Which procedure would help target stubborn bulge in the abdomen? Concerned about invasive procedures and uneven results (photos)

Question

Hi, hoping for treatment recommendations. I've been researching smartlipo and power shape ultrasonic treatments. I'm 40, 5' 5", 130 pounds, I exercise but have stubborn fat/bulge on my mid-adomen. I've had 2 c sections but told i dont have ab seperation. The skin is a little loose but not bad. I had coolsculpting 5 years ago and saw little/no results. What do you recommend? I'm a bit afraid of anything to invasive or that might cause a bad/uneven result.

Mark Edward Hennessy, MD · Answer

Judging by your photos and history provided, it is my opinion that you are a the perfect patient for 360 Liposuction. All of my patients present for Lipo: nervous and sleepless but they leave stating:" If only I had known that this would be so easy ...then I would have slept soundly last night". Unlike Coolsculpting, you be able to see the fat that has been aspirated into a container, at the end of the procedure. I suggest that you watch a few educational videos about Lipo and converse with patients who have already completed the procedure. Also, continue your exercise routine, you appear to have elastic healthy skin and good muscle tone which bodes well for your post-lipo body. Hoping this is helpful.

Ryan Rebowe, MD · Answer

While some of what you see is skin and fat, you have the characteristic appearance, on pictures of diastasis recti, or rectus muscle separation. Although it may be minor, it is most likely present after two pregnancies. This can unfortunately only be fixed with a formal abdominoplasty. Liposuction or SMARTLipo will provide some skin tightening but the convex nature of the abdomen will only be fixed with muscle tightening.

Thomas Wright, MD · Answer

JME thank you for sharing your photos.  As I look at them you have some subcutaneous fat but not that much.  As far as noninvasive treatments are concerned: I don't think you are a good candidate for Coolsculptiing and I don't think Coolsculpting works that well even in better circumstances. Your abdomen bulge is at least partially and maybe mostly from a bulge in the muscle wall. This is the result of poor muscle tone and perhaps some internal fat. I think Emsculpt will help with muscle tone and fat loss.  You may be a candidate for liposuction as well but it hard to tell from your photos.

Marco A. Pelosi III, MD, FACOG, FACS · Answer

You're in great shape with excellent abdominal muscle tone. Nonetheless, the side view photos demonstrate the classic bulge of separated abdominal muscles. The separation is mild, but obvious to anyone who does tummy tucks and lipo routinely. Lipo will reduce the amount of fat that you pinch, but it won't make your belly flat because the flatness can only be achieved with muscle tightening. Muscle tightening can only be achieved with a tummy tuck. Anything else will NOT give you optimal results. If you want optimal results, I would recommend a lipo-tummy tuck combo.

Harry T. Haramis, MD, FACS · Answer

In our practice, we treat many prior Cool Sculpting patients with Vaser ultrasound liposuction.

This will target remaining stubborn fat and help with skin tightening, similar to Smart Lipo laser liposuction.

Prior Cool Sculpting can have thick, lumpy scar tissue. Vaser helps this also.

You should get a nice result, minimally invasive and avoids larger surgeries.

An exam and consultation with a plastic surgeon who performs these procedures is recommended to confirm you are a candidate as well as discuss your options and expectations.

Daniel Barrett, MD · Answer

Dear JME_2000,
it is hard to tell for sure without an examination. Based on your photos, it looks like you would benefit from liposuction. If you are considering surgery, I would suggest you consult a board-certified plastic surgeon. Only after a thorough examination, you will get more information and recommendations.
Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Louis D. Cole, MD · Answer

Thank you for your question. You appear to be a great candidate for Smartlipo. Smartlipo is a minimally invasive liposuction procedure that has 2-3 days of downtime. You should do your research and find a surgeon that has done many liposuction procedures as they will be more likely give you the results you want. One way is to view their before and after gallery to find patients with similar body types to yours. Another method is to check on their reviews. Good luck on your journey!

