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The Designer Tummy Tuck

We all know an attractive belly when we see one. It has the appearance of youth. The features suggest the fitness and trimness of a body that has not suffered the agonies of age, weight gain, surgery or pregnancy. Most of us have never had the flat stomach of a ballerina, yet there was a time when looking down wasn't so disappointing! Realistically, an appealing tummy reveals a continuation of the appearance of young adulthood into later years.

Disclaimer: Although this article may appear to be for women only, most of the problems and concerns also show up on the mid-section of men. Believe me, I know.
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It does not take a plastic surgeon to know what makes a belly look good. Smooth skin is certainly a plus - free of stretch marks and scars - although a well-healed scar is not unattractive. Thin is definitely "in" today. The abdomen has several contours to it which become hidden as we add fat over them. Too little fat may be appealing to body building competitors, but it can add a stark nature to the average body. Attractive "abs" have its borders - the rib cage on the top, smooth contours on the sides, and no rolls on the bottom. We also like to see a slight hollow below the ribcage, tight flat rectus muscles and not a hint of a lower pooch of fat. The navel should look more like a cat's eye than a purse-string bag.

Exercise and weight control always help. Toning of the muscles of the abdomen improves strength and flexibility. Because the abdomen is a cylinder of muscle with the spine at the back, this cylinder supports the spine and affects the posture. Good muscle tone along with good tone of the muscle fascia can, in fact, ease certain lower back pain problems. In contrast excess weight on the torso negatively affects the dynamics of the back. A large roll of fat on the belly pulls the lower back forward, breaking down the posture of the spine. No wonder it feels good to suck in the belly.

People always ask me if they should lose weight before a tummy tuck. Since the goal of a tummy tuck is to create smooth contours and young skin, I suggest that the right time for surgery is when the patient is at a stable weight. Excessive, unsustainable weight loss prior to surgery, which cannot be maintained indefinitely, may lead to recurrence of bulges when the weight is re-gained following contouring surgery. Pre-operative weight reduction is good when the weight is a recent addition, such as during pregnancy.

A Custom Designed Approach

In designing the right operation for the tummy, plastic surgeons determine what kind of work should be done on three layers of tissue - the skin, the fat and the muscle. The traditional tummy tuck (or abdominoplasty) taught us to work on all layers, but the newer techniques of liposuction, ultrasonic liposuction and endoscopy allow a truly customized approach to abdominal contouring. Thus we have the "designer" tummy tuck.

Torn or stretched muscles caused by pregnancy or weight gain is a common misconception. In fact, the muscles are just fine. The muscles are attached to one another by fascial tissue which is a connective tissue colloquially referred to as "gristle" or "tendon." This is the tissue that stretches out during pregnancy. Sometimes it does recover its tightness. However when it remains stretched out, the muscles appear loose, allowing them to bulge forward and sideways. If the fascia actually tears, the contents inside the belly can bulge through like a bubble on a tire. Voila! The hernia. A commonly located hernia is in the navel because the fascia there is normally weaker than
average.

Another misconception is that the muscles must be cut in order to repair them. Yes, that sounds painful. However, the muscles are not cut during surgery. Instead, the fascia is tightened with many stitches, moving the muscles back to the position that they formerly occupied. The result is a flatter belly and better muscular support.

Jack Sprat may have had no fat, but the rest of us do. As we age, the fat seems to gather in certain areas, hiding the features and creating bulges. Removing the fat entirely or shaping the fat restores the fat pattern seen in younger bodies. The fat removal loosens the skin over it and younger skin will tighten up. But if the skin is aged or damaged, it will not tighten adequately. Your plastic surgeon will know this in advance and will recommend skin and fat removal instead of liposuction alone. Recently, liposuction instruments with tiny ultrasound probes on the tip are being used to liquefy the fat before it is sucked out. This new instrument has made it possible to get better fat removal from areas that resisted re-shaping. Properly performed lipo-sculpting will reveal a trimmer body by allowing your clothing to drape better or even by reducing your clothing size.

The Icing on the Cake

If the work on the muscle and fat layers is the cake, then the skin surgery is the icing. Usually the skin from the navel to the pubic hair is redundant and it can be removed. If this skin contains stretch marks or scars these marks will be gone permanently. (Stretch marks are actually tears in the deeper half of the skin without tearing the surface). The smoother skin above the navel is pulled down, as if you were lowering a window shade, to cover the whole abdomen. The skin from the sides can be pulled toward the middle to tighten the waist and the loose skin in the lap crease can be drawn up a little bit. During the operation your surgeon will experiment with several directions of pull, depending on what your abdomen requires.

Misconception number three -- The navel is not detached. It is cored out, keeping its connection underneath and it is popped back through the skin when the upper abdomen skin is pulled down. Stitching of the skin is completely planned before surgery. My patients come in on the day prior to surgery, with a bathing suit or brief. We mark the position of the scar so that it will hide beneath this garment. Careful attention to this detail can be the difference between a good result and a great result.

At this point, a magician would say that he never reveals his secrets. But plastic surgeons' techniques are not secrets - they are tools to select from to get a nice result for every patient. The best way to tell you what we can do is to describe several body types. The most common problem is the man or woman with extra fat and skin on the lower abdomen and looseness of the muscles. This person will have the best result from a tummy tuck that flattens the stomach by cutting away the lower roll and tightening the muscles. Liposuction will shrink the love handles. The surgical scar is low and goes from hip to hip.

Many of my patients are women in good physical condition who have had children. They do not have loose skin or many stretch marks. In this case, the skin scar can be much shorter, sometimes entirely within the pubic hair. The muscles are tightened by operating under the skin using the endoscopic camera and instruments. Fat bulges are sculpted with liposuction. Endoscopic abdominoplasty is also useful if there is a surgical scar on the upper abdomen.

Some people have a belly with firm, flat muscles, yet there may be an excess of fat and/or some loose skin. In this case, there is no need to work on the muscle layer. The fat can be sculpted with traditional or ultrasonic suction lipectomy. The skin can be drawn down and smoothed out like a tablecloth. For these patients, recovery will be shorter and less painful.

On rare occasions, your surgeon may suggest a different pattern of skin removal which leaves a scar higher on the abdomen, a scar that encircles the whole body, an up-and-down scar or a scar shaped like a "plus" sign.

It is usually safe to have a tummy tuck at the same time as other surgery, such as operations inside the abdomen or other cosmetic surgery. The decision to combine two operations in the same surgery should be made by you and your surgeon(s).

This article describes the intricacies of tummy tucks. It does not give healing and other details, possible complications, surgery costs . . .or the costs of your new wardrobe!!

Sheldon M. Lincenberg, MD, FACS, is a Mayo Clinic trained, board certified Plastic and Reconstructive Surgeon practicing in Atlanta, Georgia.