Do I need a tummy tuck, I just have muscle separation?
For a background on diastasis recti repair you can check out my last blog post on the subject here.
Here is the short answer: yes. If you have muscle separation, otherwise known as diastasis recti and it does not go away with physio and exercise then, yes, you will need a tummy tuck to get flat again.
Why? The short answer: when you fix the muscle there will be extra loose skin relative to the flat belly and you won’t like the way it looks if its not removed.
Now lets do the long answer.
Why Tummy Tuck is Needed for Muscle Separation
Patient story
When we have a consultation you will notice that my partner surgeons and I will not waste your time talking superficially about plastic surgery; we will dive deep beneath the surface to understand you as a person and how much pain or emotional burden your muscle separation is causing. Our ultimate goal is to make your life better, so we need to understand you, your life, and the extent of the problem.
Here is a typical story, I have always felt that stories are an easier and better way to share information.
This is a fit mom of 3 who was referred by a friend and her dermatologist in Greenwich, CT. Let’s dive into this moms background to help you better understand her motivations for having plastic surgery. This mom is a happy and healthy person. She loves her family and she loves her body. Before babies she felt incredibly comfortable in a bikini and thoroughly enjoyed her true passion of tennis. After her last baby she returned to tennis but felt something was off. She was not able to engage or use her core like she could before her babies. For her it was not until the third pregnancy that she felt the changes to her body post babies was so severe that it bothered her. She spoke with her OB and tried physiotherapy, pelvic floor retraining, intense exercise. She noticed some improvements but when she looked at herself in the mirror with and without clothes she felt like something was missing. She is not a plastic surgery person but with the love and support of her husband she wanted to put her toes in the water and see what was available to help her fall in love with her body again. After seeing a few local surgeons she was feeling a bit down, she did not feel as though the surgeons she met had truly connected with her, she did not feel they saw the world through the same lens as her nor had they the same concept of aesthetics. She also was uncomfortable having something so important performed by someone who does surgery on the face and injectables she was not going to do this until she found someone who “got her” and did this everyday.
Let’s move ahead to how she came to us. After being frustrated she talked to a girlfriend who mentioned that their other friend had a tummy tuck in the city with a surgeon who specializes in mommy makeovers and loved it. She checked with her dermatologist for a second referral resource and her dermatologist who lasers a lot of our scars in Connecticut said “yup that’s the guy”.
During our consultation, the main thing I did as the surgeon was listen. I didn’t listen so I could respond, I listened so I could understand. She was a thin fit mom who was used to living life loving her body. She was not a plastic surgery kind of person but she didn’t want to live the rest of her life hating being naked, hating being in a bikini, having to wear compression under dresses, and interestingly mostly for her she wanted her core to work because as a college athlete avid exercise enthusiast and legitimate tennis pro it seemed practical and logical to fix her body. We really connected with shared interest in what we do at the gym, where we travel, and the importance of family. She liked that this is all we did and we had a large team there to support her. Her husband loved that we always had two anesthesia docs and always had a big group of well trained nurses around during surgery (usually 10!!!) which helped him feel at ease. The two of them especially loved that we don’t send people home after big surgery. She stayed at the Plaza for 4 nights with our 24/7 aftercare nurses who deal with medications, garments, food, supplies, and help you get in and out of bed, monitor your drains and vitals and generally remove all stress and anxiety from the early recovery period which is the hardest especially on an untrained care giver.
Side note: you may be wondering why I always talk about working with patients who are happy. The reason is that if someone is tying the existential idea of happiness to the results of their plastic surgery it is almost impossible to obtain and thus its unlikely the patient even with the best possible outcome surgically will perceive the results to be satisfactory.
Another side note: if you wondered why almost every single referral we get is from a doctor or a patient its because our hyper-focused pursuit of excellence in outcomes, experience, and safety in a very narrow set of operations allows people to find peace in a busy world because they don’t have to sort through anything- they know they are in the right place.
Her surgery was 6 hours because we did a breast lift with implants, we used an internal bra and did some custom cleavage creation with fat grafting along with the lipo of the entire torso, aka lipo360, tummy tuck and multi vector muscle repair.
Who typically needs a muscle repair?
- Moms who had big babies
- Moms who had multiple babies
- Moms who had big babies multiple times
This is what many many fit and petite moms’ tummies look like after a few kids (and they hate it).
How Muscle Repair is Performed
Did you ever wonder how we actually repair the muscles after muscle separation from babies. Some patients ask me “so do you cut them or what”. Let me give a little background into how diastasis recti or muscle separation occurs.
