Tummy tuck explained: what actually happens during the surgery?

A tummy tuck, medically known as abdominoplasty, is one of the most comprehensive body-contouring procedures.

Many people think of it simply as surgery that removes excess skin from the stomach. In reality, depending on the patient's anatomy, the procedure can address several different structures: excess skin, abdominal wall laxity and, when appropriate, separated abdominal muscles. Liposuction can also be incorporated to refine the contour.

This is why two patients asking for a "tummy tuck" may receive very different surgical plans.

What is a tummy tuck designed to correct?

Pregnancy, significant weight loss, weight fluctuations and ageing can change the abdomen in ways that exercise alone cannot always correct.

The skin may become loose or hang over the lower abdomen. The abdominal wall may also become stretched, and the rectus muscles can separate, a condition known as diastasis recti.

During an abdominoplasty, excess skin is surgically removed and the abdominal contour is reshaped. When indicated, the surgeon can also repair the separation of the abdominal wall by bringing the inner edges of the rectus muscles together with sutures.

It is important to understand that a tummy tuck is body-contouring surgery, not weight-loss surgery.

What actually happens during the operation?

In a standard full abdominoplasty, the surgeon makes a horizontal incision across the lower abdomen. Its exact length depends largely on how much excess skin needs to be removed and on the patient's anatomy. The incision is normally positioned low enough to be concealed by underwear where anatomy allows.

The abdominal skin and underlying tissue are then elevated, giving the surgeon access to the abdominal wall. If muscle separation or significant laxity is present and repair is part of the surgical plan, the abdominal wall is tightened.

The upper abdominal skin is then brought downward, excess tissue is removed and the remaining tissues are carefully closed.

This is why a tummy tuck is considerably more than simply "cutting away some loose skin".

What happens to the abdominal muscles?

This is one of the areas that causes the most confusion. People often say that the surgeon "sews the muscles together". More precisely, when rectus diastasis is being treated, sutures are used to tighten the abdominal wall and bring the separated inner borders of the rectus muscles closer together.

Not every patient requires the same degree of repair, however. That decision depends on the condition of your abdominal wall and what the surgeon finds during assessment.

And one important distinction: diastasis recti is not the same thing as a hernia. They are different conditions even though they can sometimes occur together.

What happens to the belly button?

This is another question I am asked very often. During a standard full tummy tuck, the belly button itself is generally preserved on its underlying attachment while the surrounding abdominal skin is repositioned.

After the upper skin has been pulled downward and the excess removed, the surgeon creates an opening in the repositioned skin and brings the belly button through it. This creates the scar that you normally see around the umbilicus after a full abdominoplasty.

The appearance and position of the belly button are therefore an important part of planning an aesthetically balanced tummy tuck.

Where will the scar be?

A tummy tuck creates a permanent scar. With a standard abdominoplasty, there is usually a horizontal scar across the lower abdomen and a scar around the belly button. The length of the lower scar depends on how much tissue needs to be removed.

I think this is something patients should understand before surgery, rather than discovering afterwards.

The objective is not to have surgery without a scar. The objective is for the surgeon to position and design the scar appropriately while achieving the required correction of the abdomen.

Are there different types of tummy tuck?

Yes, and this is exactly why looking at somebody else's before-and-after photograph does not tell you which operation you need.

Full tummy tuck

A full tummy tuck addresses more extensive loose skin and can include repair of abdominal wall separation.

Mini tummy tuck

A mini tummy tuck treats a smaller amount of excess tissue, primarily below the belly button. The umbilicus is generally not repositioned.

Extended tummy tuck

An extended tummy tuck removes excess tissue across a wider area, extending further towards the flanks or lower back.

Fleur-de-Lis tummy tuck

A Fleur-de-Lis tummy tuck adds a vertical component to the usual horizontal excision. It can be considered when there is substantial excess skin in more than one direction, often following major weight loss. The trade-off is an additional vertical abdominal scar.

Reverse tummy tuck

A reverse tummy tuck is a less commonly performed technique in which excess skin is removed from the upper abdomen rather than the lower abdomen. The incisions are typically positioned within or along the natural crease beneath the breasts, and the upper abdominal skin is lifted upward rather than pulled downward. It may be considered in selected patients whose skin laxity is concentrated mainly in the upper abdomen, particularly when the lower abdomen does not require a traditional tummy tuck.

There are also variations of these techniques. Which one is appropriate is determined by your anatomy, amount and distribution of excess skin, abdominal wall condition, previous surgery and the result that can safely and realistically be achieved.

And where does liposuction come into it?

This deserves clarification because tummy tuck and liposuction are not competing procedures. They do different jobs and are frequently combined.

A tummy tuck primarily addresses excess skin and, where indicated, the abdominal wall. Liposuction removes selected deposits of subcutaneous fat through small incisions using a cannula.

When liposuction is combined with abdominoplasty, it is commonly referred to as lipoabdominoplasty. Liposuction may be used to further contour appropriate areas and improve the overall abdominal shape.

For some patients, liposuction alone is appropriate. For others, removing fat would still leave significant loose skin. And for some, the best surgical plan may involve both.

Why your consultation matters

You cannot choose the correct tummy tuck simply from a procedure name. During assessment, the surgeon needs to consider your skin, abdominal wall, fat distribution, previous operations, scars and overall anatomy before deciding what technique is appropriate.

This is also why I never believe in treating plastic surgery as choosing something from a menu.

My role during the consultation process is to help you understand the procedures, organise the information your surgeon needs and guide you through the process so that you know what is being proposed, why it is being proposed and what questions you should ask before making your decision.

Your final surgical plan is made with your surgeon.