Tummy Tuck

In a previous blog on Mummy Makeover I covered surgical options to rejuvenate the breast. In this second blog in the series, I will address the other area that also suffers the greatest impact of childbirth, the abdomen. This is classically addressed with a “tummy tuck” (called an abdominoplasty by plastic surgeons).

The expansion of the mother’s abdominal wall by the growing baby affects all the layers, including the muscle, fat and skin. In pregnancy, many of the female hormones such as oestrogen and relaxin are at extreme levels to prepare the mother for childbirth. These hormones are produced to soften and weaken ligaments and tendons to allow the pelvis to expand and accommodate the passage of the baby at delivery. They also, however, have key adverse and undesirable effects that produce the hallmark damage to the mother’s abdominal wall.

Firstly, these hormones affect the collagen of the skin and weaken it. Collagen is the key structural component of the dermis of the skin (the strong leathery part of the skin). The weakened collagen, acted upon by the extreme stretching of the skin in late term, produce the characteristic stretchmarks of pregnancy. Stretchmarks are a fracture in the dermis, where the dermis has gone beyond its elastic limit and has been literally torn apart. Stretchmarks do not repair and are permanent. They will fade with time but will always be there once produced.

The human being is very good at growing skin. As the baby enlarges, the skin not only stretches, but the mother actually grows more skin on her abdomen. Unfortunately, after the baby is delivered, loose folds of skin may persist. Couple this with the reality of being a new mother, with the change in lifestyle and difficulties in maintaining a pre-baby exercise program, the “baby fat” of pregnancy is very hard to shift and leaves fatty rolls in combination with the loose skin. You absolutely can’t “tone” skin with exercise as some would have you believe.

Another critical victim of stretching and hormones is the connection between the two rectus abdominus muscles that are held together in the midline. Again, once this is overstretched no amount of exercises will bring it back to normal. The muscles each side of the gap can be strengthened, but the bulge between them will persist. This is called rectus divarification or separation. I have seen a patient who went to the gym literally twice daily, 7 days a week, and had the most incredible “6 pack” that was unfortunately separated by about 6 cm due to rectus separation, left with a tummy that bulged and still looked pregnant.

Separation of the rectus muscles not only has a cosmetic consequence, ranging from a bump up to what looks like a full-blown hernia and full term pregnancy, but also has a functional consequence. Most modern back pain rehabilitation regimes centre on strengthening the core muscles. The muscle core depends on all elements working together, and in many ways is only as strong as the weakest element. The rectus muscles are a key element in the core, and if they are significantly separated result in abdominal bulging with muscle contraction. This results in “bleeding” of energy and weakening of core strength.

I have had much success in treating post-pregnancy back and pelvic pain with abdominoplasty surgery. There is a growing body of literature supporting exactly this. There is also a growing body of literature showing the benefits of core stabilisation with abdominoplasty, regarding improving urinary leakage and urinary incontinence.

So, in the Mummy Makeover tummy tuck many elements can be addressed that a mother can’t fix no matter how much she exercises and diets. Removing and tightening excess skin and fatty rolls. Removing skin that contains stretchmarks. Repairing muscle separation that both flattens the abdomen and restores the integrity and strength of the core muscles. Finally, liposuction can be performed to those pesky fatty deposits that weren’t there before around the flanks (love handles) and pubic region

As with all procedures, the patient would ideally like a little operation and a big result. Certainly, there are “mini” procedures that may be ideal in specific circumstances. What is essential is to have an expert experienced surgeon who can match the ideal operation to the patient’s circumstance.

So how long should a scar be for a tummy tuck? Well, no longer and no shorter than is needed to do the operation properly. Certainly, it will be low, lower than a caesarean scar, and running in the crease across the abdomen. This scar usually heals very well and is well hidden in panties or a bikini. This scar rarely concerns a patient, and is an excellent trade-off for the result routinely achieved.

A specific circumstance in the mummy tummy is the roll over the caesarean scar. The scar tethers to the underlying structures and even a small roll can bulge and fall over that point. This tends to roll over pants or a bikini. This can be distressing to a mother who otherwise has a good tummy, but it can in the appropriate patient be corrected with a sub-umbilical (mini) abdominoplasty. This fixes from the belly button (umbilicus) down, has no scar around the umbilicus and can be strategically combined with liposuction as required or desired. The scar can be sited very low, and depending on circumstance may not be much bigger than a caesarean scar. This is commonly done as a day only procedure, and recovery is quick.

Another specific circumstance is the patient who has relatively good skin (especially above the belly button), but the main problem is separation of the rectus muscles. Again, this can be addressed by a low scar, not much longer than a caesarean, by a procedure called an “umbilical float” abdominoplasty. This again does not have a scar around the umbilicus. In this float procedure, a tunnel can be created for the whole length of the abdomen, via a low scar below the site of a caesarean. This allows the rectus separation to be repaired as for the more radical procedure. This procedure, though, only really allows partial removal of skin below the umbilicus.

So, what is the appropriate timing of surgery? Ideally a mother having a tummy tuck should have completed her family. Certainly, further pregnancies may undo the good work of the surgery already performed. Having a tummy tuck doesn’t affect the ability to subsequently get pregnant and carry full term. I have had a patient who had thought she had completed her family, and got an excellent result from an abdominoplasty. With a change of circumstance, she subsequently had children with a new partner. Her abdomen held up pretty well with the new pregnancies, but she elected to have the abdominoplasty redone, very successfully, as she was now accustomed to a very flat and lean abdomen.

Following delivery, I think at least 6 months is needed for recovery to a steady state before abdominoplasty is contemplated. If the mother qualifies for Medicare item numbers, by the rules the surgery can’t be performed before the youngest child is aged one year.

As with all procedures, mothers’ tummies are unique in both physical characteristics and what the mother is desiring to achieve. The appropriate operation should be married to what must be fixed to get the desired outcome. It is essential that a mother looking to resurrect her tummy to what it was pre-baby seeks the expert advice of someone skilled and experienced in all the options available.