The Orange County Breast and Body Plastic Surgery Practice

Tummy Tuck Facts and Opinions

About Dr D:
Dr Di Saia (Dr D) is a plastic surgeon in solo practice (you see him each time you come to the office for an appointment) in Orange County California. His practice focuses on breast and body contouring. This FAQ is mainly for his tummy tuck patients as it reflects his philosophy of the procedure. If you are not a Dr D patient, you are not advised to implement any changes to your care plan without advising your surgeon first.

General Tummy Tuck Wound and Scar Care Especially For Dr Di Saia's Patients:
Just following surgery, you will have steri-strips (tapes glued to the skin) on part of your wound and xeroform (a yellow gauze) over sensitive parts (such as the belly button.) Leave the steri-strips in place. You may change the dry gauze over them to keep it clean (as needed). The yellow gauze may be left in place and moistened with Neosporin twice a day to keep it just moist. The drains will require a gauze cover to keep them from rubbing against the garment. Drain bulbs should be drained several times a day noting how much fluid has accumulated. Record drainage times/totals per bulb and bring this information to your follow-up appointments. This helps the doctor figure when you no longer need your drains. Keep the bulbs in the compressed position.

Showering is OK but get help the first few times. You may want to wait until your pain pump has been removed. Only shower when you are steady on your feet. Be careful not to inadvertently remove your drains or the pump. Place the xeroform on the counter top and moisten it with Neosporin when you replace it after patting your skin dry. The xeroform can be re-used until it gets dry or dirty. The steri-strips may still be moist after patting them with a towel. A hair dryer can be used to dry them better before replacing the binder and clothing.

Over the first few weeks Dr Di Saia will change your steri-strips and strip your drains to make sure they are working. The xeroform will be discontinued when no longer needed. He will remove the drains and pain pump when the time is right. You will see him twice a week for the first few weeks.

After you no longer have scabs on your wounds, you may start placing sun screen (SPF 15 or greater) below your clothing to keep the scars covered. Wear your garment to help support the healing and control swelling for at least the first 4 weeks. If you wish at 5-6 weeks after wound closure, you may start using Mederma or other silicone sheeting product a few times a day. Scar massage may help the scars heal with the most forgiving scarring. These generic instructions will be altered as needed when the doctor sees you in post-operative care.

Dr D's Wife's Recovery From Her Extended Tummy Tuck

General Comments / FAQ:
"What's the difference in a good Tummy Tuck vs a great Tummy Tuck? I like to use the example of getting a car painted. If you've got an old rust bucket and you take it to Maaco for the $199 special, when you get it back, it's going to look dramatically different and you'll say: 'Wow!' However, you take the same car to a custom shop and pay $2000, and then compare them closely, you'll see the huge differences. So, can you explain what a patient should look for to know whether their doc is a Maaco or custom shop kind of guy?"

A tummy tuck is not just one operation. The procedure is characterized in textbooks and can be performed in a "cookbook" fashion, but it has components that can be expanded upon [muscle repair, skin removal, fat removal] and tailored to the patient. It is the extent to which each of these is addressed and how they are interlaced with one another that determines the quality of the outcome. These things take time. You have alluded to the difference when you take the "custom shop" route. In Dr D's opinion, the biggest plus in the evaluation of a potential tummy tuck surgeon is his or her philosophy. Is this guy going to pull a two hour quickie on every patient or is he or she willing to spend the time to do the job right. There are always limitations in how tight a muscle repair can be, but Dr D has not to date had one rip and we make them as tight as they can be. In some patients we place three suture lines in a case in which most surgeons place one. In a moderate or larger procedure, that patient is scheduled as our only operation for that morning or afternoon. These operations take 4-6 hours in our practice and Dr D stays at the surgicenter until the patient is nearly ready to be moved to the overnight stay with her nurse. It is the surgeon's commitment to the case that reveals that you are in the right hands. Dr D is not cheap, but earns his fee. Ask your surgeon how much time your procedure might take and how he feels about making your tummy really tight. Also ask about a pain pump and who sees you after surgery and how often.

"How long is recovery after surgery?"

This varies with the size of your procedure as well as your individual pain tolerance and the activity to which you are trying to return. Most patients are back to light activity within a week. This would be walking and lifting light objects like a phone book. Heavy activity like weight lifting is best postponed for at least 6-8 weeks.

"OK, be honest with bad is the tummy tuck scar?"

