If you've had weight loss surgery, you know how wonderful it feels to be free of the extra pounds that weighed you down for so long. But losing 50, 100 pounds or more can leave you with a new problem-loose, sagging skin hanging from your belly.

A tummy tuck or a panniculectomy can trim that drooping excess abdominal skin and fat-and let you enjoy the full benefit of the weight loss you've worked so hard to achieve.

This patient lost 165 pounds after bariatric surgery. She is shown above six weeks after undergoing a tummy tuck (with repair of an umbilical hernia), and breast lift. For more examples, visit our photo gallery

What problems are tummy tucks and panniculectomies designed to address?

“As people undergo extensive weight loss, they often develop an overhanging ‘apron’ of extra skin and fat in the lower abdomen. This is called a panniculus. Some people develop two or three of these folds. A tummy tuck or a panniculectomy can be used to improve this condition.”

What is a tummy tuck?

“A tummy tuck is a surgical procedure that removes excess skin from your belly and tightens the muscles of a lax abdominal wall. The excess skin is pulled down and removed, and the navel is repositioned.

“This is a more demanding procedure than a panniculectomy and provides a more visually pleasing result. A tummy tuck can be combined with an outer thigh lift and buttock lift to perform a lower body lift.”

What is a panniculectomy?

“A panniculectomy is the surgical removal of the overhanging panniculus in the lower abdominal area. There is no other structural work done-that is, the abdominal muscles are not tightened as in a tummy tuck-and the skin is closed simply. The belly button is not affected.”

Who is a candidate for a tummy tuck or a panniculectomy?

“Most people who have lost a lot of weight, whether through bariatric surgery or diet and exercise, are excellent candidates for a tummy tuck or a panniculectomy.”

Can a panniculus cause medical problems?

“Definitely. Bariatric patients often find that perspiration gets trapped under the hanging folds of abdominal skin. This can lead to non-healing skin ulcers, recurrent skin rashes, skin infections and foul odors.

“A panniculus can also lead to balance problems, sexual dysfunction and back pain. In extreme cases, if the blood supply to the panniculus is insufficient, a person can even develop gangrene.”

How do insurance companies view panniculectomy vs. tummy tuck?

“Sometimes, a conflict arises between tummy tuck or abdominoplasty and panniculectomy because most insurance companies do not distinguish one from the other. Even though an abdominoplasty is a dramatically different operation than a panniculectomy, it has the same insurance code.

“Most insurance company computers automatically consider this to be a cosmetic operation. Let's face it, sometimes it is. However, in weight loss patients, the procedure is without question more likely to be what we call ‘medically necessary’ because of the true medical problems that can develop because of the panniculus, as I've just described. For more information about medical necessity, see financing and insurance.”

How is a tummy tuck performed?

“I begin by making a horizontal incision just within or above the pubic area, as shown in figure 1. The length of the incision, which extends outward toward the hip bones, will depend on the amount of skin I need to remove. The more loose skin to be removed, the longer the incision will be.

“Then I lift the skin of the belly to allow access to the abdominal muscles, as shown in figure 2. I tighten the underlying muscles by pulling them together and stitching them in place, as shown in figure 3.

“After that, I make a second incision around the belly button so I can separate the excess skin above the navel from the deeper tissues. Then I pull the skin downward to tighten it. At this point, the belly button is temporarily covered by the upper abdominal skin.

“Then I bring the navel out through a new incision at its normal position. Although the belly button's position remains unchanged, it may look slightly different. Next, I trim away any excess skin from the lower abdomen, as shown in figure 4. If this skin contains stretch marks, some of them may be removed as well.”

Will a tummy tuck scar be visible?

“The day before your tummy tuck when I mark you for surgery, I'll ask you to bring in the bikini bottoms, panties or low-rider jeans you plan to wear so I'm sure your scar will be concealed by them.

“All I ask is that you keep it within reason. One patient brought in string panties. I laughed and had to say, ‘Come on!’

“It's important to realize that the kind of garmets you want to wear after a tummy tuck will determine where I place your scar. If you bring in low-rider jeans the day I mark you for surgery, your incision will have a very different placement than for a French-cut bikini. And once you've had the operation, we've literally drawn that line-you can't change it later.

“I take great pride in the symmetry and exactness of my scar placement. If a patient tells me, ‘I want the scar to go from one centimeter below my hip bone to the same place on the other side,’ I can come pretty close to that. My scars never wander around-they're well-placed and precise.”

Can you have a tummy tuck if you already have abdominal scars?

“Scars from previous abdominal surgeries may limit what a tummy tuck can do for you. On the other hand, sometimes I can use an existing scar for the new incision.”

Will a tummy tuck make the waistline smaller?

