The Holistic Approach to a Flatter Tummy (and a stronger back!)


  • Lose weight (by diet 80%  exercise 20%!!! or bariatric surgery if you qualify)
  • Core exercises (incorporating it into aerobic exercise and resistance training)
  • For some, extra help with surgery like abdominoplasty

Things to know…

  • Simple anatomy of the ‘belly’
  • It’s not always just fat
  • No, not everyone can have a flat tummy after tummy tuck

What is abdominoplasty, aka tummy tuck?

One of the most common plastic surgery operations is abdominoplasty (aka tummy tuck). This is often performed to get rid of the excess fat and skin from the abdomen. However, it is often not the only solution to a flat tummy!

There are different types of abdominoplasty and not one type is suitable for everyone. To name a few, apart from the standard abdominoplasty, there is the mini-abdominoplasty, the extended abdominoplasty, lipo-abdominoplasty (where liposuction is also performed), and if we go around to the back circumferentially, i.e. 360 degree, we call this Body Lift or belt lipectomy (different designs but similar technique).

In a nutshell, the standard abdominoplasty involves removing the lower excess abdominal fat and skin and this requires raising the upper abdominal skin (and fat) flap all the way to the ribs margin, and in the process, detaching the belly button (umbilicus) from the skin (while keeping it on its stalk); using sutures to tighten the rectus sheath (like an internal corset), before ‘pulling’ the abdominal skin flap downwards; get rid of the excess tissue and suture the large wound close. A small hole is then made over where the belly button lies, bringing the belly button out and suture it to the skin.

Simple anatomy 101

Belly aka Abdomen

  • The “Inside”
  • The “Wall”
  • The “Outside”

Firstly, the “Inside”…

Our ‘belly’ is a complex structure. On the ‘inside’, or in medical term, the intra-abdominal cavity, we have organs such as the gut, liver, gallbladder, etc etc…  in addition to lots of blood vessels (including the ‘big blue vein’, the inferior venae cava, IVC, that brings blood back to the heart from down below), and FAT!  I specifically mentioned the latter 2 because they are relevant to this topic, especially when comes to surgery. More about these later…

The “Wall”- Abdominal wall (+ back muscles, pelvic floor and diaphragm)

Our ‘inside’ is protected and covered by the abdominal wall, which is essentially part of our ‘core’. This strong multi-layer structure consists of 3 muscle layers on the sides, that form a tough connective tissue (rectus sheath) centrally and it surrounds the 2 rows of rectus abdominus muscle (the commonly known ‘6-pack’ muscle) lying side by side. It joins at the midline where it is known as the linea alba. This layer is very important to keep things ‘in’. When there is a hole or defect at the sheath, you get a hernia (a sac with content from the intra-abdominal cavity). When the sheath is weak, you get a bulge, that may resemble hernia. This is a very common finding in people with weak core.

The anterior Core of muscles and fascial sheath

Figure 1

Many now also include other parts of the ‘wall’ as core muscles and these include the back muscles (multifidus and erector spinae), the pelvic floor and diaphragm as they form the roof and floor. They are sort of interconnected and the pelvic floor strengthening is often incorporated into core exercises. As for the diaphragm, we are constantly using it to help us breathe. I do encourage doing gentle ‘abdominal or belly breathing’ exercises as a start during recovery after abdominoplasty. This utilizes the diaphragm as we gently reactivate our abdominal wall during breathing.

The ”Outside”

On the outside, there is skin, and in between the skin and the sheath, there is fat. This subcutaneous fat has 2 layers, a superficial layer and a deep layer. There is a thin fascia called the Scarpa’s fascia in between these 2 fat compartments. This fascia is much thinner than the rectus sheath and may not be easily found in some people.

Subcutaneous fat is different from intra-abdominal or visceral fat (also known as belly fat), not just in location, but also their physiological functions. Visceral fat (~10-15% body fat) generates hormones and contribute to inflammation. To reduce belly fat, you need to eat right and increase physical activities (i.e. lose weight)!

Figure 2: The 2 subcutaneous layers of fat- Superficial and deep

So, what is removed or repaired during abdominoplasty?

In liposuction and abdominoplasty, we only reduce the subcutaneous fat and not the belly fat. The main target area of fat removal is the deeper fat that sits above the core. We do need some fat under the skin, as we do not want shrivelled and indented skin and the blood vessels network within and under the skin has to be preserved!  

How much skin and fat we remove depends on several factors.

Safety is the number one concern. ( Firstly, DO NO HARM!)

  • The more we remove, the tighter the closure. If it is too tight, there is a higher risk of the wound breaking down, forming ulcers that can take a long time to heal. They may need further surgical debridement and skin graft if large.
  • The tighter the closure, there is more risk of losing some skin and fat left behind due to skin or fat necrosis (dead tissue).
  • If we leave the skin too thin, the same problem may occur.
  • We avoid or perform minimal liposuction at the ‘danger zones’ with important blood supply to the abdominal skin to ensure there is adequate blood supply to the skin and fat we leave behind for closure.
  • If you smoke or has diabetes, the risk of complication is even higher. (that is why I do not operate on current smokers!)

