Tummy Tuck

Tummy tuck on large belly poses some unique challenges, which should be recognized prior to surgery to achieve the best results possible and to avoid or at least minimize the incidence of complication.


To shed light on the effects of tummy tuck on large belly, leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently posted videos and photos of a female patient who had this anatomy.


tummy tuck on large belly

Before and after photos of a patient with large redundant abdominal skin and fat rolls along her flanks and back—“cosmetic” issues addressed during surgery.


Aside from the apron-like abdominal skin, the patient also had “bra and back rolls” caused by excess superficial fat, which sits close to the skin. This is different from the deeper visceral or intra-abdominal fat that is linked to obesity and so the only way to eliminate it is through weight loss.


To eliminate the fat rolls along the flanks and upper and lower back, Dr. Smiley performed liposuction prior to the creation of tummy tuck incision.


“I always perform liposuction along the flanks first so I would know how much skin to pull and tighten during tummy tuck,” he said.


During liposuction, Dr. Smiley created several small puncture wounds where a hollowed tube called cannula was inserted and used to break up and remove the superficial fats responsible for the “unsightly rolls” that are more apparent in tight clothing.


Afterwards, the celebrity plastic surgeon created a flank-to-flank tummy tuck incision that was made very low, slightly below the pubic hairline, so “the resulting scar is hidden by the patient’s underwear.”


Dr. Smiley said bleeding is one of the issues in tummy tuck and so all efforts are made to minimize it.


“I pre-treat the abdominal area. Epinephrine is injected prior to the creation of tummy tuck incision; this is a drug that constricts the blood vessels to reduce bleeding,” he explained.


Keeping the patient’s blood pressure relatively low, which is possible because of general anesthesia (administered by board-certified anesthesiologist), also contributes to less bleeding and reduced risk of large fluid imbalance, Dr. Smiley added.


Dr. Smiley measures the thickness of the apron-like skin he removes during tummy tuck surgery.

In his previous Snapchat posts, Dr. Smiley said he only works with board-certified anesthesiologist to ensure patient safety.


(Note: Anesthesiologists not just administer numbing medications and sedatives; they also monitor the patients’ vital signs such as blood pressure, oxygen level, and heart rate during surgery.)


Meanwhile, Dr. Smiley removed a chunk of excess skin and fat that almost reached the patient’s knee; it also had a thickness of about 2 inches.


After removing the excess skin and tightening the abdominal muscle, he closed the wound in several rows so the skin would receive no or very minimal tension, which is the key to “favorable” scar, he said.

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Honest discussion and good communications during tummy tuck consultation are the foundations of any successful result, which is generally defined as a postop appearance that satisfies both the patient and her surgeon.


Leading Los Angeles plastic surgeon Dr. Tarick Smiley has explained the topics typically involved during the initial tummy tuck consultation.


tummy tuck consultation

  • Cosmetic goals and expectations


The patient must be able to explain in detail her cosmetic goals, allowing her surgeon to recommend ancillary procedures (such as liposuction of the flanks for a narrower waistline), adjust the incision pattern, and use the appropriate surgical maneuvers.


While a good surgeon respects and acknowledges his patient’s input, he must be able to explain certain limitations and caveats such as the appearance of the hip-to-hip scar, downtime, and risks associated with any surgery.


Meanwhile, patients who have unrealistic goals and expectations or cannot accept the ramifications that come with surgery are poor candidates for tummy tuck or any type of body contouring procedure.


  • Patient’s individual health


The patient’s candidness and commitment will play a critical role to the success and safety of her surgery. She must fully disclose her drug use (including supplements and recreational drugs), medical history and condition, previous surgeries, and drug allergies to her surgeon and anesthesiologist.


  • Incision pattern and other surgical maneuvers


During tummy tuck consultation, doctors conduct physical exam to determine the extent of pannus (loose abdominal skin), condition of the rectus muscle, navel appearance, shape of the flanks, and even the pubis. Not many patients realize that they will also need a pubic lift so the area will not detract from the smoother results.


After the physical exam, the surgeons will explain to their patients the length, shape, and position of their tummy tuck scar; all efforts are made to ensure that it will lie very low that it is easily concealed by the underwear.


  • Patient safety


A good surgeon must not only inform his patients about the benefits of tummy tuck, but also the potential risks. Nonetheless, he must be able to allay their concerns by explaining his contingency plan should problems arise during surgery or afterwards; and the preparation and surgical methods to prevent or at least minimize risk of complications.


Furthermore, reputable tummy tuck surgeons only conduct their operations in an accredited surgical facility and are always accompanied by board-certified anesthesiologists and highly trained medical staff during the operation.