Leonard Grossman, MD · Answer

Your best solution to getting rid of the unwanted fat around your abdomen, as well as your flanks (love handle) is by means of liposuction. When liposuction is performed by an experience plastic surgeon, the results should be excellent with practically no visible scar. You can also find a plastic surgeon who performs J-plasma (Renuvion) tissue tightening as that will help your abdomen even more so. In addition, if you would like to have larger breasts or rounder, sexier buttocks, you can have that obtained from the abdomen and the flank area transferred to where volume is desired. Fat grafting produces wonderful results which are permanent and natural. When we perform fat grafting in our office, the results are natural with nearly 100% of fat take   I hope this helps and good luck from New York City Plastic Surgery.

Mats Hagstrom, MD (license on probation) · Answer

There are four variables that determine what someone’s abdomen looks like. In other words if someone doesn’t like the way their belly looks it is always because of one or more of four different tissue types.
The four variables are skin laxity often due to previous pregnancies, weight fluctuations and sometimes age, excess subcutaneous fat(The fat layer between your skin and muscle layer) muscle separation from previous pregnancies and finally excess visceral or intra-abdominal fat(fat around your internal organs that cannot be removed surgically)
Based on your picture your skin looks pretty good especially having had two pregnancies. your subcutaneous fat layer does not seem particularly thick. I’m guessing it’s 3/4 of an inch. To assess the thickness of your subcutaneous fat layer put your skin under gentle tension with one hand and with your other hand take one finger and very very gently pressed against your skin till you feel the underlying muscle wall or ribs. It requires very little pressure and in your mid abdomen i’m going to guess it’s just under 1 inch thick. Your muscle wall bulges. this can either be from muscle separation, excess visceral fat or a combination of both. If it’s visceral fat it can be demonstrated in one of two ways. take your nondominant hand and press your abdomen flat in a standing upright position.
For reference a flat abdominal wall should create a beeline between your sternum and your pubic bone. Unhealthy fit individuals who don’t have issues with their abdomen that is the alignment of their muscle wall.
If the muscle wall sits significantly in front of an imaginary line between your sternum and your pubic bone it is bulging. To me it’s evident on your pictures and it’s bulging quite a bit.
Visceral fat creates increased intra-abdominal pressure pushing against the back of the muscle wall causing it to bulge similar to what pregnancies do to some degree.
The second way to differentiate visceral fat versus muscle separation is to simply see what it looks like when you lay on your back.
If the problem is visceral fat then your abdomen will still bulge while laying on your back. if it’s muscle separation your abdomen will go completely flat when laying on your back.
I’m not sure who told you you don’t have muscle separation. All women who have term pregnancies will have muscle separation. It doesn’t mean you necessarily have to be able to get your fingers between your rectus muscles. muscle separation is a condition of the muscle fascia. It doesn’t affect the muscles themselves in any way it simply stretches the facia which is the flat tendon covering of abdominal muscles.
Treatments should be aimed at what the underlying ideology is. In other words the first step is to make an accurate diagnosis followed by an appropriate treatment.
If subcutaneous fat isn’t the problem then the fat reducing procedures are not the best option.
In your case it’s important to differentiate if visceral fat is contributing to your abdominal bulging. If it is weight loss is the only way to get your ab to bend to get flat. if it’s muscle separation a tummy tuck is the correct procedure.
Nobody hast to have a tummy tuck. Nobody has to have a liposuction.
For thousands and thousands of years women lived with pregnancy related changes. The right time to consider surgical intervention is when that condition bothers you enough that you’re willing to have surgery.
The worst case scenario is choosing the wrong operation.
That is done when people do not have a clear understanding of what the problem is.
Differentiating the four variables that change the abdomen is pretty straightforward from a plastic surgeons perspective but you’d be surprised at how many times providers do not go through all four of them such as during virtual consultations.
The only non-surgical treatment that it’s going to make your abdomen look better is weight loss. If visceral fat is contributing or may in fact be the primary problem then weight loss is the only treatment and no surgical intervention will be necessary.
My best guess is he will have substantial muscle separation regardless of what some other doctor (probably not a plastic surgeon) told you.
Your abdomen looks classic for muscle separation it only requires differentiating visceral fat to know which one is a greater significance.
