A: This is a common question and concern and one I think about when doing a tummy tuck in every women that has a c-section scar. I always want to use the c-section scar whenever possible for two reasons. The first is the one which concerns you and that of the unsavory cosmetic issue of adding another scar to the one you already have. But a more important consideration, and the one that I am most concerned with, is the survival of the skin between the two scars if the c-section scar could not be used as part of the tummy tuck. The intervening skin between these two scars may not have a good blood supply and could either not heal well or actually die…which would obviously create a significant after surgery complication. For this reason every effort is made to use a c-section scar in a tummy tuck and if you have as much loose skin as you describe this would not be a problem to do so.

Dr. Barry Eppley

Indianapolis, Indiana

A: A tummy tuck will only solve the problems that lie within its zone of tissue excision. When looking at the markings of a tummy tuck, you will see that the love handles and the pubic area lies outside the excision zone. However, the addition of flank liposuction is a part of most tummy tucks with the recognition that the goal is an extended waistline reshaping that wraps around to the back. Pubic or mons reduction, if needed, can be incorporated as part of the tummy tuck procedure whether it is reduced with liposuction or it is lifted as part of the tummy tuck design. You can see in planning a tummy tuck that the entire area must be taken into consideration to get the best overall result.

Dr. Barry Eppley

Indianapolis, Indiana

A: This is  classic question posed by many patients who have some amount of a stomach overhang. By definition, the description of an overhang signifies that there is a skin excess problem as well as too much fat. Liposuction alone will only magnify the prior result of what weight loss has done, it will deflate the overhang (aka pannus) further but it will still leave a flap of skin. You need this cut off by a tummy tuck. Liposuction is only useful in your case when combined with a tummy tuck, as it may help contour the waistline better to the sides where the tummy tuck excision does not go. 

Dr. Barry Eppley

Indianapolis, Indiana

A:  Your question is both a good and a common one. While many people have been successful with a fair degree of weight loss, they sooner or later ‘hit the wall’ and can just not lose anymore. Ideally, I tell my patients that if you are within 15 to 20 lbs of the weight they desire then a tummy tuck is reasonable. If you weigh much more than that then you should wait until you lose the extra weight so you do not create loose skin after surgery should you undergo more weight loss. Realistically, however, once the weight wall is hit for most people that is as far as they will usually get so that has to be taken into consideration. Most patients that I see for tummy tucks appear when they are frustrated with their ongoing lack of weight loss results. You should also understand that only the stretch marks from your belly button to you pubic hair line will be removed.  Any stretch marks above the navel will still be present after surgery, they will just be moved lower to a new position below the belly button.

Dr. Barry Eppley

Indianapolis, Indiana

A:  You are to be congratulated on your weight loss efforts and results. Reduction of fat can be rewarded with diet and exercise but your loose abdominal skin will not. Skin is not metabolically responsive like fat nor can it be toned like muscle. Do not waste your money and hopes on miracles in a jar or an exercise device. Only the manufacturer will benefit from your purchase. You will need to consider some form of a tummy tuck to get rid of this loose skin and tighten your abdomen. Whether the scar and the surgery expense is worth it merits a thorough discussion with a board-certified plastic surgeon.

Dr. Barry Eppley

Indianapolis, Indiana

A: While I have not seen a picture of you, your description alone of your belly has already answered the question. The idea of an overhang suggests a lot of loose abdominal skin. If some weight loss has not made a difference in its size, then you know exercise is not the final answer. Undoubtably some form of a tummy tuck is what you need. You can’t exercise off loose skin no matter how hard you try. Just ask any gastric bypass patient who undergo a lot more weight loss than you have. This is a surgical problem. When it comes to exercise and weight loss, however, I would recommend that you get in the best shape as possible for a tummy tuck. Preparing for such surgery, like training for an athletic event, will have you recover faster and may also help you achieve a better result.

Dr. Barry Eppley

Indianapolis, Indiana

A: Many women, who are not overweight, have developed a little pooch in their lower abdomen between their belly button and their pubis. Its relatively small size suggests that it is a non-surgical problem that can be exercised away. Usually I see women who come in after they have proven to themselves that they can not get rid of it on their own. Your wrinkled skin that sags when you bend over is the key in answering the question of whether this is a surgical or non-surgical problem. This tells you that there is too much skin and it will not shrink down on its own. Excess skin most certainly can not be exercised away. The only real solution is that of some form of a tummy tuck, particularly if you are using the criteria of how it looks when you bend over. Stretch marks are a sign that the elasticity of the skin has been destroyed and no recoil or shrinkage of it can occur. Only surgical removal will solve this loose saggy skin condition.

