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    What is a tummy tuck?

    A tummy tuck or “abdominoplasty” is a surgical technique used to remove excess skin from the abdomen. In Germany, this operation was performed over 24,000 times in 2019 (924,000 times worldwide) [1]. Operations to beautify the abdominal contour were first described in 1890 [2] and have been constantly developed since then.

    Depending on your needs, the tummy tuck can be combined with liposuction, for example on the abdomen or waist. If after pregnancy the straight abdominal muscles are weighted apart, the muscles can be brought back to their original position during the tummy tuck. There are three main types of abdominoplasty:

    • Abdominoplasty is also called abdominoplasty, upper abdominoplasty, or major abdominoplasty:
      During the procedure, the skin between the lower edge of the costal arch and the mons pubis is tightened. The excess skin between the navel and the mons pubis is removed. At the same time, stretch marks in the lower part of the abdomen are removed. The skin between the ribs and the belly button is loosened and moved downwards. The skin is closed in the bikini area, leaving a fine and inconspicuous horizontal scar. The belly button itself is not actually moved. Rather, the belly button is given an opening in the skin mantle that is tightened above it. After all, the fine scar around the belly button is barely visible.
    • Lower abdominoplasty also called mini-abdominoplasty or small abdominoplasty:
      In this type of tummy tuck, the area between the belly button and the mons pubis is tightened. The wrinkled skin is removed in a spindle shape. After the wound is closed, a scar remains which can be compared to a very fine caesarean section scar.
    • Tummy tuck in T incision technique also called Fleur de Lis tummy tuck:
      The technique is suitable for beautifying the silhouette with a sagging belly, also called fat apron. The technique allows tightening the skin on the abdomen in two directions: Horizontal and vertical. The advantage is that the skin is tightened very effectively and the waist is contoured. In addition, stretch marks and any scars from previous surgeries are removed along with the excess skin. The disadvantage of the Fleur de Lis technique is that a vertical scar remains in the middle of the abdomen.

    What is the Brazilian tummy tuck technique?

    A slim waist is generally perceived as particularly attractive [3]. In countries with tropical weather like Brazil, unflattering body contours cannot be concealed under several layers of clothing. These circumstances, coupled with the skill and creativity of Brazilian surgeons, may provide an explanation as to why most tummy tuck techniques have been described by Brazilian plastic surgeons:

    Saldanha Oswaldo Ribeiro has disseminated a technique that contours the waist through extensive liposuction, especially in areas where fat cannot be removed.

    Avelar Juarez Moraes has described several scar-saving techniques to leave very inconspicuous scars that can be easily hidden in the bikini area.

    Ricardo Baroudi has developed a special suturing technique to reduce complications (accumulation of wound water, wide scars).

    A special focus of Brazilian plastic surgeons is the harmonious alignment of the adjacent body region, for example, through a tightening of the mons veneris or an autologous fat treatment of the breast.

    A tummy tuck in twilight sleep or under general anaesthetic?

    The difference between twilight sleep and general anaesthesia is artificial respiration. Paralysis of the respiratory muscles, as caused by general anaesthesia, is no longer a prerequisite for painless surgery. Pain elimination techniques have evolved tremendously. Thanks to the precisely dosed administration of sleeping pills and painkillers, abdominoplasty can be performed comfortably and safely in twilight sleep [4]. The targeted anesthesia of the skin nerves of the abdomen ensures that you have less pain even after surgery [5]. As of 2021, over 15 scientific studies have been published confirming the comfort and safety of targeted anesthesia of the abdominal wall nerves before, during, or after abdominoplasty [6]. The benefits of twilight sleep with targeted nerve anesthesia are:

    1. They are more quickly awake and fit after surgery [7]. [8].
    2. You need less strong painkillers.
    3. After an operation in twilight sleep, you do not have to stay overnight in hospital.
    4. The risk of a blood clot interrupting blood flow in the leg (thrombosis) or lung (embolism) is lower with twilight sleep than with general anesthesia [9].

    What is rectus diastasis?

