How does a plastic surgeon determine whether there is fat above or below the abdominal muscle?

Great question!  I can understand how these two recommendations could leave you confused. Me too! They are completely opposite and only one of them is right!  There are simple tests to get some clues as to who is giving you the real truth and who is telling you what you want to hear.  First, when you are resting, on your back, is your stomach basically flat, or do you have a rounded belly that is still bulging? If you are basically flat, then muscle separation or weakness is the likely problem and a tummy tuck with muscle repair will help.( Remember though that your surgeon can only stitch the muscles back together. He cannot make them contract! You have to do that by sucking it in. Only with good posture and resting muscle tone can your tummy stay flat.)  If you find your belly remains rounded, try sitting up, thereby tightening those " abs". if you can pinch a thick fatty layer that moves on top of the muscle, then liposuction and tummy tuck surgery will help. If you cannot  pinch it and move it, then that fat is very likely internal fat around the organs. It cannot be improved by anything other than good old sensible diet and exercise leading to weight loss, Prior to tummy tuck surgery. You can still have that flat stomach, it will just take more work; but if you do it, your sense of accomplishment and self empowerment will far surpass even your wildest expectations! I see it every day. So go for it.....and start today! 

Generally, tummy tuck and liposuction can remove "pinchable" fat. This means that the fat is located underneath the skin rather than surrounding your internal organs (visceral). If you can grab your fat, then it can be removed. Muscle repair is necessary when the abdominal muscles have separated. This can be checked by lying flat on your back and doing a crunch. If you can fit more than a couple fingers in between the natural vertical ridge down your stomach near your belly button, then you may have separated ab muscles (diastasis recti).

Here's a test you can do:  lie down, and do an abdominal crunch, tensing up the rectus muscles.Now pinch your abdomen, lifting the fat that's above the contracted muscle.  This is the layer that could potentially be treated with liposuction ("subcutaneous fat).  Everything else is "internal" fat, which can not be treated with lipo.So, if you have a "beer belly" type shape, with lots of internal fat, but little subcutaneous fat, you're not going to able to get the flattening you want.  Only diet and exercise works for internal fat.All the best,

Hi and thanks for your question. Understand that abdominal protrusion can be caused by external fat ( that which lies from the abdominal muscles and the skin and visceral fat ( that which surronds the intestine and other organs). A tummy tuck is meant to address the issue with the external fat. Liposuction also addresses this area.Visceral fat, however, is not amenable to either of these two cosmetic surgical procedures. Visceral fat is usually treated with weight reduction surgical or otherwise.We can usually tell the distribution of this fat by a simple pinch test of the fat. This ca give pretty good idea of how much fat is visceral and how much is external. I would strongly caution against expecting an "iron flat stomach". It's simply not realistic. After 29 years of performing tummy tucks, my approach is always to tell patients that they will look flatter than before but not completely flat. It is very important that the expectations of the patinet be in line with the surgeon's evaluation. It is counter productive to tell, a patient that they will be completely flat because it may raise the patient's expectations to a level simply not possible by surgery.I wish you the best in your journey and hope that these words have been helpful.

       If your belly protrudes and you have little subcutaneous fat (which you can pinch between your fingers), the protrusion is due to abdominal wall laxity or visceral fat.Kenneth Hughes, MDLos Angeles, CA

My simple explanation to patients is "If I can pinch it, I can get it."  Everybody carries fat in two areas of the abdomen:  1.  between the skin and muscle 2.  under the muscles around the intestines and other internal organs  In cosmetic surgery (tummy tuck, lipo, etc), we remove the fat under the skin (1) but not the internal fat (2).  Generally speaking, women carry their fat "externally," which is why we tend to get flabby, hanging skin and fat of the abdomen, while men carry their fat "internally," which is why they tend to have a round, full belly when they gain weight.  Having said that, many women still have quite a bit of internal fat that can diminish their results from cosmetic surgery.  If you've received conflicting opinions regarding the results you can expect from a tummy tuck, you may want to consider a third opinion, but I would tend to believe the surgeon who tried to give you a realistic expectation rather than the one who was more optimistic.

Some patients have excess fat harbored in the abdominal cavity. This is not available to liposuction. Over tightening the abdominal wall. In this situation can be dangerous.A skinfold thickness of more than an inch implies there is at least some surplus fat between the skin in the abdominal wall.

This is a common issue and it is important for the plastic surgeon to accurately assess the patient's body shape so that they can outline a plan to accomplish the patient's goals.  If the patient has a large amount of intra-abdominal fat then a tummy tuck is not going to be helpful.  Think of a "beer belly"--a middle aged man with a firm, round, protuberant abdomen.  There is little fat overlying the muscle and the abdomen feels firm.  That is intra-abdominal fat.  A person with that build will not be able to "suck it in" and make their tummy flat.  Those patients don't benefit from a tummy tuck because muscle tightening simply isn't possible.  The pressure from the intra-abdominal fat will prevent a significant improvement.  I often see males with this build and there just isn't anything to offer them surgically.  Now if the patient can actually make their tummy flatter by "sucking it in" and tightening their muscles then a tummy tuck will be helpful.  This is the case often for women that have had stretching of their abdominal wall after having kids.  The muscles and fascia are loose and therefore fall forward.  It isn't from the internal fat pushing out.  An experienced plastic surgeon will be able to tell the difference.  Be careful going with a doctor who seems like they are telling you what you want to hear.  If there are significant differences between what you are hearing from doctores you should continue doing your research.  Make sure you visit with plastic surgeons who are board-certified by the American Board of Plastic Surgery.

A very simple way to get an idea of how much fat is above your muscle is to tighten your abdominal muscles ( either standing or while doing a sit up) and grab the skin and fat in your hand.  The firmness below that is your abdominal muscle, and what you can "pinch" is your skin and fat.  If you don't have much in your hand, and you have a large rounded belly, you may have a large amount of intra-abdominal fat, which is not correctable by a cosmetic procedure (liposuction or tummy tuck).Other factors can contribute to your ultimate result and how "flat" you will be, but this at least, can give you a guide to judging what is above your muscle.Seek a well qualified plastic surgeon to get a more definitive answer.  If you don't understand what they are saying, they may not be the best doctor for you.  Find one who is knowledgeable, skilled, and can relate to you in a way that you understand....

When different surgeons are providing contradictory opinions about potential surgical results, I would tend to believe the more pessimistic of the two. But, the best way to get an accurate answer would be to pose your question to both of the surgeons that you have already met. Beware of surgeons that promise amazing results, especially if there are no before and after photos of their own patients that evidence such results. You probably know which of the surgeons that you spoke with is more likely to be trustworthy. If you have a BMI that is over 27 or so, achieving "an iron flat" abdomen with a tummy tuck and liposuction is probably unrealistic. Best of luck.