  • Surgeon’s qualifications


Prudent patients can utilize tummy tuck consultation to their advantage. They must ask their plastic surgeons about their qualifications particularly relating to their board certifications (the American Board of Plastic Surgery is the gold standard), education, experience, and training.


Patients can evaluate the “artistic skills” of their surgeons through the before-and-after photos of their actual work and must insist to talk with at least two previous patients.


When looking for tummy tuck surgeons, it doesn’t hurt to seek second or third opinion until the patient has found the doctor she finds to be the “right fit.”


  • Patient’s responsibility and commitment


During tummy tuck consultation, the surgeons explain to their patients that the success of their surgery also boils down to their commitment. For instance, most known healing problems can be minimized by avoiding tobacco products, aspirin and other drugs/supplements with blood thinning effects, and poor lifestyle/diet well in advance of the surgery.


Furthermore, the patients should be committed to their recovery. The general rule of thumb is to avoid rigorous activities, smoking, certain drugs and supplements, and unhealthy diet (particularly foods high in sodium as they can lead to persistent swelling).

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Tummy tuck with pubic lift aims to achieve a smoother, more natural transition between the lower abdomen and the pubis. Oftentimes, massive weight loss patients not just suffer from apron-like abdominal skin (pannus) but also from sagging mons pubis that needs to be lifted at the same time as the surgery.


To demonstrate the impressive contouring effects of tummy tuck with pubic lift, leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently posted a series of videos on Snapchat showing a female patient who had sagging mons pubis and large pannus after losing a significant amount of weight.


tummy tuck with pubic lift

The patient is ecstatic with her final results as seen from the after photo.

While her body mass index was relatively high at the time of surgery, Dr. Smiley said that BMI should not be the only factor considered during the patient selection process.


“A good surgeon must be a good clinician, not a technician. Occasionally, patients with a relatively high BMI can benefit from tummy tuck provided that they are healthy, they have no chronic medical condition, and they are not expecting large weight loss in the future,” he said in the video.


(Note: Popular guidelines suggest that a normal BMI range is between 18.5 and 24.9, while a range of 25 to 29 is considered as overweight. Meanwhile, obesity is defined as 30 and higher.)


Despite having a relatively high BMI, the female patient’s pair of abdominal muscle, which runs between the sternum and the lower abdomen, was “relatively tight,” Dr. Smiley further explained. Nonetheless, he sutured them in the midline to further achieve a flatter appearance especially when she is “lying down,” he added.


Due to the extent of her pannus, Dr. Smiley used an extended tummy tuck technique in which the incision pattern went from flank to flank. Nevertheless, the resulting “curved” scar is positioned beneath the underwear area.


After tightening the muscle and removing the pannus, Dr. Smiley injected Exparel into the abdominal muscle to control the amount of postop pain. This numbing medication can provide comfort for up to four days, which in turn promotes healing.


When the patients feel less pain, they tend to move around more and breathe with more ease, all of which contribute to faster recovery, Dr. Smiley explained.


Before suturing the flank-to-flank incision, Dr. Smiley slightly elevated and anchored the mons pubis into the deeper tissue so it will not detract from the tighter and more refined lower abdomen.

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Extended tummy tuck surgery with PAL liposuction is generally reserved for patients who have lost a significant amount of weight, leaving them with large pannus or apron-like skin along their abdominal area. Pannus not just causes unsightly rolls beneath one’s clothing, but it also results in skin breakdown, non-healing irritation, and foul odor due to the trapped sweat and moisture.


Compared to the standard technique in which the resulting scar goes from hip to hip, the extended tummy tuck uses an incision pattern that goes a bit longer and so the scar may be visible along the flanks (or lower back).

extended tummy tuck with PAL liposuction

Leading Beverly Hills plastic surgeon Dr. Tarick Smiley says the length of tummy tuck incision must cover the “entire rolls of skin and excess tissue” to achieve a smooth and natural contour. Attempting to use a shorter scar technique despite the extensiveness of the redundant skin, meanwhile, will inevitably result in poor outcome due to the residual rolls.


In Dr. Smiley’s previous Snapchat post, he showed one patient who had extended tummy tuck and PAL liposuction as its ancillary procedure. The idea is to further contour the flanks and achieve a more feminine silhouette.


PAL, which is an acronym for power-assisted liposuction, uses a cannula (straw-like device) that has a vibrating tip that makes fat extraction more precise and quicker, thus leading to shorter operation, improved safety, and less surgical trauma.


He first performed PAL liposuction along the lateral aspect of the torso before placing a flank-to-flank incision. The idea was to remove the unwanted fats, allowing the skin to “shrink down” before removing the pannus through an extended tummy tuck technique.


Liposuction uses tiny round incisions about the size of a grain of rice. The goal is to remove the excess superficial fat beneath the skin. It is important to note that it cannot suction out the obesity-related visceral fat (it is positioned deep within the abdominal organ and cavity) that only responds to real weight loss.


