Dr Cruises Philosophy

Joseph T Cruise, MD's Tummy Tuck Philosophy

Loose hanging abdominal skin is one of the most frustrating board certified plastic surgeon Dr. Joseph Cruiseproblems for both men and women. This is because it persists no matter how much diet and exercise you do. Those who have had an abdominoplasty continue to enjoy an extremely high level of patient satisfaction. Simply put, there is no other way to get rid of this excess skin.

Why does skin laxity occur? Often it is a combination of things but the top of the list includes child birth. During pregnancy the abdominal skin is often stretched beyond its ability to snap back. This leaves the women with loose skin as well as stretch marks.

Another common reason is significant weight loss especially after a Gastric Bypass surgery. Many patients who have received gastric bypass surgery believe all the problems will be solved. Unfortunately, they are often left with large amounts of skin that need to be removed.

The other common reason is simply growing older. With age the skin looses its elastic recoil and stretches. Regardless of the reason, abdominoplasty is an extremely effective way to get rid of this excess skin. The key is to make the result as beautiful as possible with the least amount of scarring.

When you have your tummy tuck consultation make sure your plastic surgeon is considering all the options so that your abdominoplasty addresses your problems specifically.

My goal is to walk you through my thought process as much as possible, almost as if you were sitting in my office. It is meant to educate you so that you know what to expect. Also, it allows you to speak more clearly with your plastic surgeon so that you can better convey what you are looking for. Keep in mind there a many excellent plastic surgeons who do things slightly different. Still, the principles remain the same:

  1. Do the least Invasive abdominoplasty necessary
  2. Liposuction with abdominoplasty
  3. Tightening the abdominal muscles
  4. Improving waist line
  5. Creating a natural belly button
  6. Keeping the incision as low as possible
  7. Pubic lift
  8. Post op scar management

Do the least invasive abdominoplasty necessary

There are many advantages to doing the least invasive tummy tuck as long as the problem areas are corrected. This includes smaller incision, often less obvious incision, less down time and often less money. Remember, however, it is not wise to try to "get away" with a smaller procedure when a larger one is necessary.

Let's go over the different types of tummy tucks outlining their advantages and disadvantages.

  • Mini Tummy Tuck
  • Standard Tummy Tuck
  • Extended Tummy Tuck
  • Circumferential Body Lift
  • Mini Abdominoplasty (AKA Mini Tummy Tuck)

Mini Tummy Tuck

The Mini Tummy Tuck is my favorite version and, in my opinion, under-utilized. It is the the least invasive abdominoplasty. More importantly, it allows me to place the scar so that it is completely unnoticeable with even the most revealing lingerie. My mini tummy tuck has evolved to the point where the incision lies right at the top of the pubic hair. The length of the incision is within the pelvic bones.

Mini Abdominoplasty Incision. Notice how low and short the incision can ideally be positioned.

The best thing about the mini abdominoplasty is that there is no incision around the umbilicus. To me, and my patients, this is very important as the umbilicus with standard plastic surgery technique is usually the most tell tale sign of a tummy tuck.

The ideal candidate for this procedure typically has redundant skin and an abdominal 'pooch' located below the umbilicus. Laxity of the abdominal wall below the umbilicus (a. k. a. abdominal pooch) can be dramatically flattened with a mini abdominoplasty.

Mini Abdominoplasty. Correction of abdominal 'pooch'.

4 months post-op. Patient mid. 30s, Mother of 2


The mini tummy tuck is ideal when the excess skin is located primarily below the umbilicus. If there is some redundant skin above the belly button, but not enough to perform a standard tummy tuck, a modified mini tummy tuck may be performed - with release of the umbilicus. Here, the umbilicus is released from its cord and is moved down slightly, usually less than an inch. By doing this, the excess skin above the umbilicus is tightened. This nicely changes the belly button from a horizontal appearance to a more youthful vertical appearance.

The abdominal muscles below the belly button can still be tightened with a mini tummy tuck. This is more than acceptable as this is where the vast majority of the muscle looseness is located.

The mini tummy tuck has its limitations. If you lower the belly button too much it will look unnaturally low. This can only be determined during your consultation with an experienced plastic surgeon.

Mini Tummy Tuck with Umbilicus Release. Patient 39-yrs old. Three months post-op. Notice the tightening of the excess skin below and above the belly button. Notice the more youthful appearance of the belly button with no scarring around it.

Standard Abdominoplasty (Standard Tummy Tuck)

The standard abdominoplasty is the most common abdominoplasty. It does an excellent job in eliminating the excess skin and 'abdominal pooch' both above and below the umbilicus especially in women who have given birth. It is necessary when there is a significant amount of excess skin within the upper abdomen. Remember, the determining factor of whether you need a mini or a standard abdominoplasty is the amount of excess skin ABOVE the belly button.