    The paired straight abdominal muscles run from the bottom of the ribs to the pubic bone. In the midline, the muscles are connected by a white strip of collagen fibers (Latin name: linea alba). During pregnancy, the growing child stretches the abdominal wall. Especially after several pregnancies, the connective tissue between the straight abdominal muscles can be stretched from one to two centimeters to over five centimeters. Since the tissue made of collagen is inelastic, the gap does not form back after pregnancy. As a result, the straight abdominal muscles take an arcuate course. The altered direction of progression is suspected to promote back pain [10]. With an abdominoplasty, the muscles can be moved back to their original position in the middle of the abdomen. There is evidence that rectus diastasis correction improves straight abdominal muscle strength and back pain [11].

    An almost invisible scar after a tummy tuck, how does that work?

    We pay special attention to an inconspicuous scar after an abdominoplasty. With special precautions, certain technical refinements and regular aftercare, all conditions are met for optimal healing:

    1. We take care to keep a fine line-shaped scar hidden within the bikini line.
    2. Thanks to a special suture technique (gathered suture), the scar is several centimetres shorter than in conventional abdominoplasty.
    3. A special suturing technique distributes the tension to the inner connective tissue and closes the skin without any tension.
    4. A simultaneous liposuction not only helps to achieve more beautiful contours, it also reduces tension and protects the skin’s blood circulation – two important prerequisites for good healing.
    5. We suture the wound with very fine sutures in the area of the subcutaneous tissue so as not to damage the skin surface.
    6. With microsurgical precision and optical magnification, the skin layers are aligned very precisely.
    7. The formation of an elongated navel a few millimeters deep leaves a scar in the navel that is barely visible.
    8. We inform and advise our patients when and how you can best support scar healing and what you should pay attention to.

    How does the belly change after pregnancy?

    Due to the constant increase in size of the child, the skin cells multiply and the skin mantle on the abdomen increases. If cell proliferation cannot keep up with the increase in circumference, the skin may tear internally. Stretch marks form. The adaptability of the skin decreases with age. Cigarette smoking and frequent sunbathing also damage skin elasticity. If the skin does not recede sufficiently, the sagging skin forms wrinkles around the belly button or above the caesarean scar. Scientific studies show that fat deposition inside the abdomen around the viscera increases after pregnancy [12]. A rectus diastasis also leads to an increase in the circumference of the abdomen. The shape and color of the belly button can also change unflatteringly due to pregnancy. Redistribution or increase of fatty tissue often also affects the mons pubis, back and waist.

    When can an abdominoplasty be performed after childbirth?

    A birth is accompanied by many changes. The abdomen and breasts are the areas of the body that change most significantly with pregnancy. The skin on the areolas, pubis, armpits, and around the belly button (linea nigra in Latin) may turn dark. After birth, the body metabolism and hormone balance changes. Many changes that occurred during pregnancy regress after birth. The dark discoloration of the skin fades after a few months. The collagen of the stretched skin is remodeled. The metabolic processes of the skin can be compared to those of a healing scar. Women who have given birth by caesarean section notice that the scar appears red and somewhat hardened in the first few months. After half a year, the scar becomes paler and softer. Metabolic processes that lead to the regression of the skin are similar to the remodelling processes of a scar. During the first nine months, the skin may recede somewhat. We therefore recommend waiting this period after childbirth before performing an abdominoplasty. Since any surgery involves the administration of medication, you should have weaned your baby by then. A life-changing procedure, such as a tummy tuck, should be performed under the best possible circumstances. Keep in mind that you should avoid heavy lifting and carrying for the first four to six weeks after surgery. Therefore, make sure that you can get support from your family, friends or colleagues during the first few weeks.

    When can I return to work after an abdominoplasty?

    When you can return to work after the abdominoplasty depends largely on the extent of the operation and the requirements of your professional activity. On average, our patients return to work after one to three weeks. After a mini-abdominoplasty, young and healthy patients can return to work at home after only a few days. If your job requires you to lift or carry heavy loads frequently and persistently, you should allow a recovery period of four to six weeks after correction of a rectus diastasis.

    When can I go to …. after a tummy tuck?

