As both a Plastic Surgeon AND (in a previous life) a Personal Trainer with a Master’s Degree in Exercise Physiology, I have learned quite a bit about the muscles that make up the abdominal wall. Many patients come to me and are upset that they can’t get their tummy flat again after child birth. Some of their friends look great after they had kids and they don’t understand why they can’t get their physique back to the shape they are used to from their youth. Some of them develop feelings of guilt or incompetence which are completely unfair. In this essay I’d like to explain what the problem really is and why exercise and diet will NOT help you overcome a true diastasis recti completely. Let me emphasize, however, that diastasis recti is an unusual circumstance and the MOST women simply develop laxity of their abdominal wall after pregnancy. While this too can be frustrating and sometimes difficult to overcome without surgery, it is NOT the same entity as a diastasis recti.
As depicted above, women with a real separation of the muscle of the abdominal wall have a very specific appearance and look very much like each other. There is almost always a profound protuberance near the umbilicus and hanging skin below that. With poor diet and lack of exercise or with many post pregnancy tummies, the excess skin and the belly paunch are both lower and might even hang down, but they tend to be together. Not so with a diastasis recti. So, what exactly is going on here?
What is Diastasis Recti?
A “diastasis recti” is a loosening of the connective tissue in the center of the abdomen called the “Linea Alba”. This is a fascial band (thick tissue) that connects the right and left Rectus Abdominus muscles (they make up the “six pack”) to each other and is responsible for the visible groove that many slim people have running from the umbilicus up to the chest.
During pregnancy there are substances called Prostaglandins that circulate through the body and allow everything to dilate, stretch, and get loose to accommodate the growing baby. This includes the uterus, blood vessels, and yes – the abdominal wall (including the line alba). During the first year post pregnancy, many of these structures snap back to tone in most people and the woman gets her old shape back, but not for everybody. Some women end up with loose tummy skin, sagging breasts, larger nipples than they had before pregnancy, or a widened space between their rectus abdominus muscles – and this is what we call the “Diastasis Recti”.
Below I have inserted a short (and graphic) video from the operating room. It depicts the loose connective tissue between the rectus abdominus muscles. Viewer discretion is advised.
So, for women with diastasis recti the abdominal muscles remain separated widely by several inches creating the appearance that they have a pot belly. In some instances it looks more like a large hernia. And in some rare cases I have seen the small intestine wiggling around under the skin (a process called “peristalsis”) as if there were a snake below wandering through the tummy. With the right kind of muscle flexion the belly may even stick out as if there were a hernia present.
Why Won’t Insurance Pay To Fix My Diastasis Recti?
Diastasis recti is a quirky little problem to have because although the cases can be rather severe and disfiguring, insurance companies don’t want to pay to fix them because there is no “functional problem” caused by the issue. Their argument is that the fascia (connective tissue) might be weak, but remains intact across the abdominal wall, so there is nothing that is “medically necessary” to fix. CT scans will confirm that the patient has intact anatomy without a hernia or break in the abdominal wall structure. However, in terms of basic normal form, this situation clearly goes off the rails.
For patients with this issue, life can become very depressing. The insurance company won’t help, the CT report says you are fine, and some friends and family gently intimate that you should really go to the gym and work out a little harder to get through this problem. They clearly don’t understand what’s going on.
Why Won’t Exercise Help Fix My Diastasis Recti?
As a previous personal trainer I’m a huge believer in physical fitness and an advocate for anyone who believes in self reliance. That said, I’m also a realist and an advocate for patients, and this problem needs surgery. There are no two ways about it. It is no different than having a bone broken completely in half so that it is not lined up properly anymore. Unless it is put back in place, it can’t possibly heal in a straight line the way it was before – it just doesn’t work that way. In the case of diastasis recti, the muscles need to be put back in their proper place in order to restore normal function. If that doesn’t happen, then no matter how strong you might make them with exercise, they will remain separated from each other and you will always have that bulge emerge between them.
I have noticed recently that there are some charlatans (yes, I believe these are dishonest people) out their claiming that if you do their workout (for a fee) they will help you build up your “transversus abdominus” muscles to fix your diastasis recti. They claim to have published proof in medical journals that their techniques work. I encourage anyone to try whatever methods are available. You should ALWAYS try to avoid surgery if you can. However, if your diastasis doesn’t get better in the first 18 months after pregnancy, it’s not likely to to improve on its own. Perhaps it was never a real diastasis to begin with, but just some laxity that rebounds with the hormonal changes after pregnancy.
How do I know this? First, let’s start with basic ideas and then move into anatomy. When a muscle flexes, it gets shorter and pulls whatever is attached to it closer. The anterior abdominal wall (your belly) is made up of four muscles all running in different directions. Importantly, NONE of them cross the midline or flex from one side to the other. They all run their course on either the right or the left sides of the belly. There is no connection between the right and left except for the fascia in the midline – which is what gets loose in a diastasis recti scenario. Therefore, strengthening these muscles cannot pull the two sides of the abdomen together. In fact, it might only serve to pull them farther apart.
The second way I can prove this is by experience in the Operating Room. Have a look below at the very thin and attenuated connective tissue between the two major abdominal muscles in this patient. There is no exercise in the world that would strengthen this layer because there is no muscle in it. Have a look below:
How To Fix Diastasis Recti
The preferred way to fix a diastasis recti is via a tummy tuck incision because it results in a hidden scar. Certainly, the problem can be addressed with a midline incision running up and down the middle of the belly, but most of us would not want that. In an effort to be more “stealthy” an incision can instead be made across the lower tummy in the bikini line. The skin of the abdomen is then undermined to expose the separated muscles. Sutures are then placed running from one side across to the other like a shoe lace in order to create a sort of internal corset. By repositioning the muscles back in the middle of the tummy we effectively restore normal anatomy and eliminate the bulge that is so bothersome.
What About Women With Laxity Of The Abdominal Wall, But NOT Diastasis Recti?
More common than diastasis recti is a laxity of the abdominal wall after having been stretched to accommodate either pregnancies or after major weight loss. In these cases the abdominal muscles are all intact, but the connective tissues have developed laxity leaving the tummy to protrude more than it did before their pregnancies. This situation is also many times a surgical problem, even for slender people, but it typically doesn’t have the dramatic presentation that a diastasis recti does. Certainly many of these folks will end up getting tummy tucks as well and they probably look much better than they would without the surgery, but the anatomical problem is not at all the same.
To see other results see my before and after tummy tuck gallery.