Standard Abdominoplasty Incision.

By definition, the umbilicus has to be transposed in a standard abdominoplasty. This means that the excess abdominal skin is pulled down so far that a new hole must be created in the pulled down skin to accommodate the umbilicus. Remember, the cord of the umbilicus stays attached to the abdominal wall.

To me the incision around the belly button is the most tell tale sign of a tummy tuck. Therefore, it is critical to do everything possible to make it look un-operated on. The key is to make sure the it is small, recessed, and as natural as possible. This is done by creating a flap inferiorly to hide the incision. In addition, it helps to suture the incision inward to create an "inny" so that the incision is hidden inside.

Standard way of placing an incision around the opening for belly button. The incision is made in the shape of simple circle. The incision does not recess inward, therefore, is more apparent.

Modifications can be performed to hide the incision inside and allow the new belly button to be much more attractive and natural appearing. (Courtesy of Joseph T Cruise, MD)

Joseph T Cruise, MD's Standard Abdominoplasty.

Frontal view shows significant improvement in 'hour-glass' waist.

In addition, a properly performed standard abdominoplasty will help create an hour-glass waist line. The only thing a standard abdominoplasty will not do well is treat fat deposits in the flank area. This can usually be addressed with liposuction.

I routinely perform liposuction of the flanks and abdomen at the same time as the tummy tuck. This circumferential approach truly creates a dramatic result. The nice thing about removing the excess skin and fat is that it can not come back once it has been removed.

Liposuction of the abdomen must be done cautiously when done at the same time as a tummy tuck so that the blood supply to the skin is maintained. The results, however, are nothing short of remarkable. Liposuction allows me to thin the abdominal skin in addition to flattening it. Liposuction allows me to create a sexy, hour-glass shaped waist with a flat stomach. This is what defines a well performed tummy tuck.

Notice marked improvement of pooch below umbilicus and flattening of stomach.

Mother of two with loose skin and significant rippling from previous liposuction. Notice how the abdominoplasty not only tightens the skin but, also, reduces the rippling. Notice natural appearing belly button. On the right picture notice the flattening of the abdomen.

Extended Abdominoplasty (Extended Tummy Tuck)

The extended abdominoplasty is exactly what it sounds like. It is a standard tummy tuck with an incision that extends farther out laterally over the hips .Sometimes, the incision may need to go toward the back.

Extended Abdominoplasty Incision.

Extended Abdominoplasty Incision From Behind.

The determining factor is how far the hanging skin goes. The incision must go at least to this level.

Extended Tummy Tuck on a 37-y-o male after massive weight loss.
Six months post-op. Notice that the incision extends as far as the crease does on the
pre-operative picture.

As I mentioned above, I try to keep the incision as short as possible. But, when it is necessary, the incision must go as far as the abdominal crease goes. Once again, what always goes through my mind is, "how can I keep this incision as low as possible." This is very important so that the incision is not visible in ordinary pants. The incision, however, has to go higher in an extended tummy tuck compared to a standard tummy tuck. This may make it difficult to wear low rise jeans as the incision may possibly be visible when bending over. Normal clothing should be fine.

The amazing thing about the extended abdominoplasty is the dramatic improvement these patients undergo. These patients are used to having this hanging skin wrapped around their waist. Often, they feel trapped by it. They tell me that it doesn't even feel like it belongs to them; as if it were a foreign body. When this is removed they feel as if a weight as been removed. This weight is emotional as much as it is physical.

Notice the dramatic improvement in waist line and abdominal flattening.

Extended Abdominoplasty. Notice the significant improvement of waistline, hips, and flanks.

The extended Abdominoplasty gives hope to the patient who is not a candidate for a standard abdominoplasty. Gastric bypass patients frequently fit into this category.These patients are especially satisfying to me. They have already been through a very long journey during their surgery and subsequent massive weight loss. Still, they feel trapped by this excess hanging skin that just will not go away. Often, this is demoralizing. Fortunately, procedures such as the extended tummy tuck can get them to where they feel comfortable and even excited about their body.

Circumferential Abdominoplasty (Body Lift)

The circumferential body lift is a very aggressive procedure and is reserved for those patients with a significant amount of redundant skin that goes all the way around to the back. The body lift is being done more and more because of the increase in gastric bypass patients. It can produce dramatic improvements in these patients. The down side is that it is usually done in a hospital setting. This is because it usually requires an overnight stay to make sure everything is OK.

Circumferential Body Lift Incision.

Liposuction with Tummy Tuck

The most common area that needs liposuction in tummy tuck patients is the flank. The flank area is the area that begins above the hips and extends toward the back right above the buttock. The reason why it is important to address is because it may look more pronounced AFTER a tummy tuck than before. Once the stomach is flat and the excess skin is gone than the flanks become more obvious.

