Tummy Tuck: Do I Need Muscle Tightening?

Patients who develop loose abdominal tissue after pregnancy or significant weight fluctuations often develop laxity of the abdominal muscles. The rectus muscles at the front of the abdomen (the “six-pack” seen on very slim people) can spread apart, leaving a gap down the centre of the abdomen called a rectus diastasis.

It is often possible to feel this gap between the muscles, or if the muscles are tightened when doing a sit-up, a bulge might be apparent in the centre of the abdomen. Not every abdominal bulge is a rectus diastasis because a hernia can also cause a muscle bulge. A hernia is a more severe form of abdominal wall weakness because a full-thickness defect develops in the wall, through which internal fat (omentum) or intestines can protrude.

Also, some people have a bulging abdominal shape due to excessive fatty tissue around the internal organs, and in this case, tightening the muscles will not significantly flatten the abdomen. Prior to surgery, it might be necessary to obtain abdominal imaging such as an ultrasound or CT scan to determine the cause of the abdominal bulge.

During a tummy tuck, the rectus muscles can be brought closer together using a suturing technique called rectus muscle plication. Like wearing an external corset or shaping garment can help flatten and define the waist, an internal rectus muscle plication has a similar effect. Some surgeons only do a rectus muscle plication if there is a significant diastasis, but I do this procedure routinely during tummy tuck surgery, as I find that even on slim patients, the abdomen will be flatter.

Tecniques for rectus muscle plication

Many techniques have been described for rectus muscle plication, including multi-layered suturing techniques, permanent versus dissolving sutures, mesh reinforcement, etc. I prefer to use multiple, strong interrupted sutures to take tension off the repair, then do another running layer (like a baseball stitch) with slowly absorbing sutures that have tiny barbs. These barbs resist unravelling, which makes for an intense rectus plication.

In most cases, a rectus muscle plication is required to flatten the abdomen significantly. However, in some cases, even after the rectus muscles are sutured close together, there is residual laxity of the muscles. In this case, additional plication can be done on either side of the belly button, the lower lateral abdomen (external oblique plication), or both. I use my judgment during surgery to determine whether these additional muscle-tightening procedures will add to the final result. If a surgeon attempts to over-tighten the abdominal wall, the connective tissue layer (fascia) will simply tear, and no additional benefit will be achieved.

Complications from rectus muscle plication are very uncommon, but every surgical procedure has risks. Possible risks include but are not limited to bleeding, infection, chronic tightness or pain, internal organ injury, or failure of the plication. As mentioned above, rectus muscle plication will not flatten the abdomen of patients who are overweight and have a bulge due to excessive fat accumulation around the internal organs.