Tummy not flat six months after tummy tuck with muscle repair (no lipo) (Photo)

Dear Lindsayb920,

Thank you for reaching out with your concerns regarding the persistent protrusion in your abdomen six months post tummy tuck with muscle repair. I appreciate the detailed history and the postoperative photos you've provided.

While it's challenging to gauge the exact change in your rectus abdominis muscle without pre-operative pictures, I would trust your plastic surgeon and physical therapist's assessment that your muscles were indeed repaired. If they were properly repaired, then any distension is likely due to the contents of the peritoneal cavity pressing against the muscle wall.

Given that you are 103 pounds, suggesting further weight loss doesn't seem like the ideal solution. An alternative approach to consider is the insertion of surgical mesh. Here's a brief overview:

The procedure begins with an incision made along your prior tummy tuck line.
The entire abdominal wall is then undermined and exposed.
A sizable piece of surgical mesh (approximately 8" x 10") is placed over the central abdomen.
This mesh is then securely attached to the rectus fascia and tightened.
The objective of this procedure is to provide added reinforcement and constriction to the anterior abdominal wall. It's admittedly an aggressive approach, but it has shown efficacy in flattening the abdomen, even post a muscle-repaired tummy tuck.

I hope this information offers some clarity and insight into potential solutions for your concerns. I wish you all the best in your journey toward achieving the results you desire.

Sincerely,
Dr. Katzen

If there is no subcutaneous fat and the muscle repair was successful, then there is a good chance that the issue may be related to either bloating or visceral fat.

Thanks for your question! If the muscle repair is still in tact, it's not unreasonable that something in your diet could be causing bloating and distension. I would suggest seeking another opinion with a gastroenterologist. Good luck!

Pregnancy can not only separate your muscles in the midline but you can also get global laxity to your entire abdominal wall fascia that is not "repaired" when we suture the diastasis together in the midline. This causes your abdomen not to be as flat especially once you have eaten food or drank liquid as this distends your abdomen. It is more common in petite patients since there not a lot of room for the baby in the vertical direction so you stretch more laterally and project more. Also during pregnancy your rib cage can be flared out to make room for the baby. If you rib cage comes down close to your hip bone this can make your waist larger. Many women even with PS cannot get their pre-baby waist size back because of factors like this.

You do look distended and may have some food issues that are causing this. Please be checked for food allergies. EMSculpt treatments to help tone and build you abdominal muscles could also be helpful, but you would need to be at least 6 months out from surgery.

If you are not flat after a tummy tuck then it is either weakness of your stomach muscles and despite being re-approximated and in good position they are still weak so plank exercises over a year will help to flatten your abdomen. The other reason for not having flat tummy after a tummy tuck is internal fat otherwise known as visceral fat can cause bulging in the upper or lower abdomen and despite being very thin can still benefit from weight loss.

It is very frustrating for patients and surgeons when patients are not flat after having a tummy tuck. Aside from performing liposuction, removing skin and tightening the abdominal wall and repairing rectus diastases there is nothing more that can be done during a tummy tuck to get patients flatter stomach. In fact, most patients get a good result with a tummy tuck but those who do not will benefit from either a small amount of weight loss or strengthening of the abdominal wall.

If the muscle repair is intact then the issue is possibly behind the muscle wall. I encourage you to visit with a GI specialist to explore potential causes of the abdominal contour. Your surgeon is your best source to guide you towards causes as she/he is most familiar with the details of your surgery and how you've been progressing through recovery.

Hi and thanks for sharing your concerns, after your 1st round of tummy tuck you can consider liposuction with vaser lipo to help you with your skin tightening, which will give you a better and flatter appearance of your abdomen.