The other area that often needs to be addressed is the abdomen itself. Many tummy tuck patients do not realize that the tummy tuck itself will not get rid of the excess fat. This is why it is best to get closer to your ideal body weight before considering abdominoplasty. The less fat you have the better your results will be. Typically, I tell patients that they should be within 30lbs of their ideal body weight. This does not mean that heavier people can not benefit from the procedure because they can. But, the best results are with thinner patients.

As I mentioned above, liposuction of the abdomen at the same time as a tummy tuck increases the chances of wound healing problems. It may even cause skin death. This is because with a tummy tuck, the skin is separated from the underlying abdominal wall. The skin at the bottom is dependent on a blood flow that comes from above. If this area is liposuctioned at the same time then the blood flow may be jeopardized. For this reason, I do not aggressively perform liposuction at the same time. This is not to say it can't be done. If it is done, you must know the risks. I do routinely, however, perform liposuction of the abdomen with mini-tummy tucks. This is because the blood supply is not compromised as much as with a standard tummy tuck.

Abdominal Muscle Tightening

Why do we need to tighten the muscles? The most common reason is because the muscles have been stretched and separated by pregnancy. Normally, the rectums abdominus run parallel to themselves from the rib cage to the pubis. During pregnancy, the expanding baby separates these muscles in the midline. During abdominoplasty the muscles can be sutured back to where they should be.

Abdomen and Separation of the Muscles after Pregnancy

Restoring Muscles to their Pre-pregnancy Position

Click link for demonstration of muscle tightening and tummy tuck procedure .

The abdominal muscles can also be tightened with a mini tummy tuck but only the muscles below the belly button. This is more than acceptable, as it is below the belly button that the problem is most significant.

Tightening the muscles has the additional benefit of improving the bulge located just below the belly button. It can not, however, correct bulging do to intra abdominal fat. This can only be corrected with diet and exercise.

Improving Waist Line

An abdominoplasty does a spectacular job of flattening the stomach and getting rid of loose skin. It is not specifically designed to contour the waist. With modifications, however, the waist line can be improved. It is done be purposefully gathering the skin laterally and pulling it inward toward the midline. This gathering can significantly improve the waist but only on patients within approximately 30 lbs of their ideal body weight. With heavier people the contouring is less effective.

Notice significant improvement in waist.

Perhaps the most powerful way to improve the waist line is to have liposuction of the flanks at the same time. Often, this is very important as both men and women tend to accumulate fat in this region. By removing this fat not only is the waist line improved but so is the contour of the buttocks.



Example of liposuction of flanks and how it improves the overall shape of the waistline and buttocks.

Creating a Natural Belly Button

The most tell tale sign of a tummy tuck is the incision around the belly button. For this reason, I have spent a great deal of time figuring a way to make it so the new belly button appears natural. The reason why it's so important is because the lower incision can be easily hidden with almost any clothing. The belly button, on the other hand, is often exposed with sexy or fashionable clothing. A poorly performed belly button will make it so you can not wear revealing clothing.

Standard way of placing an incision around the opening for belly button. The incision is made in the shape of simple circle. The incision does not recess inward, therefore, is more apparent.

Modifications can be performed to hide the incision inside and allow the new belly button to be much more attractive and natural appearing. (Courtesy of Joseph T Cruise, MD)

A natural appearing belly button can be accomplished and needs to be a priority with your plastic surgeon. The key is to make sure the it is small, recessed, and as natural as possible. This is done by creating a flap inferiorly to hide the incision. In addition, it helps to suture the incision inward to create an "inny" so that the incision is hidden inside.

Low Incision Placement

Standard plastic surgery technique does not emphasize the importance of where the incision is located. It makes sense that the lower the incision means the more hidden it becomes. This is why I like the mini-abdominoplasty so much. It allows me to put the incision much lower than a standard abdominoplasty. Even a standard tummy tuck incision can be kept low with proper technique. You should emphasize to your plastic surgeon to keep the incision as low as possible.

Before and After of 42 yr old woman after mini-tummy tuck. Notice how the incision is easily hidden even by low rise underwear.

Pubic Lift

Some people who are considering abdominoplasty also have a sagging pubic area. The area around the genitalia has dropped similar to how a breast sags. If you do not have this problem then you will not know what I am talking about. Those who do have this problem are often too embarrassed to talk about it. The good news is that this is often significantly helped with abdominoplasty.

See before and after tummy tuck pictures for men and women, Orange County plastic surgeon, Joseph T Cruise, MD

During an abdominoplasty the entire abdomen is tightened. This means that even the pubic area is elevated back up into its proper position. If you have this problem be sure to bring this up at your consultation. 

Post-op Scar Management

Having worked in a Burn Unit for over 3 years, I understand the importance of scar management. It is important to follow the instructions as it will effect the overall result. I outline my post op regimen in the after the procedure segment of this web site.