What is the Difference Between Fat Being Above the Muscle or Under the Muscle on Stomach?

Thank you for your question, and for posting your photographs. The body does indeed store fat in the abdominal region in different anatomical locations - both outside of the fascia/muscle layer that makes up the body wall, and intra-abdominal (beneath this layer but overlying the abdominal organs themselves).  It is only this first, "external," type of fat that can be addressed with tummy tuck or liposuction.  With that in mind, however, it appears from your photos that a significant portion of your abdominal fat is indeed this external type, and that you'd be a great candidate for tummy tuck with liposuction of the flanks.

A variety of
factors can contribute to contour irregularities of the abdominal wall. These include excess saggy skin, weakened
abdominal muscles, stretch marks, excess subcutaneous fat and excess
intra-abdominal fat.The success of a procedure that’s
designed to correct abdominal contour deformities is dependent upon a careful
evaluation of these factors.All of
these factors can be addressed with the exception of intra-abdominal fat.Intra-abdominal fat is also known as visceral
fat.This fat lies beneath the abdominal
muscles and surrounds the intestines.Unfortunately, fat in this location isn’t easily approached and for this
reason often represents a limiting factor in the ultimate aesthetic result from
this type of surgery.This is especially true in men who
preferentially store fat in this location.For this reason, abdominoplasty and abdominal liposuction have
limitations in men.If you’re considering abdominoplasty
or liposuction it’s important to consult a board certified plastic surgeon with
experience in this area.This surgeon
should be able to evaluate your abdomen and make an assessment of how
intra-abdominal fat will affect your final result.

When talking about the abdomen...  The fat anterior to, (on top of), the muscle is available to the surgeon to be suctioned out, (liposuction), or cut away, (tummy tuck).  Fat that is posterior to, (under), the muscle can't be addressed by surgery.  This is why in some patients you can't pinch fat, but they have a belly that protrudes.  Diet and exercise is the way to get rid of the fat posterior to the muscle.

Only fat that is above the muscle (between the skin and the muscle wall) is accessible to treatment with liposuction and tummy tuck.  This is called the subcutaneous fat.  The fat on the inside of the abdomen, wrapped around your organs, is called visceral fat and this fat only goes away with weight loss.  This is why people with "beer bellies" may not be good candidates for surgery (but may be if they lose weight).

You appear to have a combination of excess subcutaneous fat and an abdominal deformity.  You would be best treated with a combination of abdominoplasty and liposuction.  The liposuction will reduce your hips and flatter your figure by promoting the curves of your buttocks.  You might consider simultaneous fat injection of the buttocks.

I have attached some examples from my website .

I agree that the fat below the muscle cannot be addressed with any plastic surgery procedure. A tummy tuck will address extra skin and fat above the muscle, but the final contour of your waist will be greatly limited by the fat below the muscle. For the best result, you need to loose the extra weight first.

There are two types of fat: visceral and subcutaneous. Visceral fat is located around your internal organs, under your muscles. Subcutaneous fat is located above the muscles, just under your skin. Cosmetic surgery can remove subcutaneous fat but not visceral.To see whether your fat can be removed, try pinching your stomach. Whatever is grab-able can be removed. Whatever you can't, can't be removed. Visceral fat is typical of bloated bellies, or "beer bellies". 

There are two main areas for fat deposits in the abdomen: The subcutaneous fat located directly under the skin, and the visceral fat located within the abdomen (under the muscle) surrounding the intestines and organs. In body contouring procedures, the subcutaneous fat is the fat that is liposuctioned, directly removed, and sculpted. The visceral fat is never removed or manipulated with body contouring. There are physiologic differences to these fatty deposits as well. The visceral fat is considered a "metabolically active" fat. This means that it changes in volume much quicker than subcutaneous fat (ie it can be readily removed when the body needs energy). The visceral fat is also more closely linked with cardiovascular disease (strokes, plaques, heart attacks) than subcutaneous fat.

