The Smart Patient Questions
Read any plastic surgery website and they give you the same advice. Choose a board-certified plastic surgeon. Ask to see pictures. Ask how many they have done. Ask about complications. But as soon as I see patients whip out these questions, I know they don’t understand it quite yet.
There is another list of much better questions, the ones the savvy patients know. These are the questions from people who are the real researchers, the patients that have seen five doctors, or who previously chosen bad surgeons. They really get it.
For those of you who don’t want to spend months of prep, let me tell you what they end up asking me. I love these patients, because these patients get it. Now it’s your turn to get it too! And a word to the wise… if your doctor gets defensive or negative with you getting it, then that’s the wrong doctor. Happy hunting!
What happened to Tara Reid? Or… what surgery does my abdomen really need?
A mini-tuck, a full abdominoplasty, a partial abdominoplasty, a rectus repair? Which one do you need, if any? There’s a lot of confusion between these options. And the answer starts with a quick anatomy lesson. The abdominal wall is layered, with first muscle, then fat, then skin. To have the best result, all layers of the abdominal wall need to be evaluated, and addressed. Here’s how to tell what you need… and it may not be an abdominoplasty!
The abdominal is composed of the two vertical rectus muscles down the center, with oblique muscles on the side. After pregnancy, the muscles can split, called a rectus diastasis. The muscles can be fixed through different types of incision. The most common is an abdominoplasty type incision, but for women who don’t have extra skin, smaller incisions can be used. For women with former C-sections (pfannensteil incision), the entire rectus diastasis can be done through the original C-section incision. Many plastic surgeons can’t do the whole rectus diastasis through that incision, but the really good ones can do the whole thing. This is termed, in the industry, as a full rectus diastasis repair, and it goes from your xyphoid (right under your sternum) to your pubis (at the bikini line). It’s not super easy to do through smaller incisions, but after a few hundred cases it gets a lot easier. The other, even smaller, incision that can be used is the belly button incision, also called the “umbilical incision”. This is performed with a special lighted scope so we can fix it through this tiny incision, and the scar is two centimeters inside the top part of the belly button. So just to recap: you don’t need a full abdominoplasty if you have a rectus diastasis. The skin and muscle can be addressed totally separately!
Ok, now fat. If fat alone is your problem, then losing the fat is the answer. Surgically, this means liposuction. Liposuction can’t be done on everyone though. If you have loose skin, and undergo liposuction, then the loose skin will look a lot worse. If the skin is in pretty good condition, but a little loose, then the fat can be removed with a radiofrequency treatment, which tightens the skin and fat so that it looks about the same as it did before the liposuction. What we don’t want to do is tighten the abdominal wall, AND remove skin, and then leave skin alone. This is a recipe for disaster, as the skin can really hang and look abnormal, the “Tara Reid” look for those of you that are old enough (see pic).
Skin is the final layer, and obviously, loose skin needs to be tightened or removed. The skin tightening techniques we have that are most effective are radiofrequency (RF), and they do work, but really only improve the skin by about 10-20%. So, sagging skin really needs more than just RF, it needs resection. There’s a lot of confusion about the full abdominoplasty vs. The mini-tummy tuck. In full abdominoplasty, the whole abdominal wall is pulled downward, all the way up to the xyphoid. That’s great if you have extra skin BETWEEN YOUR BELLY BUTTON AND RIBS. That’s tight, the extra skin ABOVE the belly button is only addressed with a full tummy tuck. If you have extra skin is BELOW the belly button only, only then can do a mini-tummy tuck. This is just a skin removal from the lower part of the abdomen, and none of the upper abdominal skin is removed. There is a lot of women that are kind of in between. They’ve got a little extra skin above the belly button; they’ve got a little extra skin below. Each of the cases needs to be carefully addressed. I often tighten the upper with a RF device and do a mini. Another option is the modified tummy tuck, which has a vertical incision. This is for the skinny girl with a moderate amount of skin, including above the belly button, and just a little too much skin for the mini, but not enough skin for the full abdominoplasty. Although we don’t like the incision visible, the abdomen is very flat and looks great!
Lisa Cassileth MD, FACS
