In a previous blog I covered the surgical options for breast surgery after children. In this second blog in the series, I will discuss the abdomen. This is classically addressed with an abdominoplasty, commonly referred to as a “tummy tuck”.

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 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. Some women are left with fatty rolls in combination with the loose skin. Unfortunately, you can’t “tone” skin with exercise as some would have you believe.

Another casualty of stretching and hormones is the connection between the two rectus abdominis 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 diastasis or separation.

Separation of the rectus muscles not only has a cosmetic consequence 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 significantly separated result in abdominal bulging with muscle contraction. This results in “bleeding” of energy and weakening of core strength.

There is a growing body of literature showing the benefits of core stabilisation with abdominoplasty, regarding improving back and pelvic pain, urinary leakage and urinary incontinence.

So, in abdominoplasty following children, many elements can be addressed that cannot be improved, no matter how much one 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.

As with all procedures, the patient would ideally like a little operation and a big result. Certainly, there are more limited procedures that may be ideal in specific circumstances. A comprehensive consultation would be required to match the ideal operation to the patient’s circumstance.

So how long should a scar be for an abdominoplasty? 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 underwear or a bikini.

A specific circumstance in an abdominoplasty after children 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 in the appropriate patient can be corrected with a sub-umbilical abdominoplasty. This addresses from the umbilicus (belly button) down and has no scar around the umbilicus. 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.

Another specific circumstance is the patient who has relatively good quality skin (especially above the umbilicus), 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 an abdominoplasty should have completed her family. Having an abdominoplasty doesn’t affect the ability to subsequently get pregnant and carry full term, but certainly further pregnancies may undo the work of the surgery already performed.

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 cannot be performed if there has been a pregnancy within the prior 12 months (i.e. before the youngest child is aged one year).

As with all procedures, each patient is unique in both physical characteristics and what they are desiring to achieve. An in depth consultation is required to determine the appropriate operation to get the desired outcome.

Important Note:

The content on our page in general in nature and does constitute medical advice. Any surgery or invasive surgery carries risks and has a recovery time. Please refer to the procedure page for detailed information.