So, there are many factors to consider and most surgeons tend to err towards the side of caution and be a bit more conservative. It is harder to replace what is gone, and easier to take more out in the future if needed.

What we can remove and which areas get liposuction..

What is rectus diastasis (or Diastasis recti)?

Although the abdominal sheath is tough, it can stretch out and expand too, e.g. during pregnancy. After pregnancy, it can take up to 3 months to heal with less gap between the 2 rows of rectus abdominus muscles. However, in women with many children or with large babies relatively to her size, significant rectus diastasis (Diastasis recti) can occur. The middle area between the 2 rows of rectus abdominus muscles widens as the tummy enlarges with pregnancy. If it has been stretched too wide or for too long, the sheath stays lax, like an old rubber band that has been overstretched, despite countless of core strengthening exercises. An abdominal bulge may occur that mimic a ventral hernia and this area of weakness can affect the back significantly due to lack of core strength to support the back.

When we plicate the rectus sheath (or tighten the internal corset), we can reduce the girth and strengthen the sheath to a certain extent. Over-tightening can cause indigestion (the gut doesn’t like to be squeezed too much!) and also increase risk of developing clots in the legs (deep vein thrombosis, DVT). This may also be worsened by the use of postop compressive garment. The IVC (that big blue vein) has a relative low pressure and when it is squashed by the guts and organs due to the tightened sheath, the pressure increases, and the blood flow from the lower limbs slows and doesn’t flow back to the heart as easily. When blood flow slows or becomes stagnant, risk of clots in the legs increases! This is dangerous as the clot can later travel to the heart and lungs, causing pulmonary embolism, which may be fatal. Therefore, blood thinning medication is often given early, during or shortly after the operation to prevent the formation of the clots in the leg.

If there is hernia or bulge, if it is small and does not involve the gut, this can be repaired at the same time. For bigger hernia involving the bowel, we often seek help from our general surgeon colleagues who often deal with the gut.

The above is just a snippet about what can go wrong in surgery and why. It is important to choose a qualified plastic surgeon, who is accredited to do the surgery and is safe. After all, we want to make you look good and we also want you to heal well with no complication!

Can the repair of rectus diastasis solve my back problems?

Obviously, there are many causes of back pain but the most common type of back pain is non-specific muscular pain or muscle strain. This does not include radicular or nerve type pain (sharp, or burning pain, or like electricity, that goes down the leg).  Strengthening the abdominal core helps support the back. Hence, many women who have had the repair feel a significant difference with alleviation of the non-specific back muscle pain. By removing the excess abdominal pannus (and hence excess weight) that put strains on the back also helps ease the load on the back.

However, downtime or recovering after surgery is long as it takes at least 6 weeks for the area of repair to be strong enough to withstand loading, e.g. heavy lifting, driving, core exercises. I do encourage regular core strengthening exercises after 6-8 weeks. A healthy diet is also paramount to help with healing and recovery, as well as for our general wellbeing!

Figure 3 a & b- Before and After abdominoplasty


Now, back to a flatter tummy.

I do believe that, in order to achieve that, you have to deal with all 3 components of the belly. Yes, surgery can ‘speed things up’ but ultimately, and for best results, you also have to work on the core strength for support, and to lose the belly fat, best by having good and balanced nutrition. Many studies have shown that reducing the belly fat prevents diseases such as diabetes, cardiac problems, etc. and also promotes our overall wellbeing!

Back to the basic principles… DIET and EXERCISE.

You can’t lose belly fat by doing sit-ups alone. For total-body fat loss, use a combination of aerobic exercise and resistance training, such as lifting weights. In addition, eat a healthy diet with plenty of protein, fibre and portion control — all of which are proven to help reduce body fat.

DIET- If you search the internet, there are many websites that provide good and simple information on what to (or not to) eat.

For example, Fitnesspal is a good source

If it is too confusing and you do need help, consult a dietitian or nutritionist who can assess your diet and provide a lot of useful information. They can also work with you to adjust and enhance your diet with healthier food.

As for core strengthening, again, there is a wealth of information in the web. Core exercises train the muscles in your pelvis, lower back, hips and abdomen to work in harmony. This leads to better balance and stability. I thought I’d share some useful advice from my personal trainer, Tash.

Tash says….

As discussed above, there are a number of ways to reduce belly fat. Regardless of whether it’s done surgically or not, a holistic approach to maintaining belly fat reduction and good core strength is important. Not only for ensuring the longevity and results of your procedure but also for your heart health, physical health and general wellbeing. A lot of people think that to have a strong core means you need to have a 6 pack and sub 15% body fat when in reality, it’s what under the 6 pack that counts even more when it comes to protecting your organs, your back and your results.