Within a few weeks of surgery, the scar begins to appear dark and thick. This usually lasts several months. After that the wound remodels and improves. Most patients see the scar become more thin and pliable. It also usually fades. There are some patients who have a genetic predisposition to poor wound healing. Their scars can remain raised and fail to fade. This is infrequent but can happen. The techniques used in plastic surgery are designed to make poor scarring less common. The best thing to do it to look at images of your surgeon's previous patients at intervals from the surgery. Understand that your result will vary from what you see. The pictures are just there to give you a general idea. If you smoke or have smoked, you are at higher risk for the scar to become thicker and "ropier." This possibility is made smaller the longer you are able to not smoke.

"What can I do to help my cut heal with the best scar?"

Tummy tuck scars heal dependent much upon patient factors in addition to your surgeon's skill....genetics and smoking are important. Smokers heal less well particularly if they smoke as the scar matures. Fair skinned patients tend to get red scars that fade over time. Darker skinned people trend to get pigment in their scars that usually fades over time. Keep the wound out of the fact Dr D has his patients put sun screen under their clothing for a year. Sun exposure can encourage the scar to stay dark and/or red and UV light goes right through clothing. Smoking can delay wound healing and cause thicker scarring. The longer you hold off on the cigarettes the better. Silicone sheeting products worn over the scar for many months probably help the scar mature more quickly. They are relatively inexpensive. You shouldn't wear these until your surgeon tells you it is OK.

"What is this 'Skin Necrosis' I read about?"

Skin necrosis is the loss of skin usually from a poor blood supply. This loss produces wounds that can take a long time to heal. It is more common in larger operations and smokers. The process starts usually within days of surgery. The skin changes to a red and then dark red color over a few days after surgery. It may seem cool to the touch. Then it may blister and peel and then turn black over a week or two. Smokers who quit cigarettes are still at higher risk, but it may be reduced somewhat by quitting. It is debatable as to how long beforehand the cigarettes should be stopped. Necrosis varies in extent. In larger cases, areas near the pubes are affected. In lesser cases, areas of the scar can scab and take a long time to heal. In non-smokers this is very uncommon. Many surgeons believe that back liposuction may contribute to the risk. Dr Di Saia very uncommonly performs back liposuction at the time of a tummy tuck to reduce this risk.
Read also Abdominoplasty, Smokers and Wound Healing."

"Will it hurt when my drains are removed? Do I have to do this myself?"

Dr D removes your pain pump at around six days and the drains when they are no longer needed. He does this carefully so it does not hurt. In the case of an exceptionally squeamish patient, he even puts a little numbing shot in there to make it even less uncomfortable.

"How do you choose the incision? Do they heal straight?"

There are several different types of incisions. The body type of the patient helps determine the best type of incision, but Dr D always mark his in pre-op holding so the patient can see (before any drugs). The incisions usually heal the way we like them, but can get a little crooked as the tissues stretch and pull in healing. This is a little more predictable when the patient doesn't smoke and is in good health.

Read also "Basics of Abdominoplasty Surgery."

"How about the pain after tummy tuck? I am a chicken."

The really large cases are best served with an overnight stay in the hospital for better pain control. Most patients are on oral narcotic pain medication for a few weeks. During the last five years, we have added the use of implantable pain pumps to ease the discomfort for the first few days. This has virtually eliminated our need to hospitalize patients. We do keep patients overnight with a nurse for moderate and larger cases to offer leg vein clot prophylaxis and to support the recovery from anesthesia.

After a few days to weeks, the pain tends to be a little worse (more of an ache really) in the morning and evening. Individual pain tolerance has a lot to do with how pain might be appreciated in your particular case. "Overdoing it" can make the pain worse. It's like taking a step backward in time.

"My friend who had a Tummy Tuck has numbness in areas of her tummy? What will my tummy skin feel like after a tummy tuck?"

Right after surgery, the skin between the belly button and pubes will be pretty numb. The skin outward from there will be variably numb. Larger tummy tuck procedures will leave patients with more permanent numbness than the smaller operations. Numbness will resolve in areas giving way to a "pins and needles" sensation as nerves heal. So this funny sensation is actually a good thing indicating healing is in progress. The larger operations commonly leave patches of numbness near the belly button and central lower incision. Sensory recovery is usually complete within 6-18 months.

"After TT (with muscle repair) does one still have to 'suck in' or 'hold in' their tummy muscles to keep the flat appearance?? I am 8 weeks post surgery and if I don't hold in the muscles it looks like I need another TT! Is that normal???!! (I look great if I hold it in, but 4 months pregnant if I don't--before TT I looked 9 months pregnant!)"