The only successful treatment for pregnancy related to muscle separation is a full tummy tuck. it’s not for everyone but for individuals who want a tight flat abdomen and those who are willing to have surgery to correct the pregnancy related changes it is the quintessential correct procedure.
Lumpiness from Liposuction is easily avoided by simply finding a sufficiently talented provider who has the skill and experience to deliver consistent quality liposuction results.
This should not need to be a gamble or a substantial risk.
It will be if patients don’t take responsibility for provider selection and the process of properly vetting plastic surgeons in that selection process.
Delivering consistent quality liposuction results is more difficult than most people believe and the truth is most plastic surgeons are not particularly good at liposuction and this includes board-certified plastic surgeons with an overall good reputation.
This doesn’t mean they’re orange plastic surgeons you can do a liposuction well there are plenty of us.
Liposuction is unfortunately seen as a simplistic procedure that doesn’t require much learning.
The truth is mastering body contouring using Liposuction requires decades of committed learning and doing thousands of cases.
There’s more variation and liposuction results based purely on who does the procedure than any other plastic surgery procedure I’ve ever seen.
I Cannot over emphasize the importance of provider selection when it comes to Liposuction.
To find the right provider for liposuction or any cosmetic surgical procedure I recommend patients follow the following methodology.
First and foremost familiarize yourself with quality results by looking at lots and lots and lots of before and after pictures online. this website has thousands to choose from.
Before you begin to do that get proper images of your torso with pictures taken similarly to how plastic surgeons take before and after pictures.
This means using the timer on your camera or have someone else take the picture from about 8 feet away standing in a neutral position showing your front, side and back side from your shoulders to your knees wearing appropriate revealing garments that are not tight or create skin lines. taking a pictures with your arms up changes your abdominal contour and taking a picture from the reflection in your mirror is not a quality picture.
Once you have pictures of your own torso print those out and use them as a reference when reviewing before and after pictures.
There’s no point in comparing apples to oranges. An apple will always be an apple and an orange will always be an orange.
Looking at impressive liposuction results doesn’t matter if the patient has different body characteristics in the before picture.
What you’re looking for is other women who have a slight bulging abdomen, that are not obese, with modest amount of subcutaneous fat.
Once you’ve selected out A substantial number of before and after pictures of patients with similar body characteristics to your own in the before pictures create a reading or grading system for the outcomes.
It’s very important to know when you’re looking at quality work.
Look very careful at all areas treated to make sure there are no skin irregularities, divots lumps or any undesirable characteristic in contour that was not present before the surgery. review exactly what areas were treated and if possible look very carefully at transition zones between treated and untreated areas.
Next make a list of plastic surgeons in your community who seem to have a high proportion of Liposuction before and after pictures on their website including quality pictures.
Before and after pictures are supposed to be consistent. This means arm position should be exactly the same in before and after pictures.
Be very careful if you see arms cropped were you can’t tell the arm position. simply lifting your arms straight up in the air can have a dramatic impact on what the after picture looks like and this is not surgery related.
Honest providers will not do this but the temptation of showing better results than what you actually obtained is very real. The same is true for providers who ask patients to suck in their abdomen during the after pictures. some do and some don’t. It’s unfortunate but greed and temptation is a real thing.
Next schedule multiple in person consultations with the providers who seem to do a substantial amount of liposuction and seem to be good at it. avoid virtual consultations whenever possible and I highly recommend avoiding traveling long distances for elective surgical procedure if at all possible.
For the consultation recognize that you are hiring the surgeon and you were interviewing someone who is going to do work for you.
Make notes of how much time is spent for the entire consultation as well as how much time is spent making an assessment of you and explaining it, reviewing before and after pictures, discussing the preparation and recovery from surgery, discussing risks and benefits and alternative procedures, your medical history etc. did they leave plenty of time for you to ask any questions?
Detail oriented surgeons tend to be detail oriented in all aspects of their work and this includes consultations.