    Washing myself (with shower patches):On the first day
    Dressing and undressing:On the first day
    Walking in the house / apartment:On the first day
    Stair climbing (1 floor):On the second day
    Outdoor walking (10 minutes):On the second day
    Cooking (a small meal for myself):On the second day
    Housework (laundry, vacuuming the floor):After a week
    Doing the shopping (groceries):After four to five days
    Driving (up to 50 km):After four to five days
    Sexual intercourse:After two to three weeks
    Sports (one hour of light fitness training):After four weeks*
    Endurance training (cardio training):After six weeks

    *If rectus diastasis has been treated, abdominal exercise should be avoided for at least three months.

    The data are approximate values for orientation. Depending on the general state of health or the extent of the tummy tuck, there may be variations.

    What do I have to consider after a tummy tuck?

    • After the operation we would like to be convinced of the proper healing and your satisfaction. At the same time as the operation, we therefore also arrange the appointments for aftercare, which in individual cases can take place by video consultation.
    • Drains are not needed for every tummy tuck. If an increased bleeding tendency is detected, drains are used, which are usually removed the very next day.
    • On the first day after the operation you can shower as usual. It is best to use shower plasters to keep the bandages dry. It is recommended that you take your first shower just before your follow-up appointment so that the dressings can be changed afterwards.
    • The wound in the bikini area is sutured with fine threads that dissolve by themselves. Only at the navel the sutures are removed between the tenth and fourteenth day after the operation.
    • During the first two weeks, make sure that the hips are slightly bent when lying down (side position with legs drawn up or supine position in a stepped bed). Thus you relieve the abdominal wall and support the healing process.
    • The compression garment supports the decongestion. If a rectus diastasis has been corrected, the girdle protects the sewn straight abdominal muscles like an abdominal belt. We recommend that you wear the compression garments day and night for the first six weeks.
    • Scar healing begins immediately after surgery. Your surgeon sets the stage for fine and inconspicuous scar healing. By massaging the scars and applying silicone patches, you can make a significant contribution to beautiful healing in the weeks and months that follow. Refrain from sunbathing while the scar is healing so that the scar does not discolor.
    • The decongestant effect of arnica, bromelain, or of combination preparations such as Wobenzym has not been proven by scientific studies [13].

    When does a tummy tuck make sense?

    We recommend an abdominoplasty to beautify the contours of the abdomen. Abdominoplasty is particularly suitable for healthy women or men who suffer from increased fat accumulation and skin folds on the abdomen.

    Before a tummy tuck you should have reached your desired weight. Weight variations can affect the final result. If you gain weight, your abdominal circumference will increase even after a tightening. However, it is not the case that the liposuctioned fat tissue forms anew. There is also fatty tissue in the abdomen, around the intestines, that increases in volume with weight gain. Conversely, if you lose an extreme amount of weight after a tummy tuck, it can have a detrimental effect on the results of the surgery.

    Since severe overweight increases general surgical risks such as thromboses, embolisms and wound healing disorders, we advise against abdominoplasty for patients with a BMI over 40.

    An abdominoplasty should be performed under the best possible circumstances. This, of course, concerns the operation, which our entire surgical team meticulously prepares. The time after the operation also requires a certain amount of preparation. Avoid binding appointments during your recovery period. A perfectly executed operation will not lead to an optimal result if recovery or aftercare following the operation is not guaranteed.

    Occasionally people ask about the best time of year for a tummy tuck. The time of year does not affect surgery or healing. During the aftercare, you should above all be able to rest. A compression girdle should be worn for four to six weeks. The special fits as well as the light and breathable fabric of the bodices are usually not perceived as uncomfortable. At any time of the year, it is of course advisable to adapt to the weather by wearing appropriate clothing and air conditioning in order to avoid freezing or sweating after the operation.

    When will I see the results of a tummy tuck?