“That depends on how much excess abdominal skin you have. A tummy tuck will help get rid of a lot of tissue, but some people have a large skin envelope around their torso that needs to be reduced to give them any shape.

“If you want a smaller waistline and already have-or don't mind-a middle scar on the tummy, I can perform a fleur-de-lis abdominoplasty with a lower body lift. I generally do not use the fleur-de-lis technique unless you already have a midline abdominal scar.”

What is a fleur-de-lis abdominoplasty?

“A fleur-de-lis abdominoplasty is a tummy tuck method that removes the middle section of skin, like a piece of pie, up and down the abdomen. This produces an anchor-shaped scar on the belly.”

How does a fleur-de-lis abdominoplasty work?

“Since people gain weight in three dimensions, restructuring the abdominal contour the way you want it sometimes works better if I can pull the skin tighter from side to side as well as from top to bottom.

“If you were wearing a t-shirt, for example, pulling it down might make it tighter, but if you wrap it around you, that's how it gets snugger around the waist.”

Who should consider a fleur-de-lis abdominoplasty?

“A fleur-de-lis tummy tuck is well-suited for people who have a lot of excess skin horizontally as well as vertically. Remember, I typically won't use this method unless you already have a midline scar on your tummy. The ideal is to keep tummy tuck scars within the bikini line, except for the tiny one in the belly button.

“But if you're a candidate for a fleur-de-lis abdominoplasty, the procedure can enhance the results of your lower body lift. It's virtually always worth it.”

How does a tummy tuck affect the navel?

“Your navel will not move after a tummy tuck-it will just come through a new opening I will make in your abdominal skin after I've removed the excess skin.

“The umbilical stalk-the place where your navel connects to your inner abdomen-does not change. This is the ‘lifeline’ for the navel because it has no other way to get a blood supply.

“It's important to realize that the actual umbilicus is the same before and after a tummy tuck. However, the shape of the scar surrounding the navel may significantly affect the appearance of your belly button-usually for the better.”

Are there alternatives to a tummy tuck?

“Yes. A tummy tuck alone isn't necessarily the best choice for everyone. However, if you have lost a substantial amount of weight and have a lot of excess skin hanging from your belly, then surgery is probably your best option.

“Working out at the gym and losing more weight will enhance your muscle tone, but not your skin tone. In your personal consultation, I will advise you if any other options will work well with your anatomy to meet your surgical goals.

• “Liposuction may be used along with a tummy tuck to create a more pleasing body contour after surgery. I may recommend performing liposuction in any one of a number of areas if you have lost a significant amount of weight.
• “A lower body lift may be a good option for you if you have a great deal of excess skin surrounding your torso. This procedure not only removes the loose tissues of the abdomen and back, but also lifts the skin of the thighs and buttocks to give you a much more youthful body.”

Does a tummy tuck after massive weight loss require a hospital stay?

“If you're having only a tummy tuck, no hospital stay is involved. However, if I'm performing your tummy tuck as part of a lower body lift, you can expect to spend two nights in the hospital.”

What kind of anesthesia is used for a tummy tuck?

“A tummy tuck is performed under general anesthetic, so you will be asleep through the entire procedure.”

What should you expect immediately after tummy tuck surgery?

“After your tummy tuck, you'll be taken to a recovery area. You will likely have small drains left under your skin to help prevent fluids from accumulating.

“There will be a bandage covering your wound and you will be wearing an elastic garment over that. You will need to wear this support garment for about six weeks after your surgery. It helps to decrease swelling and promotes healing in the area.

“Although you may not be able to stand perfectly straight at first, you will be encouraged to get out of bed soon after surgery to promote blood circulation. In this early phase of healing, you should avoid straining, bending and lifting. Bruising and swelling will reach a peak within the first week after surgery.”

How long does it take to recover after a tummy tuck?

“You should be able to go back to work within 10 days, unless you have a physically demanding job. Bruising and swelling will continue to heal and you'll begin to see the results of your surgery.

“I will typically remove your drains 7-10 days after your surgery, and let you know when you no longer have to wear your support garment. You can gradually increase your activity and exercise, but don't overdo it.

“After a few months, you'll see a better picture of the final results of your tummy tuck. Any feelings of numbness or tightness will disappear, and your incision line may begin to fade. It's important to avoid sun exposure on your healing skin.”

What results can you expect from a tummy tuck?

“A tummy tuck is a very satisfying operation because most patients notice the difference in their physique immediately after surgery. As healing progresses and swelling decreases over time, the results only seem to get better.

“You should notice that clothes fit you in a much more flattering way. And your newly slender figure will allow you to wear fashions that you may have only dreamed of wearing before.”