Providers who are primarily motivated by financial gains typically cut corners anywhere they can and are in the end serving themselves not their patients. obviously providers need to make a living but the best plastic surgeons always serve as patient advocates and put patient care first and foremost in regards to priorities.
During each in person consultation ask each provider to open up their portfolio and show you their entire collection of before and after pictures. being shown a handful of sample pictures which most likely represent the best results of a provider‘s career is totally insufficient to get a clear understanding of what average results look like in the hands of each provider or how many of these procedures that surgeon has actually performed.
For reference an experienced plastic surgeon should have no difficulty showing you a minimum of 50 sets a before and after pictures of commonly performed procedures like abdominal liposuction or a tummy tuck. highly experienced surgeons will have hundreds or even thousands of before and after pictures of these procedures.
With that many pictures it should be easy for the provider to find a substantial number of pictures of patients that look very similar to your body characteristics as reference pictures. remember the four tissue variables when it comes to finding sample pictures.
Ask the provider to show you examples of excellent outcomes, average outcomes and less than outcomes. Ask each provider what the revision rate is for the procedure you’re interested in and what their revision policy is. all plastics have a certain revision rate. Those who claim they do very few or no revisions are probably not serving their patients needs in an ideal manner. Excessively higher revision rates indicate there is a potential issue. 5 to 10% is probably a very appropriate revision rate for most plastic surgery procedures.
During the consultation it’s the right time to have a very clear understanding of what is covered, what is not covered, who decides when a revision is indicated and what the financial implication will be.
When reviewing the before and after pictures always look for areas of technical insufficiency. This means look for any contour irregularities anywhere on any treated area. ask the surgeon to review pictures with you asking them exactly what area was treated and what area was not treated. Try to look at transition zones between treated and untreated area. abdomen 360 or treating the upper lower abdomen with love handles and waist is a very common combination. A lot of plastic surgeons do not include the entire back so when that’s the case they’ll be a transition zone on the mid torso on the back. Likewise there is a transition zone between the love handles and the buttocks and that area should have ideal female curves. make sure you spend equal amount of time looking at pictures from all angles. The pictures showing the backside are very important.
All plastic surgeons have a variety of outcomes including results we’re not proud of. This is universal. an honest and experience provider should be comfortable showing you a variety of results if requested.
If plastic surgeons a wreck house intent of opening their portfolio and continue to stick with the preselected set of images representing the best results of their career then you should let them know that one of your deciding factors will be based on how many before and after pictures each provider shows including showing a variety of results. You are hiring the surgeon and you have a full right to see as many before and after pictures as you need to to be very comfortable with a clear understanding of what average results look like in the hands of each provider.
During all of this you need to take notes because you need to be able to go home and compare provider to provider.
Consulting with plastic surgeons is a skill and no one is going to get it right the first time.
It takes practice to properly vent to plastic surgeons.
It can be an intimidating process and patients are sometimes made to feel like they are the patient and the doctor is the doctor.
You need to change that perspective around and realize you are the person with the money who is hiring someone to do work for you.
You are in a sense comparing bids for contractors.
Finally make it absolutely clear exactly what areas Will be included with the procedure. It’s very important to ask if the patient will be turned during surgery if the procedure is formed under general anesthesia.
Shaping the waist, love handles and back well is virtually impossible if the patient is laying on their back. If general anesthesia is used the patient needs to be turned to treat the backside
personally I do liposuction with patients awake and this makes it easy to have patients whole different positions. With the exception of the front of the abdomen most of the contouring is done with patients laying on their side. while laying on the side the body contour can be seen perfectly and this is how we get ideal female S-curves.
For every area of Liposuction the surgeon recommends you include you need to see before and after pictures showing each and every area you’re paying for.
If they’re telling you you need to include the back and you’re just seeing a lot of good looking abdomens then you haven’t gone through the process efficiently. You also need to see what backs look like on a consistent basis.
