abdominoplasty with mesh reinforcement if you are not planning future pregnancies, The mesh creates a more hourglass figure by compressing the abdominal wall resulting in early satiety and helps maintain a reduced weight.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

Carmina Cardenas, MD · Answer

Based on your photos you have the combination of both visceral fat and subcutaneous fat and you must reduce both before surgery, reach a healthier BMI below 30 and the closest to 25 to end up with a toned, defined abdomen otherwise you will be disappointed. 
Toned well defined body Results are achieved as the combination of thin subcutaneous fat, no visceral fat, toned muscles all over your body and a successful surgery in the hands of a highly skilled plastic surgeon. Muscle repair is only part of surgery to help to tighten muscles. 
Be encouraged!!! You can do it and achieve awesome results. 
Dr Cárdenas

Camille Cash, MD · Answer

From your photos and description it is likely you have both subcutaneous and visceral fat.  Your results will be limited by the amount of visceral fat as this can only be improved with weight loss.  I encourage you to visit with a board certified plastic surgeon.  During an examination your surgeon can demonstrate what you can expect in terms of results.

Mats Hagstrom, MD (license on probation) · Answer

Do you understand your candidacy for the tummy tuck? It’s important to consider that there are different tissue variables determine what they have them and looks like and which of these tissue variables are treated with this procedure.
The four variables that determine what the abdomen looks like, include skin laxity, excess subcutaneous fat, muscle separation from previous pregnancies and excess visceral or intra-abdominal fat. Based on your pictures it appears you have all four.
You also appear to be overweight in this impact your candidacy for the procedure and has an impact on what your results are going to look like.
A tummy tuck primarily treats, skin, laxity, and muscle separation. The ideal candidate for the procedure has only those two tissue variables as being problematic. The more access subcutaneous, fat or visceral fat someone has the lesser of a candidate. They are for the procedure. Plastic surgeons will vary on their comfort level in regards to how much fat they will remove using liposuction when done in conjunction with a tummy tuck. Aggressive Liposuction done Circumferentially can increase serious complication rates, including skin necrosis, and wound dehiscence. 
If you’re looking to be a better candidate, and you want higher quality results, then consider losing a substantial amount of weight before having surgery. Individuals with thick layers of subcutaneous fat and excess visceral fat do not make great candidate for a tummy tuck.
At your current weight, you should expect an improvement, but I’m not sure if you would consider the result as that of a “toned” person. 
Differentiating, visceral, fat versus muscle separation isn’t all that difficult. You can do this by simply laying on your back and seeing if your abdomen goes completely flat. If it does, then the problem is more related to muscle separation. You can also determine access, visceral fat based on how much pressure it takes to press your observation flat. A flat abdomen means that they abdominal wall creates a bee line between your sternum and your pubic bone. Based on your pictures, I think you have both muscle, separation and excess visceral fat. 
An experienced plastic surgeon should be able to differentiate each of these four tissue variables, and help explain your candidacy for the procedure. Likewise, they should be able to show you before, and after pictures of previous patients who had similar body characteristics to give you an idea of what your results are likely to look like. Individuals who have excess visceral fat will often bulge after the procedure, and the bulging can look unnatural because the bulging is more in the upper abdomen rather than the lower abdomen. 
This abdominal contour also happens on individuals who are more barrel chested. If your sternum sits forward to your pubic bone by any significant amount, then the final outcome is likely to have a backwards sloping abdomen. The bulge is more in the upper abdomen rather than the lower abdomen.
This can be corrected to some degree by not doing overly aggressive muscle tightening on the lower abdomen.
Without addressing your obesity and excess visceral fat before the procedure, your candidacy is limited.
You can still have the procedure, but should lower your expectations in comparison to what you could get if you were at a healthier weight when choosing to have surgery.
Best,
Mats Hagstrom, MD

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