    Immediately after the removal of excess skin, the abdomen is already firmer and the contours are slimmer. Healing is an ongoing process. The following picture should give you an impression of the healing process:

    Operation DayDepending on the extent and state of health, you can stay overnight at home.
    Day 1Inspection of the wound, checking the correct fit of the bodice and renewal of the dressing. After liposuction, the dressings absorb the fluid from the tissue injections for the first 24 hours.
    Day 3On-site inspection of the wound and renewal of the dressing. Naturally, there is a slight swelling in the area of the operation.
    Day 6On-site visit or video consultation. Occasionally, bruises are now a little more noticeable as the blood spreads through the tissues and follows gravity.
    Day 10On-site inspection of the wound and renewal of the dressing.
    Day 13Removal of fine stitches from the belly button and instructions for scar care. Due to the breakdown of the blood pigment hemoglobin, the bruises are now orange-yellow. The colour initially changes to violet via green to yellow.
    41st dayOn-site visit or video consultation. As a rule, a clear reduction in swelling is already noticeable. You do not need to wear the girdle now. It is quite normal that the abdomen still feels a little numb.
    90th dayOn-site visit or video consultation. In 90 percent of the patients, the final result is 90 percent recognizable.
    180. DayOn-site visit or video consultation. The scars slowly become a little softer and paler. Scar healing progresses faster and better the more regularly and consistently you care for your scars.
    360. DaySite visit. About a year after the operation, it can be assumed that the tissue no longer changes. Now the before and after pictures can be compared and judged best.

    Can an abdominoplasty be performed if I am overweight?

    The answer to this question is, as so often, it depends! Already from a body mass index of 25 kilograms per square meter one speaks of overweight. The question about body weight is used to estimate the risks of surgery. There are a wide variety of factors that influence the risks of surgery. The interaction of these factors means that each patient must be considered individually and as a whole.

    The increase in surgical risks due to a limited state of health and the extent of an operation is scientifically well documented. The characteristics that influence the health status include: Age, body weight, cigarette smoking and concomitant diseases. The extent and duration of surgery are determined by the dimensions of the abdomen and the surgical goals.

    A risk is usually expressed as a percentage. A risk cannot be described in terms of “never” or “always”. Cigarette smoking is a risk. Smoking twenty cigarettes a day is more harmful than smoking one cigarette a day. Even someone who smokes only one cigarette a day lives more dangerously than a non-smoker.

    In young, healthy non-smokers, body weight therefore plays a subordinate role. Nevertheless, we do not recommend an abdominoplasty if your BMI is over 40.

    Can I get pregnant after a tummy tuck?

    Ideally, an abdominoplasty should be performed after family planning has been completed. Nevertheless, there is no need to fear any disadvantages in pregnancy after an abdominoplasty, neither for the expectant mother nor for the growing child [14] [15]. An abdominoplasty is also not an obstacle to natural childbirth [16]. Before pregnancy, we recommend waiting one year after abdominoplasty.

    When does the health insurance pay for an abdominoplasty?

    The costs of an abdominoplasty are only covered by health insurance in exceptional cases. The Social Security Code stipulates that the benefits provided by the health insurance funds must not exceed what is necessary. This requirement applies to both private and statutory health insurance. Medically necessary, for example, is the removal of skin folds in case of recurrent skin inflammations after exhaustion of all non-surgical treatment options. The removal of a disfiguring fat apron, which constantly attracts many glances, is also considered medically necessary. If a mental impairment is certified, the Medical Service of the Health Insurance Funds (MDK) usually recommends mental treatment, but not surgery. The benefits provided by health insurance companies are limited to what is medically necessary. Justifiably high demands on a cosmetic operation are not compatible with the goals of a medically necessary treatment. The assumption of the costs of a tummy tuck requires an application by the insured person.

    How long does a tummy tuck last?

    During an abdominoplasty, excess skin and fatty tissue is removed. Since the tissue does not form new ones, the result lasts a lifetime. Nevertheless, after a tightening operation, the abdominal circumference can change with pregnancy or weight gain. The fatty tissue around the abdominal organs, also called visceral fat, can increase with lack of exercise and poor diet and lead to an increase in circumference.

    Abdominoplasty or liposuction?