To make an accurate assessment regarding the outcome of a plastic surgery procedure we always need to see a complete set of proper before and after pictures. If you don’t have before and after pictures, then ask your surgeon to forward the pictures they took. Avoid taking your own pictures using a mirror instead ask someone else to take the picture or use the timer on your camera. there are four tissue variables that determine what the front of the abdomen looks like. This is true whether someone has had cosmetic surgery or not. For tissue variables that determine what the abdomen looks like are the following.
1) abdominal scan laxity typically due to previous pregnancy, age or weight loss.
2) excess subcutaneous fat.
3). Muscle separation from previous pregnancies a.k.a. diastasis rectii(fascial separation is not only the distance between the two rectus muscles, but can occur along the entire abdominal wall fascia). 4) excess visceral or intra-abdominal fat.
Differentiating these variables is pretty straightforward. Skin laxity is no longer an issue since you’ve had a tummy tuck. Your subcutaneous fat layer looks relatively thin. You can check yourself by gently pressing against your skin with the tip of your finger until you feel the muscle wall. I’m guessing your subcutaneous fat layer is about 1/2 inch. Your muscle separation was treated during the procedure. Each plastic surgeon has their own way of doing this, and some providers are more aggressive than others. Muscle tightening is not a matter of bringing the two rectus muscles side-by-side. Often we do far more than that during muscle tightening , I’ve seen surgeons completely bury the rectus muscles in order to get the best results.
The number one reason patience have a bulging abdomen after a full tummy tuck is the presence of excess visceral fat. This can usually be determined during a preoperative consultation, and can often be seen in preoperative pictures. Differentiating between muscle, separation, and visceral fat(they tend to create similar appearances) isn’t rocket science, and should be easily accomplished by any experienced plastic surgeon.
The best way to do this is during an examination. If the surgeon presses the abdominal wall until it becomes flat.(a flat abdominal wall should create a bee line between the sternum and the pubic bone) the surgeon will know how much pressure it takes to press the abdomen flat. If it takes a significant amount of pressure and the patient perceives this as making their abdomen, feel tight, full, and difficult to take a deep breath then visceral fat is most likely the culprit. Another way to do this if I have the patience to do this themselves using their non-dominant hand only. If you can fairly easily press, your abdomen flat with your nondominant hand then visceral fat is probably not the problem and insufficient muscle tightening might be. On the other hand, if it still feels tight and it takes a significant amount of pressure depress your abdomen flat then visceral fat is most likely the problem.
Another way to differentiate. You still lay on your back and see if your abdomen goes completely flat or if it still looks slightly full.
Individuals who don’t have issues with visceral flat will usually have the abdominal wall look slightly concave when laying on their back.
The most common reason patients have a domino bulging after a full tummy tuck is excess visceral fat that was not identified during the pre-operative consultation.
It’s an important tissue variable to assess during consultations for any cosmetic abdominal procedure because visceral fat can significantly alter potential outcomes, and it’s a major determinant for someone’s candidacy for this procedure.
Visceral fat can only be lost weight loss.
Individuals who have excess visceral fat, typically have a history of some abdominal fullness, including pre-pregnancy, especially when being overweight.
There is no treatment for visceral fat other than weight loss.
I suggest taking a set of quality, abdominal pictures and keeping them for reference. Get on the scale on a regular basis, and try to shed a few pounds. Even 5 pounds at your weight should have a significant impact. If you wait goes up or down take a new set of pictures for reference. I doing this, you will know how weight affect the outcome of your procedure. Individuals who have visceral fat king greatly improve the outcome of the procedure with appropriate weight loss. This is true for individuals who have excess visceral fat whether they are overweight or not.
When making an assessment for tummy tuck surgery surgeons should differentiate between all four tissue variables. Recognize that a tummy tuck only treat skin laxity and muscle separation.
This means that individuals who are ideal candidate for a tummy tuck, should only have issues related to scan, laxity and muscle separation.
Individuals who have excess visceral fat and or subcutaneous fat tend to not be ideal candidate for a tummy tuck.
Rarely is somebody a perfect candidate. Most people fall somewhere on the spectrum regarding candidacy for the desired procedure.
Generally, speaking, plastic surgery, quality outcomes are based on two variables. The first is the patient’s candidacy for the procedure, and the second is the skill for provider.
A talented plastic surgeon should not only be able to technically execute surgery in an expert fashion, but should also be able to make expert assessment delivering predictable outcomes. This includes recognizing individuals who may have a visceral fat issue during consultations.
You may or may not have an issue with visceral fat. It is the number one reason patient complains of abdominal bulging after this operation. Insufficient muscle tightening is also a potential explanation. It isn’t all that difficult to differentiate between the two during an examination. Consider getting a few in person second opinion consultations if your outcome is of concern enough that you’re willing to have a second procedure.
For a second opinion, consultations patient should come prepared bringing with them a complete set of before and after pictures and a copy of your operative report. These are all available from your current provider’s office if you request them.
Best,
Mats Hagstrom, MD