Tummy Tucks: Mini, Full, and Beyond (How does one choose?)

I am frequently asked whether a patient can have just a mini tummy tuck rather than a full in order to tighten loose tummy skin.  I thought it might be useful to discuss what a tummy tuck does (and what it does NOT do), and how we decide who may be able to get by with something less than a full tummy tuck procedure.

A tummy tuck refers to a procedure where an incision is made in the lower tummy beneath a swimsuit line, placed just above the pubic hairline and curving up towards each hip.

Since we will be freeing up under the skin and releasing the skin attachments so that we can re-drape the loose skin downwards and trim the excess that overlaps the incision, how long the incision will be depends upon how much loose skin there is to be removed and how far to the sides the laxity extends.

Full vs. mini

If the loose skin is only located below the belly button, the undermining or freeing up beneath the skin would stop at the belly button.  The skin would be pulled down and trimmed, and the only scar would be at the lower tummy under a swimsuit line.

This is referred to as a mini or lower tummy tuck.  There is no tightening of skin above the belly button.  If the patient has a stretched out belly button or loose or wrinkled skin above the belly button, these problems would not be corrected.

If loose skin at and above the belly button is present, a full tummy tuck is required.  The attachment of the tummy skin to the belly button needs to be released so that the upper tummy skin is not tethered at the belly button. Then pulling downward on the skin will tighten the upper as well as the lower tummy skin.

So, the main determining factor in deciding between mini and full tummy tucks are whether the belly button itself and the upper tummy skin above the belly button are stretched and loose.  If so, only a full tummy tuck will correct this.  If not, and the loose skin is entirely in the lower tummy, a mini alone is the answer.

The appearance of scarring

In a full tummy tuck, there is, in addition to the lower tummy scar, a small scar around the belly button where it is reinserted through the upper tummy skin that is tightened and pulled over it.  In this way, a stretched out and overly large belly button can be made to look much better.

I work hard to make a small, natural-appearing belly button with the scar mostly hidden in the shadow lines.  What happens to the hole where the belly button used to be attached  It is pulled down with the surrounding loose skin.

If there is enough loose skin above the belly button, unfurling this skin and advancing it will cause the old hole to move below the incision line and it will be removed.  If there is not quite enough laxity to remove this hole, it will be closed as a short vertical scar in the lower tummy.

Some plastic surgeons, trying to avoid this short vertical scar resulting from closing the old belly button hole, will raise the entire lower tummy scar to a higher location.  This allows the hole to be advanced past the incision line and removed.

I believe that this is a mistake.  The lower tummy scar may end up too high, and the pubic hair may be pulled up too high as well.  The distance from belly button to pubic hair may be abnormally short.  This just seems like a high price to pay in order to avoid a short vertical scar.

Tummy tucks and muscle tightening

There are some other factors to consider.  Oftentimes after pregnancies the abdominal wall fascia giving support to the abdominal muscles is stretched, the rectus (sit up) muscles are separated (this is known as diastasis recti), and when a woman stands up her tummy protrudes forward. Her abdominal wall is not properly supporting her bowel’s  That is why, in most full tummy tucks, we usually are tightening the fascia and muscles prior to tightening the skin.

Certainly there are some situations where this is not required. There are also some patients in whom this is the main problem causing them to seek treatment; sometimes this protruding fascia fills out their loose skin so that they are more aware of the protrusion than of the problem of skin laxity.

However, in most of these patients, once the fascia is tightened and pushed back where it belongs, the overlying looseness of the skin becomes more noticeable and the need for a full tummy tuck more apparent.

If the fascia and muscles are protruding both above and below the level of the belly button, a full tummy tuck with release of the belly button is needed to gain access to repair the upper abdominal wall.

If only mild fascial laxity is noted in the lower tummy at the time of a mini tummy tuck, this can be repaired, but one must be careful: over-tightening the lower fascia without tightening the upper fascia can lead to bulging of the upper tummy just like pushing in on one part of a balloon will cause another part to bulge out.

Tummy tucks and fat reduction

There is some controversy about removing fat at the time of a tummy tuck.  Certainly the fat of the lower tummy will be advanced with the loose skin and whatever portion advances past the incision line will be removed.

But what about fat that remains in the mid- to upper tummy? It is tightened downward, but it is not removed.  Although some surgeons will perform liposuction of the tummy at the same time as a full tummy tuck, there are dangers involved: there is a higher risk that the skin loses its blood supply and dies due to the trauma of liposuction.

Many of us, in order to avoid these serious risks, prefer to not liposuction the central tummy, the same area where the skin is undermined, at the time of a tummy tuck.  It can be safely done at an earlier stage a few months before a tummy tuck or some months after. And some patients have so much thick tummy fat that they are just not good candidates for a tummy tuck unless they experience significant weight loss first.

Somewhere in between a mini and full tummy tuck

Just for the sake of completeness, there is one variation of tummy tuck that lies somewhere between a mini and a full, and that is a modified tummy tuck with an umbilical float.   If someone has very mild laxity above the belly button, one can release the belly button from underneath, dividing the stalk where it attaches to the fascia, free up the skin above that point, repair the muscles if needed, and then advance the skin down and reinsert the belly button stalk to the fascia perhaps an inch lower.

This will allow some mild tightening of the skin above the belly button with no belly button scar and no small vertical scar below it. Unfortunately, most women are not candidates for this operation¦they need to have belly buttons that are high to begin with, not stretched out, and only very mild skin laxity above the belly button.

If lowering the belly button about an inch makes its location look too low on your tummy, you are not a candidate, I have seen patients who have had an umbilical float procedure whose belly buttons are about one inch above their pubic hair, this is not a good look and is very difficult to correct.