    Before treatment, your goals must be precisely defined, as each treatment method has different objectives. An abdominoplasty serves to tighten the abdominal skin. Liposuction reduces the volume of fat and beautifies the contours of the body. In the case of a protruding abdomen, there is usually both an increase in fatty tissue and excess skin. Therefore, we usually recommend combining an abdominoplasty with liposuction. In the case of a pot belly, the excess skin is in the foreground. In a bulbous abdomen there is often an increase in fat tissue and occasionally a rectus diastasis.

    What are the risks of a tummy tuck?

    Every treatment is associated with opportunities but also with risks. The likelihood of the risks changes with the patient’s health and the extent of the surgery. Your safety and satisfaction are our top priority. To keep the risks as low as possible, cigarette smoking should be avoided before and after surgery. In order to reduce the risk of thrombosis, the use of the contraceptive pill should be temporarily discontinued.

    The rate of abdominoplasty complications requiring treatment is roughly put at four percent [17]. General surgical risks include inflammation, secondary bleeding, thrombosis and embolism. Food supplements (omega-3 fatty acids, St. John’s wort preparations, etc.) and vitamin preparations (A, E) can impair blood clotting and increase the risk of secondary bleeding. We therefore recommend that you stop taking certain nutritional supplements four weeks before a tummy tuck.

    Specific complications of an abdominoplasty include numbness, usually temporary, wound water collection, and skin peaking. Careful planning and preparation as well as regular follow-up are important in order to prevent complications, detect them in time and treat them.

    Can a tummy tuck and breast lift be performed in one operation?

    Yes, in principle, cosmetic surgery on different parts of the body can be combined. Performing a tummy tuck and breast surgery at the same time is called a “mommy makeover” in the US. We recommend carefully weighing the combination of different interventions:

    When sitting or lying down, the flow rate of blood in the body vessels is reduced. This is why there is a risk of blood clots forming in the leg veins during air travel, for example. As expected, the risk of thrombosis is greater for long-haul flights than for short-haul flights. It is therefore not surprising that an operation that lasts, for example, one hour, has in principle lower risks than an operation that lasts 8 hours. Scientific studies have been able to prove this connection, and recommend not to exceed a surgical duration of six hours [18] [19].

    How is an abdominoplasty performed?

    • As a rule, the skin on the lower abdomen is sutured with self-dissolving skin threads, with the exception of the navel.
    • Depending on the findings, drainage tubes are inserted into the wound, which can be removed again after a short period of time.
    • The surgery time for an abdominoplasty is two to three hours, depending on the extent of the procedure.

    Anatomy of the abdominoplasty

    1 Straight abdominal muscle 2 Rectus diastasis 3 Saw muscle 4 Horizontal subdivision of the straight abdominal muscles 5 Lateral limitation of the straight abdominal muscles 6 Cutaneous nerves of the spinal cord 7 Deep lateral abdominal muscle 8 Muscle and cutaneous nerve 9 Artery of the abdominal wall 10 Hip 11 mons pubis 12 Vibration liposuction handpiece 13 V-bar 14 Remaining scar 15 Excess tissue to be removed 16 Waist 17 Water with adrenaline and narcotics

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    The author

    Dr. med. Stéphane Stahl

    “We provide you with extensive expert knowledge so that we can work with you to select the best possible treatment path.”

    Dr. med. Stéphane steel is the former director of the Clinic for Plastic, Reconstructive and Aesthetic Surgery / Hand Surgery at the Lüdenscheid Clinic. Dr. Stahl studied medicine at the Universities of Freiburg and Berlin. In 2011 he passed the European and 2012 the German specialist examination for plastic and aesthetic surgery. Further specialist qualifications and additional qualifications followed (including quality management, medical didactics, physical therapy, emergency medicine, laser protection officers, hand surgery) as well as prizes and awards. In 2015 he completed his habilitation in plastic and aesthetic surgery in Tübingen. He is an experienced microsurgeon, a sought-after expert and a regular speaker at specialist congresses. After a multi-stage selection process, Stéphane Stahl became a member of the American Society for Aesthetic Plastic Surgery (ASAPS), one of the world’s largest and most influential specialist societies for aesthetic surgery. His authorship includes numerous articles in respected peer review journals and standard surgical textbooks.

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