Why do some tummy tuck incisions look pleated?

Thank you for you question. You are looking at this all wrong. The appearance of the incision has nothing to do with the surgeon preference and everything to do with the patient. It's not like some surgeons out there are sitting around in the OR thinking "I am just going to make this incision look crappy and let the patient deal with it."The biggest difference is the amount of skin that needs to be removed. This determines how big the incision needs to be and how pleated it ends up being. If there is very little skin to be removed, then the distance of the upper and lower portions of the incision are roughly of equal length. In this case, the incision can be short and when closed, the upper and lower portions match up and there is very little pleating. If, on the other hand, there is a large amount of skin to be removed, then the incision has to be longer and the upper and lower portions of the closure do not match. In other words, how do you match two edges when one is 30 inches and the other is 20 inches.......you pleat 10 inches up on the longer side. You cannot close an oblong skin excision in a straight line without making some concessions somewhere. Also, you are probably looking at pictures at different times from surgery. The longer the scar is there, the more it settles and fades, and the more "perfect" it gets. In cooking, the quality of the ingredients makes the final dish. It's kinda like that in surgery. The pre-op status often dictates the quality of the post-surgical outcome. Hope this helps your understanding.....

I wouldn't focus too much on the pleating. It is an excellent observation, but the final result is what is most important. The length of the scar depends on the location of the excess skin. Excess skin that is isolated to the middle uses a shorter scar, but when hanging skin extends to the hip then the scar is extended. I attempt to use the shorter scar possible, but make sure that it long enough so that there are not excess skin on the sides. Consider several consultations with board-certified plastic surgeons, so that you can decide which tummy tuck surgeon is best for you.

Thank you for your question. This is a complex issue, partially dependent on patient's skin elasticity, amount of skin removed, how fat the patient is( not all are ideal candidates for tummy tucks), surgeon's skills and experience. Remember, long scars and short scars are permanent. I am one of those surgeons who prefers to give the shortest possible scar to my patients. Yes, this will cause some puckering at the ends, which smoothes out over time. Occasionally, I do a revision if excess pucker persists, under local anesthesia. This still gives a shorter scar, which does not go into the thighs or buttocks or almost circumferentialy as you might have noticed. This needs to be discussed with the patient during the consultation so they understand your philosophy and your ability to give them the best results with the shortest scar. Difficult to hide a long scar in a bikini, and no patient of mine said that the  "temporary disfigurement", as you put it, wasn't worth it.

While it may seem that the incision varies by surgeon, the look of the incision actually varies by patient. It is reflective of the patient's skin elasticity and the amount of skin that needed to be removed. The same is true for the length of the scar. Typically pleated incisions heal very well, as do non pleated incisions. I encourage you to look at before/after photos of the surgeons you are considering. Ask questions and take notes. It is important that you feel comfortable and confident in your surgeon and surgical plan.

It is not that we "make patients live with any disfigurement." You are dealing with different surgeons of different skill sets who do things different ways. Its kind of like sports. Some are just more talented than others. Thats all. Some take more time with closure and attention to make them look better than others. I will tell you however that an incision should not look perfect early on. It should look puckered and heaped up for lack of better medical terms. It should be that way because the deeper sutures initially are the ones that keep tension off the scar and low tension is one thing that helps scars heal pretty. Those deep stitches cause that puckered look. You also have to take into account the quality of patients skin. Some have stretched out very thin poor quality skin that will look puckered no matter what because the collagen quality is just so bad compared to others who do not have stretched out thin skin. The length of the scar depends on how much skin needs to be removed. Some smaller patients need shorter scars while some larger patients need longer scars. So it can be surgeon dependent and patient dependent. We don't "make" anyone "deal with temporary disfigurement." It is what it is. We close the way we do for a reason. But, I think disfigurement is not the best word to use here.DrRickAZ

The beauty of the closure usually depends upon the elasticity or damage (i.e. stretch marks) more than any other factor.  An attempt to keep the scar as short as necessary is worth it over time. The best scar is the least scar.  Certain materials used for closure will give a different appearance initially--barbed sutures (Quill) are now widely employed to perform knotless and tension free closures.  They cause considerable bunching but this is to off load the tension on the final skin closure so that it does not widen over time.

It would be helpful for you to illustrate your question with before and after photographs of the appearance that you are referring to. However,...
No plastic surgeon would deliberately give someone a temporary disfigurement unless they thought there was a longer term advantage in doing so.
Pleating or puckering of skin above the wound is likely to be due to their being a mismatch between the  upper and lower lengths of the incisions. Other causes of puckering may be from quilting the space under the skin closed before the wound is closed. This puckering usually settles down with time. An advantage of this approach is that it may reduce the tendency to form seromas and can avoid the need to have drains left in the wound.
There is also considerable variation from one patient to another which results in very different results from 'the same' operations.
The best advice is to have a consultation with a suitably qualified and experienced plastic surgeon or surgeons. Show them photographs of what you like and dislike. They should be able to advise you on what may or may not be possible for you.
Best wishes