“From your photos, it seems that you still have abdominal wall laxity, and when you lay down, this looks like it’s corrected. It also seems like you still have some excess subcutaneous fat between the skin and the muscle.”
That is me, on a virtual consultation last week, reading two photos a patient sent through my tummy tuck revision page. She had her tummy tuck a few years ago in another city. Standing, the abdomen still pushes forward. Lying down, flat.
She asked me if her first surgery failed. Not exactly. It stopped short.
The Part Nobody Repaired
Here is what I told her next, word for word:
“I see patients like you routinely, where the diastasis was repaired, that’s just the separation between the rectus muscles. But during pregnancy, or when patients gain weight and then lose it, the fascia is stretched throughout the abdomen, not just between the rectus muscles.”
The first surgeon fixed the midline. The stretch was everywhere. That is the whole story of most revision consultations, and it is why the bulge survives a technically successful operation.
She had also been working her core for two years on a trainer’s advice. “Performing core exercises will strengthen the muscle, but will not tighten the fascia.” I have written about that trap before, the sit up lie. Revision patients are its most frustrated victims, because they already did everything right once.
The Retightening
“That’s why I often recommend performing a triple plication, where I plicate from the sternum to the pubis, bringing together the fascia of the rectus, and I also plicate the obliques to the lateral edge of the rectus. This is called a triple plication, which in essence creates an internal corset, or waist trainer.”
Regular readers know my analogy for the triple plication. If you look at any waist trainer at any store, you’ll see that there are multiple seams in the waist trainer. Essentially, most surgeons are just making a waist trainer with one seam, versus using multiple seams, in this case three, to bring in the waistline.
In a revision, those two extra seams retighten the fascia the first operation never touched, laterally over the obliques, and they add something the patient did not have even on her best day after the first surgery: a waistline.
The triple plication is something I have published on. I can’t take the credit for inventing it, as it is something the Brazilian plastic surgeons described many years ago. But somehow, a lot of plastic surgeons did not implement it into their procedures. I’ve been performing it for more than seventeen years, which is exactly how long revision patients have been finding their way to my office after one-seam operations.
The Fat, the Skin, the Scar
Remember the second finding in her photos, the excess subcutaneous fat between the skin and the muscle. The wall repair alone does not fix that. All my tummy tucks include liposuction, especially of the anterior abdomen, waistline, and lower back, and I often combine it with Renuvion J-Plasma for skin tightening. A scar that healed wide or rides too high gets revised in the same operation.
So the revision is really three corrections in one: retighten the wall, remove the residual fat, and improve the scar.
Recovery, Second Time Around
Patients brace for a worse recovery than the first surgery. Then I tell them my numbers. I use Exparel injected into what we call a TAP block, which numbs the area for three days, and I’m happy to say that fifty percent of my patients experience no pain whatsoever. Most patients recover in two weeks to get back to normal activity, and six weeks for exercise, running, jumping, and heavy lifting.
Patients do feel a tighter abdomen after surgery. This time it stays tight standing up, which is the entire point.
The Two-Photo Test
Standing, then lying down. If the bulge disappears when you lie flat, the wall is the likely problem, and a wall problem has a surgical answer. If it does not disappear, the answer may be liposuction, or skin, or something else, and I will tell you which.
I trained at the Mayo Clinic and I teach plastic surgery at Texas Tech. Revisions are where that training earns its keep, because the first operation already spent the easy options.
Ready to Talk?
If your tummy tuck left you flatter lying down than standing up, send me the photos. Call (915) 590-7900, text 1-866-814-0038, or book online. #StayBeautiful
@RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook.
Companion reads: the clinical revision guide on agulloplasticsurgery.com, and the practice overview at swplasticsurgery.com.