It is a lot of information to keep track of but if you get the vetting process write the chance of having an overall bad experience is reduced substantially.
As I mentioned earlier there is a substantial number of providers including board-certified plastic surgeons with an overall good reputation were not particularly good at Liposuction.
If you don’t learn to differentiate who can do the procedure and who can’t you take a risk of being left disfigured. I don’t think my words are too strong and the truth is Liposuction is a permanent and irreversible procedure.
With the correct vetting process with sufficient numbers of plastic surgeons interviewed patients should be able to eliminate the risk of this almost completely.
If you simply go to one provider who seems nice enough assuming everyone knows how to do liposuction then you are taking a major risk.
Don’t do that.
You may also get different opinions from different providers regarding what is the best treatment. Don’t let this frustrate you but understand the different providers will recommend different procedures sometimes for different reasons.
For example, plastic surgeons were not particularly good at liposuction will steer most patients towards a tummy tuck where they know they can get a good outcome.
Some of those patients may have done much better with Liposuction because it avoids a very large scar, potentially a natural looking bellybutton and has one of the longest and most intense recoveries of any cosmetic surgical procedures.
If Liposuction was efficient and you were told do you need a tummy tuck it may simply be because that provider doesn’t do well with Liposuction and isn’t moving forward to get better at it.
On the other hand if you consult with cosmetic surgeons who are not board-certified in plastic surgery and only do liposuction but do not have the training or privileges to do a full tummy tuck they’ll be biased in the opposite direction and will tell patients they don’t need a tummy tuck and Liposuction will fix everything. Generally speaking avoid any provider who is not board-certified by the American Board of plastic surgery. That is the only certification that’s important and providers who’ve not done for a full residency training in plastic surgery should be eliminated from the list.
I don’t know how many consultations patients need to find the right provider. A lot depends on their ability to hone in on the better providers with Internet searches.
I recommend starting with at least five consultations and simply continue having more until you feel very comfortable you found the right provider.
When in doubt slow down and schedule more consultations.
Do not schedule surgery or commit to a surgery date during a consultation. Always give yourself time to think about your decision and make sure you finished all scheduled consultations before committing to surgery.
In the end you may not want to have surgery and simply live with your current condition. If your abdomen is bulging due to visceral fat there is no surgical treatment available and the only way to get your abdomen flat is with weight loss. if in addition you also have muscle separation and most likely you do. then the only way to get a true flat abdomen will be with a tummy tuck.
Liposuction will probably bring in your abdomen by about 3/4 of an inch. It’s certainly not enough to get you a flat abdomen but it will help. Liposuction will be much better on your backside reducing your love handles and harmonizing feminine S-curves. you seem apprehensive about having surgical intervention and I think that is a very healthy and appropriate view to take.
I would however encourage you to stop wasting money on procedures that don’t work and get an accurate assessment by those who will have the authority to do so. In other words get consultations with senior board-certified plastic surgeons so you know what your treatment options are. Had you done that in the beginning you would’ve known not to waste money on cool sculpting.
If that was recommended by a plastic surgeon then shame on them because they know very well that the procedure fails to deliver consistently.
Despite having a slim bulging of your abdomen you look far better than most women of had to children.
That in itself is something to be pleased and grateful for.
Good luck,
Mats Hagstrom MD

David E. Berman, MD (retired) · Answer

you definitely want to make sure you have a board certified plastic surgeon, do your smartlipo. i have done more than 1,500 smartlipo cases in the office. If the job is well done, it is very unlikely you will be uneven or lumpy. you get some skin tightening from Smartlipo. One of the excellent things about smartlipo is that you can return to work the very next day. You can shower first thing the next morning. You do need to be patient since you will continue to improve for 6 months. Many of the patients that I have treated have come to me, after they wasted their money trying Coolsculpt which I think is not effective at all.

david berman md,

david berman md,

Which procedure would help target stubborn bulge in the abdomen? Concerned about invasive procedures and uneven results (photos)

Answers (11)

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