I Don't Have The Flat Stomach I Expected After Tummy Tuck

Question

I had a full TT 5 months ago I was 5'4 and weighed 123lbs. I workout and have a low-cal diet, I never had a fat stomach just separation of muscles and loose skin. I expected to look completely flat after my full TT with slight liposuction but its not, I still have a slight pouch. I told my PS and he said everyone will still have a slight pouch or they are sucking in. I am back working out but the change is not like I expected. No one can tell I had anything done and I am 120 lbs is this true?

Richard H. Tholen, MD, FACS · Answer

You certainly sound fit and non-obese, but your surgeon still had the same volume and weight of intra-abdominal contents to "contain" within your tightened abdominal wall after removal of excess skin and fat. No matter now tightly your surgeon sews the rectus muscle sheaths together, your "insides" (intra-abdominal organs, intestines, mesenteric fat, and omental fat) still had their exact same size, weight, and volume "pushing out" against a tightened, but not rigid and unyielding, abdominal wall and skin. That's just anatomy, and this has nothing to do with your surgeon's skill (or lack thereof), or the technique used. (Unless, of course, he "skipped" the muscle repair.) It's the natural stretchiness of your (even surgically-tightened) abdominal wall combined with your own intra-abdominal contents.

An example might be helpful. Think of your loose stretched (pre-op) abdominal wall as a trampoline (one that is a bit older and well-used; i.e., a bit stretched out). Now put some pressure on that trampoline, like a bowling ball tossed onto its center and being pulled by gravity. No matter how tight you screw the turnbuckles on that trampoline, the bowling ball will still stretch the fabric somewhat, even if you somehow also tightened the fabric by removing some of it. An imperfect example, I know, but one that illustrates that your "insides" still push outward, no matter how tight your abdomen has been made. True, some patients do achieve flat, but usually only if they were flat before surgery (just loose skin and stretched muscles).

If the amount of skin and fat removed was 3 pounds, this would be a good amount for a woman your size. Sorry to be the bearer of bad news, but it sounds as if the only problem here was unrealistic expectations. Unfortunately, sometimes we surgeons are the cause of these expectations if all we show are the "perfect" results with the "flat" after photographs.Yours is the more common result. Talk to your surgeon, but there is likely nothing further that can be done except to lose 10 pounds or so--and this may still not even give you the "flat" tummy you seek. Best wishes! Dr. Tholen

J. Timothy Katzen, MD, FACS · Answer

Hello, thank you for your question about a pouch after your tummy tuck or abdominoplasty.  Your questions are difficult to answer without any pictures or a physical examination.  If your tummy tuck was performed correctly, you should not have a pouch.  During a "standard" tummy tuck, three areas should have been addressed.  1) Muscle: the rectus abdominis muscles should have been tightened from the sternum to the top of the pubic bone.  Typically, I use about 40 permanent sutures in two layers.  2) Fat: tummy fat is removed with direct removal with a scalpel.  If there is still residual fat, liposuction can be used be improve the hourglass figure of the tummy tuck. 3) Skin: skin is removed by direct excision with a scalpel during a tummy tuck.  In your case, I would guess the muscle was not tightened or not tightened enough.  Please  seek advice from your plastic surgeon or find another board certified plastic surgeon who specializes in tummy tucks.  Make sure they have performed at least 500 tummy tuck surgeries and have the before and after pictures to prove it.  Carefully examine their before and after pictures and check their reviews on RealSelf.  Check out Youtube also.  If you have any more questions regarding the abdominoplasty or tummy tuck, please contact my office. Sincerely, Dr. Katzen. (Certified by the American Board of Plastic Surgery, Fellow of the International Society of Aesthetic Plastic Surgery, American College of Surgery, and International College of Surgery and member of the American Society of Plastic Surgery and American Academy of Cosmetic Surgery.)

Camille Cash, MD · Answer

It's difficult to say if your results could be improved without photos or an examination.  It sounds as if you have expressed your concerns with your surgeon and have been given his opinion.  As you still have concerns, you may wish to visit with another board certified plastic surgeon near you for a second opinion.

Israel Manon, MD · Answer

Hello
To make a specific treatment recommendation I would like to see some pictures first. I suggest you to let your plastic surgeon know that this is still concerning you so that he/she can explain again and guide you on what you can do. Meanwhile keep doing some exercises to help tone up the muscle. Good luck.
Regards
 Dr. Israel Mañon
  
Certified Plastic Surgeon

Tom J. Pousti, MD · Answer

Thank you for the question.

	It is difficult to give you advice without examining you and/or  viewing pictures. Direct examination will be necessary to determine if revision of your tummy talk will allow you to achieve the results that you are looking for. On the other hand, physical examination may demonstrate an excellent result and a potential problem with communication and/or realistic expectations prior to surgery.

	I would suggest that you continue to follow-up with your plastic surgeon to communicate your questions and concerns.  if you feel that there is a &ldquo;failure to communicate&rdquo;, seek an additional consultation in-person with a well expensed board-certified plastic surgeon.

	Best wishes.

Robert L. Kraft, MD, FACS · Answer

I'd appreciate it if you would post photographs.  If there is a pouch, like a bulge, you might need a small revision but please know that women are not built "flat as a board" and that you shouldn't have the expectation of an abdomen with absolutely no contour.

Benjamin Gelfant, MD, FRCSC (retired) · Answer

Dr. Tholen's answer to your inquiry is comprehensive. You cannot achieve a completely flat abdomen as  a result of surgery, nor is it likely to occur  naturally. Even teenagers have some fullness and convexity to the lower abdomen. Perhaps  as a result of the illusion that a flat abdomen is the ultimate aesthetic, many teens and young adults even before pregnancy are overly concerned that they have less than a completely flat abdomen. As Dr Tholen explained, there needs to be space for your internal organs, your intestines, stomach, liver, etc. Furthermore, your spine is a lot closer to the surface of your front than you would imagine; what you know of your spine, that part you feel and see in your back, is only the very back extent of the spinal column, and the main part of these bones sits almost in the middle between your front and back.
Discuss this further with your surgeon; he or she is the best person to advise you further.

Best wishes,

Benjamin Gelfant MD

Margaret Skiles, MD (retired) · Answer

Without pictures it is very difficult to give you advice other than just general comments. I have found with my patients that sometimes the scar pulls in and makes it appear that there is more of a pouch than there really is. Scars will often soften and stretch out with time and massage. Hope this helps.

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