Every abdominoplasty is different. This is why Dr D always indicates to his patients that improvement is virtually certain. We have yet to meet a patient who wants her extra tummy tissue back. :) A flat abdomen is not always in the cards however. This has to do with the differing characteristics of each woman's abdominal tissues. Some tissues relax more than others after the tightening. Some patients with weak or thinned fascia have tissues that will not accept tightening beyond a certain point or they literally rip. Dr D stops short of this point so that the repair holds. In some patients, he has placed three or four different suture lines to get the improvement. These can be along the center of the abdomen or along the sides or both. Some patient's tissues relax on the table visibly. More suture lines can be placed in this circumstance. Others patient's tissues relax after surgery. Improvement is relative to the tissues we have available for repair. Absolute symmetry and an absolutely flat tummy are rarely possible. We can usually get pretty close though.

Some patients have scarring and distortion from previous surgery. They frequently cannot obtain the same quality results as other patients. Abdominal tightening occurs at both the level of the muscular repair and the removal of skin. Abdominal muscular tightening is performed depending upon the patient's health. Some ladies don't have the best lung function. Tightening of the abdominal wall when taken to extremes can impair breathing. This is of course discussed before surgery. When lung function is really poor, Dr D does not offer the patient an operation.

"Does one have long term problems such as swelling, pains from having a Tummy Tuck and/or liposuction? Are there on going problems or is there a recovery period after which a woman should feel normal again with no swelling,pains etc...? "

Tummy Tuck surgery is not one operation but several. It represents one of the largest groups of procedures a plastic surgeon can perform for a patient, but not every surgeon does the same degree of surgery. Patients have varied issues that can be corrected....muscle repair, fatty removal, skin removal, etc. There is not consensus as to what should be "fixed" in any individual patient.

Some patients also heal more rapidly than others. On average patients are pretty much back to normal at 3 months. In a really large case this might be closer to 4-5 months. Swelling in our patients is not incapacitating due to our selection of patients and Dr D's technique.

Occasional pains (really muscle spasms) are fading in strength and frequency at 2-3 months. The binder helps with these. Most of our patients are back to work in a few weeks, so these aches are down to the level of "soreness" by then in most patients.

"My surgeon has recommended a 'Modified Tummy Tuck?' What exactly dos this mean?"

It means you need to ask more questions. Remember tummy tuck surgery is not one operation; it is a family of related operations. The main components of these procedures are skin and fat removal plus or minus abdominal wall tightening and/or liposuction. Some surgeons refer to anything other than a full tummy tuck as a modified tummy tuck. Suffice it to say that the term "modified tummy tuck" means different things to different surgeons. Ask what exactly your surgeon plans for your case.

"I have heard about 'Swell Hell' and it scares me. How much swelling is there after tummy tuck surgery? How do drains and garments help?"

Swelling varies with the size of your procedure as well as your overall health. The use of drains helps make it less severe and may assist in healing by preventing fluid buildup. An abdominal garment helps here also providing support to keep pain down. Fluid buildup may also be more severe in patients that have more surgery; a reason that in large abdominoplasty procedures Dr D does not add other procedures on that day.

Surgery is trauma and trauma contributes to fluid collections. For similar reasons, patients with larger procedures may need drains for longer than in smaller procedures. "Swell Hell" is a term patients have coined. It can be much less than they indicate, but will vary between patients and surgical techniques.

"I understand that the lymphatic drainage system is interrupted during the tummy tuck surgery and that is why we tend to swell for so long. My PS told me that when I have a scar revision my healing will be a quite easy compared to the TT because it is a skin only revision. My question is about the lymphatic system - will that be cut through again in a skin only revision? Will I experience the same kind of swell hell again or will the swelling be limited to immediately following surgery around the scar area.

Swelling after surgery relates to the size of the operation...larger operations tend to cause more swelling in a given patient. A simple scar revision (removal of the scar only) would therefore tend to cause less swelling than a full tummy tuck. If liposuction is included, then swelling may be increased.

"I may have several procedures for loose skin after weight loss. There's always swelling after the surgery, right? Can this swelling cause more loose skin?"

This would be unlikely although when swelling resolves it tends to show looseness of the skin that was hidden before. Take into account that only so much of the loose skin can be removed at any one operation. Also, those whose skin has become lax can certainly become lax once again after surgery. Re-operative rates from surgery can be low, but not zero for this reason even when you've got a top notch surgeon. This is one of the reasons that Dr D tends to be conservative when predicting what any operation might accomplish in this group of patients.

"Will I have Staples or Sutures? Is there a Difference?"

Personally, Dr D has not used staples for skin closure since he completed his first residency. Closures with staples are fast but can lead to increased scarring..."Frankenstein Marks." Some of the "bargain basement" surgeons use them probably to limit operating room time and therefore decrease the expense.

