Surgical Options

This is a significant decision. Where it is appropriate, the correct surgery can be transformative. However, it is an invasive procedure, requires time to heal and carries its own risks.

We have spoken to surgeons to understand the details of surgical options that are available. General answers to commonly asked questions are provided below. However, this is not medical advice. Please see your own GP or surgeon to discuss your specific situation.

When is Surgery appropriate?

For female patients, it is important that their family is complete and they do not plan to become pregnant again. Pregnancy requires the abdomen to stretch to accommodate the baby. A further pregnancy would undo the benefit of the surgical correction and the separation would reoccur. Unplanned pregnancies can and do occur, but this will undo the surgical correction. If you have rectus muscle separation and are planning to become pregnant, then physiotherapy and exercises would be of benefit to support core function as the separation is likely to get worse with further pregnancies.

Patients should try all non surgical options to improve the functional integrity of their anterior abdominal wall such as physiotherapy and suitable exercise. Both pre-hab and re-hab are important for the patient to get the best result for them. Patients with good abdominal muscle strength have a better surgical and post-operative journey. ‘Good abdominal muscle strength’ does not just mean gym-goers, but refers to child-carriers, dog walkers, grocery shoppers and people who live a mobile life. Many people do have reasonable muscle strength.

It is worth noting that for diastasis recti repair surgery, having a lifestyle that allows you to maintain a healthy weight is best. The muscle repair surgery is not a weight loss surgery.

If you are considering surgery, it is worth an early stage consult with a surgeon to explain your specific case and understand the level of pre-hab recommended prior to surgery. At this point, they will do an assessment of the abdominal muscle function and clinical examination to assess the degree of separation and the potential presence of hernia through the gap due to the attenuated linea alba. If weight loss is important to you, then speaking to a general surgeon with expertise in bariatric surgery may be of benefit for both non surgical and surgical approaches.

What type of surgery is appropriate in which situation?

There are three main approaches to rectus muscle plication (muscle repair). These are defined by the incision used to gain entry to the muscles:

Transverse (horizontal) Incision, hip to hip. This is the abdominoplasty approach, carried out by a plastic surgeon. The scar can be kept low, to gain access to the anterior abdominal wall to view the abdominal muscles, the attenuated linea alba, any hernia and to allow the re-approximation of the rectus abdominus muscles using a plication suture to close the divarication. No mesh is required. Excess skin and fat can also be removed. The lateral incision may in some cases need to be extended up the midline into a Fleur de Lys (FDL) incision. This is still an abdominoplasty approach. This whole procedure is commonly known as a ‘tummy tuck’, though that term is imprecise. Often, the muscle repair and the removal of excess skin and fat are both carried out at the same time, but they can also be done independently of each other. It is possible to repair the muscles and remove very little skin via this method. For those who are very slim but still have muscle separation, then the abdominoplasty approach is still very effective and there is always a small degree of lax skin that can be removed. And it is also possible to just remove excess skin and fat even if there is no muscle separation to be repaired. Both of those situations would fall under the category of ‘tummy tuck’. Despite the muscle repair being both structural and functional, this is at present, often considered ‘cosmetic’ surgery and not always covered by the NHS.
Midline (vertical) incision down the belly. This is the general surgical approach, carried out by general and gastric surgeons. We are seeking further information from a general surgeon on when this type of surgery is suitable. This point of entry will not allow for removal of excess skin or fat. It may include mesh, a synthetic material used very successfully for treating hernia. This entry route for the same diastasis recti issue would not be considered ‘cosmetic’ surgery.
Laparoscopic (keyhole) incision. This also a the general surgical approach, carried out by general and gastric surgeons. This is primarily used for umbilical hernia repair. This point of entry will not allow for removal of excess skin or fat. It may include mesh, a synthetic material used very successfully for treating hernia. This is unlikely to be used for muscle repair due to the size of the muscle involved. There are surgeons developing laparoscopic routes for muscle plication, but these are very few at present.

Theory

Real world example

Umbilical Hernias

Umbilical and other mid line hernias, can be treated in isolation via the general surgery approaches described above. Hernias carry a risk of strangulation of the bowel which can be life threatening and this makes them a higher priority for surgical repair than the muscle separation alone. Hernias can also be repaired as part of a larger abdominoplasty surgery. It is worth noting that an open general surgery approach may require undermining of the belly button that may mean that it may not survive a subsequent abdominoplasty. Hernias may or may not be treated with mesh, a synthetic material used very successfully for treating hernia. If you are in need of hernia surgery but are considering a muscle repair or tummy tuck at a later date, please inform your surgeon as this may impact whether or not mesh is appropriate. For those with associated vaginal prolapse, but note that the results of the use of mesh in the surgical treatment of vaginal prolapse caused a number of significant problems.

Belly buttons

The belly button, or umbilicus, lies in the middle of your abdomen and originally connected you to your mother via the placenta in the womb. Once the umbilical cord is cut, the belly button forms to close off these important connections and seal the body from the remains of that cord. Under the skin, the belly button sits on a ‘stalk’ that previously connected to your vital organs.