Dr. Barry Eppley

Indianapolis, Indiana

Everyone knows that a tummy tuck is the removal of skin and fat with muscle tightening to get a flatter stomach and better waistline. While it is almost always a very satisfying procedure, and many patients say afterwards they wish they had done it sooner, it is major surgery and is not just a weekend recovery. When considering a tummy tuck, be aware of the following considerations.

There are two basic types of tummy tucks. If your excess skin and fat is mostly located below the belly button, you may do just fine with a mini tummy tuck. Because the skin and fat removal is done below the belly button, there is a shorter incision that can be placed very low and the belly button is not moved. There is also a slightly shorter recovery with emphasis on the word ‘slightly’. If  the loose skin and stretch marks are above the belly button, only a full tummy tuck will do. With that comes a longer scar, a bellybutton scar and a longer recovery.

I have seen recent treatment approaches, particularly online, that tout a ‘scar-free tummy tuck’. There is no such thing and this is just marketing spin to say they are offering stomach liposuction. That raises a question that many people would like to pursue…liposuction instead of a tummy tuck for their flabby and sagging stomachs. That has become a popular request, particularly since Smartlipo (laser liposuction) technology has become available. While it is true that Smartlipo does have some skin tightening ability, it is quantitatively different than what many people need. Smartlipo tightens skin as measured in millimeters, most people need stomach skin tightening as measured in centimeters. With this understanding, it is easy to see that liposuction is not a substitute for a tummy tuck.

Liposuction, however, is very often a part of a tummy tuck. But it isn’t necessarily used to make the tummy part looking better. It is used to shape the areas outside of where the effects of the tummy tuck occur…the outer waistline and back. (i.e. muffin tops) A tummy tuck alone is a 180 degree or frontal torso change. By adding waistline and back contouring with liposuction, the results becomes more of a 270 degree torso change.

Dr. Barry Eppley

Indianapolis, Indiana

A: The request for abdominal panniculectomies , or an amputation of overhanging abdominal skin and fat, from insurance companies is very common. As a result, they have a very specific set of criteria to be eligible for coverage. These typically include the following; a pannus that hangs down onto the thighs (photographs are required), a documented history of recurrent skin infections underneath the pannus that requires topical medications, and a six month history of these recurring skin infections that has failed non-surgical treatments.

If a proper predetermination has been done and the insurance company has denied it, then there is nothing you can do. You are legally entitled to an appeal of which they tell you how to do it on their denial paperwork. But once an appeal has been denied then that debate is over. The insurance company controls what they will pay for or won’t pay for. Their determination is based on their policy requirements and the determination of their medical director. They obviously have determined, no matter how unfair you think it may be, that your abdominal pannus does not qualify. Your only option is to have the procedure done on a cosmetic fee basis.

Dr. Barry Eppley

Indianapolis, Indiana

A: When someone has a ‘spare tire’ around their middle, they could be referring to two basic types of waistline problems. The first would be fat only. They have thickness around the middle and waistline due to a fat collection but there is no loose or overhanging skin. The other problem is one in which there is both too much fat but with excess skin as well. Each requires a different solution. The fat only problem is treated by liposuction of which Smartlipo (laser liposuction) is my current choice. For a fat and skin problem, a tummy tuck or an abdominoplasty is needed. Often liposuction must be added to the tummy tuck to get those muffin tops which wrap around the sides of the waistline into the back.

You are correct in assuming that some surgical intervention is needed if you are not willing to try some weight loss efforts. Such ’spot’ body contouring changes require surgical treatrment.

Dr. Barry Eppley

Indianapolis, Indiana

A: While I have no idea what your tummy problem is or looks like, I can make a predictive statement that it is too good to be true. The Smooth Tuck is nothing more than a mini-tummy tuck wrapped up with a slick sounding name. Whether the smooth refers to how your tummy will look after or what it is like to go through and recover from is unknown to me. And I am not saying that it is a bad operation. The key question is whether this is an operation for you. Does the solution it can provide match the size of your problem? If you are better suited to a full tummy tuck, then this lesser operation will leave you disappointed no matter how smooth it sounds. There are some tummy tuck patients who are ideally suited for this approach but it is usually only a minority of them. You understandably are interested in something that sounds easier than the traditional tummy tuck approach. Just be certain that the real limitations of this marketed operation do not leave you with the opposite of your desired result…an unsmooth tummy that should have had a different tummy tuck technique done.

Dr. Barry Eppley

Indianapolis Indiana

A: The purpose of sewing the vertically-oriented rectus muscles in a tummy tuck together is to help correct one part of the tummy bulging problem. How much tummy skin and fat you have makes up the other components of the bulge. This muscle sewing is usually done from just under the rib cage in the middle (top of the inverted V) the whole way down to the just above the pubic bone. But it is up to the plastic surgeon’s discretion as to whether it is beneficial to cover this entire vertical length or not. More pain after surgery comes from more muscle sewing so there is no reason to do more  than is really needed. Not every patient needs the entire vertical length of the muscles swen together as tight as possible.