After liposuction, Dr. Smiley proceeded to tummy tuck to remove the pannus and then performed muscle repair in which the idea was to tighten the pair of vertical muscle by suturing them in the midline, further contributing to the cinching effect on the waistline.


Before closing the tummy tuck incision (ensuring that the scar would lie very low that it is hidden beneath the patient’s underwear), Dr. Smiley injected Exparel, a drug that can numb the surgical site for up to four days.

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Mommy makeover surgery is any combination of body contouring surgeries performed simultaneously to improve the post-pregnancy body of patients. Common combination procedures include tummy tuck with liposuction of flanks, tummy tuck with some type of breast enhancement, and breast lift with implants.


The results of body contouring surgeries are near permanent, provided that the patient manages her weight through regular exercise and superb diet. It is important to note that fad diets and pills almost always don’t work long term and so weight management should be a lifelong commitment, says leading Beverly Hills plastic surgeon Dr. Tarick Smiley.


mommy makeover surgery pictures

After muscle repair, precise skin removal, and liposuction along the flanks, this patient is ecstatic with the results.

To shed light on the issue, Dr. Smiley has recently posted several mommy makeover surgery pictures on his Snapchat.


One patient received tummy tuck to remove the redundant skin between her mid and lower abdomen. To further achieve a flatter contour, the underlying muscle between the sternum and below the navel was tightened with the use of internal permanent sutures known for their additional strength (compared with absorbable sutures).


To further achieve a more feminine silhouette—i.e., cinching effect on her waistline—she also received liposuction along her flanks. Dr. Smiley started off the surgery with this procedure so he could tighten and pull more skin during tummy tuck.


When looked closely, the “after” photo (taken six months postop) reveals some muscle definition, which contributes to the more athletic but still feminine appearance of the abdomen. Furthermore, the new navel looks smaller and more proportionate compared with the “before” photos.


mommy makeover surgery pictures

Tummy tuck and breast lift give this patient a more feminine and more youthful physique.

The second sample of mommy makeover surgery pictures shows a patient who had tummy tuck and breast lift performed simultaneously. Due to her underlying anatomy—there is a great distance between the lowest rib and hip—Dr. Smiley was able to significantly “reshape the sides” or flanks, leading to the hourglass appearance of her body.


And as seen from the “after” photos, tummy tuck has given her a flatter tummy, a significant improvement from her previous barrel-shaped torso.


To further complement the cinching effect of tummy tuck, she also had a breast lift in which her actual breast tissue, not just the skin alone, was elevated and reshaped with the use of internal sutures. Aside from the perkier appearance, Dr. Smiley has also created better cleavage and additional upper pole fullness of the breast.

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Major tummy tuck surgery entails not just the removal of apron-like abdominal skin. To achieve more proportionate and natural-looking results, it typically combines other surgical maneuvers including liposuction (fat reduction), muscle repair, navel repair, and pubis lift.


Dr. Tarick Smiley, a celebrity Beverly Hills plastic surgeon, has recently posted a series of videos on Snapchat to demonstrate one case of major tummy tuck in which the female patient has large redundant skin following massive weight loss.

major tummy tuck

While the standard tummy tuck uses a hip-to-hip incision pattern, the patient has required an extended version, meaning the scar slightly extends into the side. Nonetheless, Dr. Smiley has made every effort to place it “beneath” the bikini area (i.e., very low) for its optimal concealment.


But prior to the removal of excess skin, Dr. Smiley had performed liposuction of the flanks in which the unwanted fat was removed with a cannula (straw-like device attached to a vacuum pump). This additional step would allow the patient to achieve a more slender, curvier side.


In the past, tummy tuck and liposuction performed at the same time was greatly discouraged due to the perceived higher risk of complications. However, recent clinical studies and surveys have shown otherwise. Provided that liposuction is not too aggressive (i.e., only a small amount of fat is removed) and it does not involve the area above the navel, the combo procedure is reasonably safe.


tummy tuck

Meanwhile, large volume liposuction or extensive liposuction involving the area above the belly button is ideally performed 3-6 months after tummy tuck to allow the body, particularly its blood supply, to recover from the surgical trauma.


Going back to the topic of major tummy tuck’s components, it is also critical to reshape the belly button, which might become distorted or enlarged following massive weight loss or pregnancy. In the video, Dr. Smiley is seen creating an incision around the inner rim of the navel to improve its appearance and to look more proportionate with the slimmer waistline.


To further create more proportionate results, the patient received pubis lift (the area is susceptible to sagging after massive weight loss). The idea is to encourage a smooth transition between the mons pubis and the lower abdomen.

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