To make an assessment on the outcome of a plastic surgery procedure we always need to see proper before and after pictures. If you don’t have before and after pictures, don’t ask your surgeon to forward the ones they took. The number one reason patients have a domino bulging after a full tummy tuck is due to having excess visceral or intra-abdominal fat. There are four tissue variables that determine what the abdomen looks like. If somebody doesn’t like the way they were the problem is always related to one or more of those four tissue variables. The four tissue variables that determine what the abdomen looks like are abdominal skin laxity, excess subcutaneous fat, muscle separation from previous pregnancy, and excess visceral or intra-abdominal fat. Insufficient muscle tightening can also be a cause, but this tents to be uncommon, especially compared to under recognized visceral fat and how much this can impact the outcome of the procedure. The easiest way to differentiate visceral fat versus muscle separation is to see what you abdomen looks like when you lay on your back. If your abdomen. Try laying on your back and see if your abdomen goes completely flat. If it does, then insufficient, muscle tightening is most likely the best explanation. If your abdomen still bulges, while laying on your back then excess visceral fat is most likely the explanation. why you still bulge after the procedure. Excess visceral fat can usually be seen on before pictures and should’ve been assessed during your consultation. Visceral fat can only be reduced through weight loss. The amount of visceral fat is determined genetically. Individuals who have excess visceral fat, are going to have limited results in regards to getting a flat of them in from a full tummy tuck, unless the visceral fat is addressed before or after the procedure. Obviously, both variables can contribute and insufficient muscle tightening and excess visceral fat may in fact be what’s going on. It’s important to differentiate between the two because the solution is going to be different depending on what the problem is. Assessing the degree that visceral, fat or insufficient muscle tightening impacts the outcome of the procedure should be all that difficult. Most plastic surgeons should be able to help you with this. To do it accurately will require an examination. I suggest having a few in person, a second opinion, consultations with other local board-certified plastic surgeons. Come prepared for a second opinion consultations by bringing with you all proper before and after pictures and a copy of your operative report. These are all available from your surgeons office if you request them. Best, Mats Hagstrom, MD