A tummy tuck is a procedure to tighten the loose skin of the tummy that can result from pregnancy or significant weight loss. An incision is made low on the tummy, usually hidden beneath a bathing suit line, and through that the skin is elevated, re-draped downward, trimmed, and sutured closed. In addition, if the fascia (the supporting layer of the muscles of the tummy that “hold” the bowels in) is stretched and the muscles separated (diastasis recti), this layer is tightened as well in order to achieve a flatter tummy.
A “mini” or lower tummy tuck only tightens the skin below the level of the belly button. The only scar is the lower horizontal scar beneath the bathing suit line. The belly button is not “released”, so there is no belly button scar. As a result, there is no tightening of skin above the belly button. Some patients come in requesting a “mini” tummy tuck because they think the scar will be shorter, but do not realize that there will be no correction of skin wrinkling above the belly button.
A full tummy tuck is performed more often, as the majority of people who have loose abdominal skin resulting from pregnancy or weight loss have loose skin above the belly button as well. In a full tummy tuck an incision is made around the belly button to release it from the surround skin, and this allows the upper tummy skin to be freed up, redraped downward, and tightened. The belly button is then brought through the skin after is has been redraped, and this allows a stretched belly button to be rejuvenated. The old belly button hole where it was attached to the surround skin is brought downward. If there is enough loose skin of the upper tummy to allow this hole to be advanced down past the lower incision, it is removed. If not, it is closed as a short vertical scar.
The more common operation to reduce abdominal fat is liposuction. This operation is performed through very small incisions. It does not, however, tighten the skin, so if the skin is loose it may become even looser after liposuction. Some patients would benefit from removal of excess fat as well as excess loose skin. Any fat in the lower tummy that is attached to the undersurface of the loose or overhanging skin will be removed when that skin is trimmed. However, fat in the upper and mid-tummy will not be removed by a tummy tuck; this fat and its attached skin is re-draped but not removed. Although some surgeons will perform liposuction of the anterior tummy at the time of a full tummy tuck, this may hurt the blood supply to the remaining skin and lead to delayed healing, skin loss or necrosis, and ultimately worse scars. Extensive liposuction of excess fat in a separate procedure either before or after a tummy tuck is safer in terms of blood supply to the skin. Fat on the inside of the tummy around the bowels (visceral or intraperitoneal fat) will not be improved by liposuction or tummy tuck”only diet can reduce this fat. Patients who are obese are not good candidates for a tummy tuck until they lose weight “not only will their results be unsatisfactory, but there are much greater risks of healing problems and complications of surgery. The best candidates have loose or overhanging skin and are fairly close to their ideal weight, although some moderately overweight patients could still benefit from a tummy tuck.
Many patients are concerned about whether they might have a vertical scar from closing the old belly button hole during a full tummy tuck. This is because the long horizontal scar of a tummy tuck is hidden beneath a bathing suit, and the scar around the belly button is often hidden in the shadows and less visible. Unfortunately, some patients have enough loose skin in the upper tummy that they need a full tummy tuck, but they do not have enough to allow the old belly button hole to advance far enough down past the incision line to be removed. It is then closed as a short vertical scar.
Some surgeons solve this by raising the long horizontal scar to a higher position in order to avoid the short vertical scar. I believe that this is a mistake. It raises the longer scar to a less desirable position where it is less hidden and often does not heal as well, and it pulls the pubic hair higher and can abnormally shorten the distance between the belly button and the pubic hair. I believe that a short vertical scar, if necessary, is a better alternative. It keeps the long scar low and better hidden, and does not distort the natural shape of the abdomen.
Depending on the location and amount of excess skin to be removed, the incision and resulting scar needs to be carefully planned and extended out far enough that no skin bunching remains. When bunching occurs at each end of the incision, we call this a “dog ear”. These usually occur when the surgeon is trying to keep the scar as short as possible, and they can usually be avoided by extending the scar as far towards the hip as necessary. If a “dog ear” remains, most patients will return to have them removed, usually in a minor procedure under local anesthesia, which will extend the length of the scar anyway. It is better to extend the incision as necessary at the time of the tummy tuck. Poor planning of the incision location and direction by the surgeon at the time of surgery can lead to more skin bunching and “dog ear” formation, as well as less satisfactory scar location and shape.
If the surgeon pays attention to detail, the belly button can look quite natural after a tummy tuck. Some surgeons seem to make belly buttons that are way too large and look strange. I spend a great deal of time fashioning a belly button of normal size and work to create an “innie” so that the circular scar around it is mainly hidden in the shadow lines. Belly buttons that are thinned and stretched out after pregnancy will be made smaller and more youthful in appearance. If there is an umbilical hernia present, this can be repaired at the time of the tummy tuck.
The skin elevation and trimming of a tummy tuck is not very painful following surgery “in fact, the tummy skin is generally fairly numb afterwards. If the fascia and muscles need to be tightened, this causes more discomfort after surgery. This discomfort can be successfully managed by the use of a “pain pump”, which consists of tubes placed at the time of surgery that are connected to a reservoir filled with local anesthetic that bathe and numb the surgical area for the first few days. More recently, a long acting local anesthetic, Exparel, has been developed that is injected during surgery and offers similar long-acting pain relief without the inconvenience of carrying around reservoirs and tubes. I have found it to be more effective that pain pumps in my practice.
Most patients would take at least 2 weeks off of work after a full tummy tuck, and probably a few weeks away from most forms of exercise. Most surgeons use drainage tubes to prevent a fluid accumulation (or “seroma”), and these are most commonly removed after a few days to a week or so following surgery. Patients generally wear a support garment for several weeks to reduce swelling.