It is extremely common to see a different amount of improvement in the tummy bulge from that above the belly button to that below it.. The best result is seen between the belly button and the pubis because this is where the skin and fat have been completely removed and replaced with skin and fat from above. Between the rib cage and the belly button, there still may be some remaining bulge as this skin has just been pulled down and stretched but not removed. That is likely the reason you have some bulge remaining in this area, not because the muscle hasn’t been sewn back together. In thin women, this issue may not appear. But in those patients that had thicker amounts of fat under the skin in the upper abdominal area to begin with, the upper tummy area will not be as flat as the lower. This can be improved later with some liposuction to thin out the tissue thickness in this upper tummy area.

Dr. Barry Eppley

Indianapolis Indiana

A: While an actual examination with a plastic surgeon is the only way to know for sure, there are several key statements in your inquiry that give it away. The mixture of having had four children and a stomach that hangs over your pants indicates one key thing…you have too much stomach skin.While there no doubt is some fat under there as well, the key indicator of the choice between liposuction and a tummy tuck is how much extra skin is there. Liposuction can effectively remove fat but it has little skin tightening capability. A tummy tuck very specifically addresses the excess skin issue that exists from one hip to the other. Liposuction is quite often part of many tummy tucks in a complementary role as it helps reduce the muffin tops that most people have off to the sides of the tummy tuck. The combination of a tummy tuck and hip/flank liposuction creates a better waistline result that wraps around to the back.

Dr. Barry Eppley

Indianapolis Indiana

A: The Mommy Makeover has become a popular plastic surgery procedure amongst mothers between the ages of around 25 to 45, although it can be done at any age. It has gotten this catchy name because the procedures involved help reverse the effects that pregnancy has ravaged on a woman’s body. These procedures have been commonly done for many decades so they are not new. They have just been put together and ‘packaged’ for this specific set of female body problems, that being the breasts and the stomach areas. Breasts frequently have lost volume (deflated) and sag and the tummy has loose skin and stretch marks. The combination of breast reshaping (implants with or without a lift) and some form of a tummy tuck (with or without liposuction) is the backbone of a Mommy Makeover. They are almost always done together if a patient’s economics permits. While this combination of a breast augmentation and tummy tuck will have a dramatic change on one’s body, you must tone down the concern about getting back to working out as soon as possible. This is a setup for after surgery problems. It is understandable that you have an addiction to working out as you would not have gotten this far without doing so.  But that same addiction, which you think is good, is not so good after this kind of surgery. You must mentally plan on 6 weeks before getting back to working out like you are now. Remember that in a span of a few hours you are going to make changes that you can’t do by working out for the rest of your life. The risk is not worth it for a few extra workouts that, in the big picture, will gain you nothing.

Dr. Barry Eppley

Indianapolis Indiana

I am only 28 years old.  I want to feel young and beautiful again!  I know I deserve to and my husband deserves to have a wife who feels good about herself again.  My kids deserve a mother that feels comfortable enough to take them swimming. I would love to be able to eventually wear a bikini.

I know that some people may get depressed after they have surgery; whose to know how I will be after surgery.  Seeing that a lot of the causes of my depression are due to the way I feel about myself or view my body. I know surgery could not make my depression worse; if anything it will help improve the way I see myself and think about my body.  The only way surgery would worsen my depression is if I had surgery by a surgeon who did a lousy job.

I am not interested in looking fake.  I just want to look normal again. I would like to either be a full C or small D regarding my breast.

I suppose a ‘Mommy Makeover’ is what I am really looking for. What are your thoughts?

A: Of your situation and feelings, I understand completely and could not be more emphatic. Pregnancies can definitely take a toll on your body, and between the skin stretching and shrinking and the inevitable breast involution (loss of breast tissue), some women can not even recognize  the current skin and body that they now have.

As you have correctly pointed out, surgery is not a cure for depression. But at least it can improve one recognizeable and understandable cause of it…the way one looks. The body problems can definitely be improved and, hopefully with that, one’s self-image elevates. In my experience with women and these type of popular ‘Mommy Makeovers’, patient do report a dramatic improvement in their self-confidence and clothing options.

The classic ‘Mommy Makeover’ is some form of combined abdominal and breast rehaping plastic surgery procedures. This is usually a tummy tuck with or without liposuction and breast implants with or without a lift. In about a four hour surgery (or less), a dramatic body transformation can occur.

Dr. Barry Eppley

Indianapolis Indiana