"After Tummy Tuck, is the pubic hairline raised?"

The possibility of your pubic hairline being raised post-operatively relates to how tight your closure is. This varies with the technique used as well as your own geometry. It is not common. Most affected women adjust their waxing schedule and the problem is fixed.

"Should I try to lose weight before my Tummy Tuck?"

Weight loss is a factor in cosmetic the results of that surgery. Dr D recommends that patients achieve a weight that they feel that they can maintain prior to surgery. You don't want to starve yourself down to a weight that you can't maintain only to gain a significant amount of weight after that operation. That gain might increase your chances of changing the quality of the surgical result. Then you may desire a revision later down the line.

"Will I lose Weight after Tummy Tuck?"

Abdominoplasty is not a weight loss procedure. This should not be the primary motivator for surgery as weight loss usually slim to modest.

"What is this Arnica Montana? Does It Work?"

Arnica Montana is an herb that's supposed to help reduce bruising. It may be helpful although Dr D really hasn't seen a difference with its use. It shouldn't hurt. It can be picked up at health food stores as it is not considered a drug (at least in California).

"I want a lot of work done, but I turned 50 this year and am afraid that I'll heal slower, or have more risks than a younger woman."

Age is an issue in wound healing from surgery, but your age is only one of many factors. A history of cigarette smoking (present smoking is the worst), pulmonary or cardiac disease, steroid use, diabetes, radiation exposure, and other surgery are also important in assessing patient risk in Tummy Tuck surgery.

Years ago, Dr D operated for the oldest woman for whom he ever performed a Tummy Tuck. She was 73 and in excellent health and she did wonderfully.

"I am scheduled for surgery for what I thought was gonna be a FTT/MR (Full Tummy Tuck with Muscle Repair.) My insurance company is paying and has approved me for CPT 15831, which they told me was an abdominoplasty. Well, I went for my pre-op yesterday and my PS is telling me that he is giving me a panniculectomy and only removing some skin below my BB and doing only the lower muscle repair. He said that it would cost me an additional $3,000 cash for him to do the FTT with the upper muscle repair. How do I convince my PS to do the TT/MR. My IC said it was for an abdominoplasty so I don't know what the problem is!"

Currently, medical insurance pays pretty poorly for most plastic surgery. Our billing shows an average 33% payment relative to our 'Usual and Customary' fees by health insurance. They also on occasion do not pay at all after the surgery has been performed. Pre-approval letters routinely state: "This is not a guarantee of payment." The basic tenet upon which insurance companies deny plastic surgery after the fact is "necessity" or lack thereof. In essence, they claim that the service was cosmetic and therefore is the patient's responsibility. Be careful trying to get your insurance to cover cosmetic work. It might not be all that cosmetic when it is all said and done.

Abdominoplasty is a primarily cosmetic procedure. Pregnancy does contribute to the development of the pannus, but as you may see resection of the pannus (panniliculectomy) and true abdominoplasty are very different operations. I suggest that you discuss the planned operation carefully with your surgeon to make sure that you are OK about the potential outcome.

Dr D does not do abdominoplasty or even pannus resection routinely under insurance for these reasons. "Non-payment" is too very costly to the practice as it is hard (of not impossible) to get patients to pay after the fact when insurance companies "opt out." At insurance rates, 33% for a tummy tuck is simply not revenue positive.

P.S. Doctors that own Surgical facilities might be an exception here as they collect not only their surgeon's fee, but also a share of the facility fee which is usually much larger. This makes the realized revenue higher for the case of course.

"I know PS's say to lose the weight before a TT but in my case could I not get a FTT now to strengthen the stomach muscles and get that weight off my stomach to improve my posture and mobility? Right now, I literally grab ahold of my stomach flab and lift up and the pressure on my back is somewhat alleviated."

To minimize the potential need for further surgery, we recommend that patients stabilize their weight before surgery. The reason here is that post-operative weight loss (or gain) leads to a high rate of revision. Getting your weight to a weight that you feel you can maintain minimizes the desire for additional surgery later.

If you are unable to lose weight before surgery, you would need to be assessed for your current state as to what a tummy tuck might do for you. On the issue of strengthening muscles, the tightening we do at surgery doesn't result in strengthening. This is an aesthetic operation. There are patients that are better able to exercise in their post-operative condition (hopefully after they heal), but this is probably due to the removal of the pannus that "gets in the way."

Why Choose A Tummy Tuck?

A Good Dr D Tummy Tuck After Four Months

Take A Look :)

"What about Tissue Glue? Can this limit the need for Drains?"