Before babies you can think of your core as like a steel door. Your insides you know the kidneys, the liver, the intestines when they lean against the door nothing really happens. When you have a baby you have to make room for the baby so your body separates the muscles. It gets wider as you go lower because the baby lives in the lower abdomen aka the pelvis. The thinner and fitter you are paradoxically the worse the diastasis recti is usually because you are stretched out more.
Post pregnancy, as the pregnancy hormones leave your body, the muscles can slide back together. Again, the more babies, the bigger the babies, and the more big babies you have, the harder it is for the rectus muscles to slide back together. When the muscles don’t slide back together the intestines and the organs lean on what was once a steal door and is now a screen door – which means you get a bulge.
My patients hate this, they like to look and feel sexy and for them that means a nice flat tummy and a working core so they can enjoy exercise. They want to do a plank and not have everything fall out on the floor. So they try intense core workouts which may make the muscles bigger but wont move them together. They do physio and pelvic therapy which can help but many want a permanent solution because they don’t want to spend the rest of their life with an uncontrollable bulge. That’s how I would feel; that’s reasonable and its logical to fix.
So during the tummy tuck we lift the skin off the muscle like lifting up the hood of the car, then we get in there and repair the engine (aka the muscle separation or diastasis recti). We slide (not cut) the muscles back together all the way from the sternum to the pubic bone. We sew the muscles together in many many layers with literally absorbable aka dissolvable barbed wire (see picture, below). We like these sutures over the permanent ones because they last as long as is needed for the muscles to seal then they go away so you don’t have to worry about them popping through the skin a few years later.
Helping Patients with Significant Diastasis Recti
Here is another story that we hear frequently: “I had 5 kids doc, am I a lost cause?”
This brings up two very important concepts:
- Sometimes we have to repair more abdominal muscles than just the up and down ones; this is a multi vector repair. At our practice you don’t leave until every muscle is fixed.
- A huge dramatic improvement is still worth it even if you don’t get perfectly flat.
This mom of 5 saw many docs – she told them she hated the idea of plastic surgery but she looks pregnant and its ridiculous already. She chose us because of our extensive experience in these cases.
How was the recovery?
- She was in the hotel with nurses for 4 nights and 5 days
- She had drains for 3 weeks
- She wore a garment for 4 months
- She was sore for a month
Anddddd she said “this was the greatest thing to ever happen to me, I literally went from looking 9 months pregnant 10 years after my last kid to bikini ready anytime, I would do it 100x over”
Why doesn’t everyone do multi vector muscle repairs?
Because recovery sucks and a lot of docs simply don’t have the manpower – we have 30 clinical members all working cohesive and collectively. We can be there and take care of our people. This is not a do an operation and see you later scenario, but we tell you this upfront and we take care of you after surgery, so far I have never heard of anyone in our office who wished they didn’t fix their tummy because it was sore for a few weeks.
Patient Photos
Lets take a look at a few more moms who just wanted to have their muscles fixed but trusted us to do the right operation for their goals which was a complete tummy tuck because doing the wrong operation is a waste of time and just a ridiculous concept.
Do it right and do it once.
Post Operative Pain
People and patients who know me know I tell the truth and speak the facts, this is going to suck, however the suck makes the final result better. Think about how good it must feel to get to the top of Everest compared to walking up a little hill in your neighborhood.
So how do we get through it? The first thing to know that when you have a muscle repair or diastasis recti repair with us is that we know how to help you get through it.
During surgery
We will place exparel which is the fancy numbing medication directly into your muscles.
We will give you Toradol – an injection into your arm muscle that is the strongest anti inflammatory there is (don’t worry you will be asleep while we are doing this).
We will give you intravenous Tylenol which until recently was only available at hospitals.
After surgery
The most important thing is having a private nurse who will take you to your hotel get you into the bed in the proper position and take care of you. Your friend/husband etc probably can’t, and for sure doesn’t want to, do this for you. Once properly positioned you will have your vital signs monitored and medication will be administered by a trained professional to help you get comfortable. Now we can’t make the pain zero but after 1000’s of cases we know how to get you comfortable. The medication, the garment, the drains, the leaking etc is complicated so let the experts do it because the last thing you will want to do the night of surgery is figure out your myriad of medications and instructions.
I find the soreness peaks day two, it doesn’t come on like a thunderbolt it kind of feels like you are doing an ab workout for 24 hours straight. We will try to get you on Tylenol gabapentin and Toradol by the third day and wean you off of oxy and valium, which most patients need at the beginning. Expect your abs and back to be sore for two weeks.
Listen, a lot of patients breeze through this but this is the average experience so be mentally prepared to go through it to get through it. If it was easy every person would look like you are going to look, but it takes self awareness and a desire for the most out of life.
Our morning visits will cheer you up and make you laugh. It’s a fun journey and we cant wait to start with you!