Visceral fat makes up the majority of "beer bellies" that we see in men. The way to reduce visceral fat is through diet and exercise, not surgery (except for gastric bypass). High amounts of visceral fat will lead to issues with rectus muscle separation, abdominal wall hernias, etc. For patients undergoing a tummy tuck, the Plastic Surgeon will often attempt to quantify how much visceral fat is present versus how much subcutaneous fat is present. If a lot of visceral fat exists, the results from a tummy tuck may still have quite a it of abdominal bulging. This is distressing to patients if they are not educated about the limitations of abdominal contouring. Schedule an appointment today with a Board Certified Plastic Surgeon to find out what options will work best for you.

For purposes of discussion, the abdominal (tummy) region may be thought of as being comprised of five physically distinct layers. From the most superficial layer to the deepest layer, they are: skin, fat, muscle, the lining of the abdominal cavity, and, lastly,  the abdominal cavity itself.

Anatomically, the fat in the abdominal region is located in two distinct areas and is referred to as being either extra-abdominal or being intra-abdominal.

Extra-abdominal fat is the fat that is located just below the tummy skin and it sits on top of the abdominal muscles; this is the fat that is physically removed during a tummy tuck procedure. Fat found in the hip/waist/flank, and back areas that is located at this same level (below the surface skin but above the muscle) is removed during liposuction procedures.

Intra-abdominal fat is the fat that is found inside the abdominal cavity (remember this cavity anatomically exists far below and is deeper to the tummy muscles, being physically separated from them by the lining of the abdominal cavity), along with the intra-abdominal organs such as the gall bladder, uterus, intestines, spleen, and kidneys, etc. This fat is intimately  associated with the arteries, veins, and lymphatic channels associated with these intra-abdominal structures and the critical maintenance of their functions and, therefore, is never involved in the tummy tuck procedure. Furthermore, this intra-abdominal fat responds favorably only to the increased caloric expenditure and decreased caloric intake associated with weight loss. 

In my opinion, a critical component to the result of a tummy tuck involves the  tightening or repositioning of the tummy muscles back to their most optimal anatomic location with the use of sutures.  However, the presence of excessive intra-abdominal fat may place too much pressure on the back side of the abdominal musculature and may physically impede the adequacy of any attempted muscle tightening/repositioning; the end result could be a suboptimal visual appearance of abdomen (persistent convex or protuberant shape).  In combination with the removal of pre-existing flank fat by liposuction, this undesirable effect may be even more dramatic.  

Additionally, muscle tightening in the presence of too much intra-abdominal fat can even result in difficulty with breathing after surgery as the tightened muscles may put pressure on the intra-abdominal fat itself (same amount of intra-abdominal fat now in a smaller space brought about by tightened tummy muscles) which then interferes with the dynamics of breathing.

Routinely, a well-trained and experienced tummy tuck surgeon will determine the physical contribution of both the extra-abdominal and intra-abdominal fat layers to the visual appearance of the tummy area before surgery such that he/she will, ultimately, be able to deduce the likelihood that the presence of excessive intra-abdominal fat will limit the results following surgery.

People come in all shapes and forms and how they are genetically determined to carry their body fat varies tremendously. Some people store their fat on their hips, some on their legs, and still others within and around their abdominal organs like their intestines, liver and pancreas. If a person caries a large amount of fat around their organs, it can push out on the overlying muscle wall and cause it to bulge.

Unfortunately, it is not safe to remove fat around your organs. This would be outside the scope of any plastic surgical procedure. The muscle wall can be tightened pushing in on your organs: this would be the equivalent of and internal corset. However there will be a limit as to how much this can be tightened. 

I hope this is helpful for understanding the limits of your upcoming procedure and I wish you all the best.

Fat inside the abdomen, surrounding your internal organs plays a role in the width of your abdomenal girth. However, I have never heard of a plastic surgeon who will remove any of this fat.

The fat removed during liposuction or a tummy tuck is fat outside the muscles that protect your internal organs.

Therefore if you have a lot of fat inside the muscles, plastic surgery will not address this concern.