Fibrin Glue has been used in surgery for a few years. It is a purified clotting factor derived from blood products. Newer forms of it are cloned which reduces infection risk. In abdominoplasty, there are surgeons using these "tissue glues" to encourage the tissues to adhere to the abdominal wall after surgery. There is no good scientific evidence that this improves the outcome and it could plug drains leading to increased risk of seroma. At present, we are not using it.

"What About Dermabond? I heard that this 'tissue glue' limits the need for sutures and might make the scar better."

There are at least two "Crazy Glue" cyanoacrylates on the market in the US at present. Dermabond was the first and is the best known. Dr D has used these in the dressing (under the skin strips) in a few cases. It made no difference. Dr D would chalk this one up to "mostly hype." There is a lot of this in plastic surgery right now.

"What are 'Dog Ears'? Are they always present after a tummy tuck?"

Dog Ears are folds in the skin and fat. Think of the tissues corrected in Tummy Tuck Surgery:

(1) Muscle (sutured and tightened)
(2) Fat and Skin (removed)

Dog ears are folds or "bunching up" in these tissues at the border at which "corrected" tissues meet "minimally or uncorrected" tissues. They will usually appear as the swelling from surgery decreases over the first few weeks. Large ones will be visible immediately after surgery particularly in "short incision" cases.

Dog ears can be minimized by making incisions longer. Small ones can be revised in the office under local six months to a year after surgery if they still persist. Time usually results in improvement especially in small cases. Dr D has not needed to go back to the operating room to revise a dog ear in one of his prior patients in ten years. Some of this is technique. :)

"How long do I need to wear that damn Binder? Is it really necessary"

Tight-fitting garments after tummy tuck actually help control swelling and assist in the healing process. They also help decrease pain by supporting the muscular repair until the body binds it with healing over 4-8 weeks. Wearing a binder or tight-fitting girdle is also key to decreasing drainage allowing for the removal of drains earlier. Our patients are instructed to wear the binder for at least 4-6 weeks. The tightness of the garment is adjusted in post-operative visits. There is an optimal tightness.

"When Can I Take a Bath or Shower after Surgery?"

A shower is "do-able" a day or two after but you will need help. Consider placing a chair in the shower and having someone there to help you. If you are still "woosy" from the medication, wait until you are not. If you still have drains, a patient of mine thought up a trick using two shoe laces put tied together with some pins for the bulbs to keep them up near the neck. Wear it like a necklace. You need to be careful not to pull your drains out by mistake. On bathing, we recommend patients wait until the wound is pretty solid (no holes) and the drains have been out at least ten days. If you are uncomfortable with any of this, there is always the easy sponge bath.

"I may have a hernia. Is this repairable during surgery and do insurance companies consider this?"

Health insurance billing is often confusing. The real question you are probably trying to ask is whether or not the insurance company will make your operation less costly to you by covering a hernia repair if you need one. The answer requires a look into medical billing. The major determinants are whether the insurance company pays or not and the rate charged by the operating facility. Operating room bills can be huge and are generally quite large for insurance business. Cosmetic cases scheduled for operation at surgery centers often take advantage of severely discounted cash rates. When insurance enters the picture most operating facilities bill at their higher insurance rates. Frequently your share of cost for an insurance case is several times that which you would have paid if the case were strictly cosmetic (because of this rate difference).

The kicker here is that insurance companies have a nagging tendency to deny payment on claims months after the procedure. The operating facilities then often stick the patient with the insurance rate as they have utilized their billing services and realized expense in doing so. This may leave the patient with a much larger bill than if she had paid cash in the first place.

The net of the equation here is that small hernias in our practice get repaired without billing the insurance. Large late bills after cosmetic surgery are something we try our best to avoid. Other practices in other states certainly may disagree here (or may have ownership interest in the facilities we are discussing.)

"I feel a lump under the healing scar. It doesn't hurt and is not red. Will it go away?"

It is best to have your surgeon look at anything new that develops over the first few months after your tummy tuck. Lumps can develop in the area that is healing. These usually represent areas within the wound that are healing. Sometimes fat can become encased in scar and form hard lumps under the skin. Most of these lumps become much smaller or disappear over 6-12 months. Very rarely they are removed by another small operation. I haven't had to do this for one of my patients in over ten years. :)

This page is specifically designed for Dr Di Saia's patients. Patients of other surgeons should get the advice of their own surgeon before doing anything listed here. Follow your surgeon's plan. This is not medical advice.

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© John Di Saia, MD... an Orange County California Plastic Surgeon Dr D

(949) 369-5932