Our core or as Beryl put it, the abdominal ‘wall’ serves two main functions:

  1. To protect our vital organs; and
  2. To keep us upright, mobile and stable – this in turn protects our spine from injury.

The abdominal walls main ‘strength’ components are your transversus abdominis or the ‘inner layer’ and the rectus abdominis or the ‘outer layer’, also commonly known as the ‘six pack’. Strengthening both layers of your core is important and there are a few solid exercises that will do both and have you reaping the benefits after a few weeks of consistent training.

Exercise One: Alternating Bird-Dog

How: kneel face down on a mat with knees directly under hips and hands flat on the ground directly under shoulders (table-top position). Maintain a straight back by keeping eyes on the floor in front of your hands. To create stability, grip the ground with your fingers and toes and once stable in this position start by lifting one hand and the opposite foot just a few centimetres off the ground. If this feels steady and you can keep hips and shoulders level with the floor, fully extend the opposite arm and leg out, squeezing your buttocks as you lift the leg up. Swap sides and repeat.

Easier: set yourself up as per the above guidelines but instead of extending arms and legs, start by lifting just the legs. If this still feels unstable, start by lifting just the arms. Swap sides and repeat.

Perform a total of 14-20 repetitions per set for 2-3 sets with a 20-40second rest between sets.

Exercise Two: Plank

How: lie face down on a mat and place forearms on the mat with elbows directly underneath your shoulders. Place feet hip width apart then raise your body up onto your toes until you’re in a straight line from shoulders to feet. Hold this position for as long as possible, ensuring your belly button is sucked in towards your spine and that glutes (i.e. your bum) are squeezed and tucked in for the entirety of the hold.

Easier: the Plank can be made easier by performing the movement from your knees instead of feet. Hold your body in a diagonal line from shoulders to knees for as long as possible. Ensure your belly button is sucked in towards your spine and that glutes (i.e. your bum) are squeezed and tucked in for the entirety of the hold.

Perform this exercise 1-3 times with a 30-60second rest between sets.

Exercise Three: Side Plank

How: lie on your side on a mat and place forearm on the mat directly under shoulder, perpendicular to your body. Place upper leg directly on top your lower leg and straighten knees and hips so that they’re in a straight line with your ear and shoulder. Raise your body upward by lifting from the waist and hips so that your body is rigid. Hold this position for as long as possible, ensuring your belly button is sucked in towards your spine and that glutes (i.e. your bum) are squeezed and tucked in and hips are lifted, for the entirety of the hold. Swap sides and repeat.

Easier: set yourself up as per the above guidelines but instead of keeping both legs straight, bend knees at a right angle with feet behind the body. Your body should still be in a straight line from ear to knee. Raise your body upward by lifting from the waist and hips so that your body is rigid. Hold this position for as long as possible, ensuring your belly button is sucked in towards your spine and that glutes (i.e. your bum) are squeezed and tucked in and hips are lifted, for the entirety of the hold. Swap sides and repeat.

Perform this exercise on each side for 1-3 sets with a 20-40second rest between sets.

Exercise Four: Leg raises

How: lie flat on your back on a mat with arms by your side and palms face down. Raise legs up in the air so that they’re in a straight line directly above your hips with a slight bend in the knees. Lift head and shoulders off the floor and tuck chin to chest so that your body is in a ‘C’-shape. Suck your belly in towards your spine and take a breath in then lower one leg towards the floor, moving from the hips only i.e. don’t bend from the knee. Lower leg until just before your foot reaches the floor or just before you feel your lower back starting to lift off the floor – which ever happens first. Raise leg back up to meet the other and repeat on the other side.

Easier: set yourself up as per the above guidelines but instead of keeping your legs straight, bend them to <90 degrees then execute the move as per the above guidelines.

Perform a total of 10-20 repetitions per set for 2-3 sets with a 30-60second rest between sets.

The easier an exercise becomes, the longer you perform the exercise for, or more repetitions and sets you do. To actually reap the benefits of physical training, it should be done consistently at least twice a week, anything less is still great for our mental health but beyond that… Results may vary!

The above exercises provide a base for good core strength. Done correctly and consistently, the benefits will range from better posture, decreased back and/or neck pain, improved pelvis and bladder control (especially for new/expecting mum’s!) and; in conjunction with a good diet (and possibly surgeon) – a flatter tummy!

The importance of weight management in maintaining a tighter, stronger core cannot be over emphasized. The more fat we carry around our mid-section, the more at risk we are of a number of serious health issues and joint and back problems. This doesn’t mean that we all need to walk around with 6-packs to be healthy and strong but it should mean making healthy food choices at least 70% of the time and controlling the amount food we eat. Because even after abdominoplasty, your body won’t hide a bad diet for long!


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