During an abdominoplasty there are two options for managing the belly button:

For patients who require a larger resection of skin and fat, the belly button may stay in position on its stalk, cutting the skin around it, and then be brought out in a new position on the abdominal wall. i.e. the skin moves around the belly button.
For very slim patients whose main issue is the muscle separation, the alternative is to cut under the belly button, disconnecting from the stalk and allowing the belly button to be repositioned down the abdominal wall, i.e. the belly button moves with the skin.

C-Sections

A common question among those who nearing completion of their family is ‘I am having a C-Section', can the muscle separation be repaired at the same time?’ Unfortunately, the answer is No. This is for several reasons:

The dissection of a c-section is low down and not as far up as the major muscle separation and this should not be attempted at this time.
Due to the natural expansion during pregnancy, it is difficult to assess the extent of the separation at that time.
The muscles will draw back together to a degree over the first 8 weeks post partum as the body goes through its natural healing process.
C-Sections carry their own risks for mother and baby, the management of which must be the priority.

Who to see?

NHS

Unfortunately, at present, most diastasis repair surgery is not readily available on the NHS. However, there are circumstances, often aligned with the presence of a hernia, and dependent on the patients’ particular circumstances and pain and distress levels where you could be referred by your GP to an NHS gastric or general surgeon for hernia repair and they may refer you on to an NHS plastic surgery team. Please note that waiting lists are long and you may have to go through several referrals and wait times before you find yourself in the right place. Details about what cosmetic surgery may be offered on the NHS.

Private

Most muscle repairs are carried out within the private sector. They are most commonly done via an abdominoplasty incision (hip to hip or fleur de lys) and carried out alongside a ‘tummy tuck’ to remove excess skin that has occurred beforehand or is created during the operation. So how do you find the right surgeon to meet your needs?

The best starting point is a referral from your GP or another surgeon who are aware of who is best to see.
Personal recommendations from previous patients are also a good option, whether this is through local word of mouth, or through social media support groups.
The British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) offer a search facility of their list of members.
The British Association of Aesthetic Plastic Surgeons (BAAPS) offer a Find a Surgeon facility.
The Royal College of Surgeons also lists their members who are Certified Cosmetic Surgeons.

Because muscle repair has fallen within tummy tucks surgery, these are currently classed as ‘cosmetic’ procedures. The NHS provides a very helpful list of questions to ask when seeing a private surgeon and a variety of other useful information about cosmetic procedures in general.

When choosing a surgeon, it is worth considering and asking about post operative care. If you are travelling a distance for the surgery, what happens if there are any complications in recovery? Do ensure there is post operative care plan in place.

How much does it cost?

An initial consultation with a surgeon is likely to cost roughly £200-£350. This should be clearly indicated on their website or told to you over the phone when making a booking. This is the starting point.

The cost of the procedure is a more difficult question to answer as it depends on many factors including:

Surgeon fees, which vary by surgeon
Hospital fees, which vary by facility
Anaesthetist fees, which vary by anaesthetist
Your body and the likely duration of the procedure
Your procedure and whether you have any additional procedures carried out alongside the muscle repair
The likely length of hospital stay required for recovery

For the most straightforward of muscle repair and tummy tuck, costs can vary from £8,000 to £15,000 depending on location and surgeon. With additional procedures, the duration of the surgery, the recovery time and the costs will increase.

Post-Op

Initial recovery period

The recovery from an abdominoplasty is very similar to that of a C-Section, though no baby to distract you, or keep you awake. It is slightly different for everyone but rest is vitally important. There is good support on social media forums to discuss variations in recovery time. Your surgeon will guide you on specifics related to your procedure and your body.

As a very loose guideline for use when considering what support you may need during recovery, based on feedback from patients in social media support groups, for situations with no post operative complications, the below timeline may be useful. Weeks are provided as a range, some people are mobile in week 3, others will take a bit longer.

Day 1-4 - Post operative pain, usually managed in hospital. Rest in hospital or at home. Pain often starts to reduce day by day after day 4, or when any drains are removed.

Week 2-3 - Pain managed with over the counter medication. Mobile around the house for personal care, but difficulty standing up straight. Rest is vital. This is not the time for vacuuming - partners, friends and cleaning services can do this. Help around the house will be needed for 2-3 weeks post op.

Week 3-4 - More free movement around the house, able to stand up straight more easily. May be able to resume limited childcare by the end of this period, depending on your family size circumstances. May be able to return to some desk based work from home. Speak to your surgeon about your specific circumstances both in recovery and returning to work.

Week 4-6 - Free movement outside the house, building up strength. May be able to resume limited childcare during this period, depending on your family circumstances, number of children and their ages. May be able to return to some desk based work from home. Speak to your surgeon about your specific circumstances both in recovery and returning to work. May be able to return to some desk based work from home. Speak to your surgeon about your specific circumstances both in recovery and returning to work.

Week 7 onwards - normal life.

Please do have a look at our case studies for individual stories from other patients.

There are a number of aids to recovery that may make you more comfortable. These are discussed often in social media support groups and include conversations about clothing options, recliner chairs, bed supports, compression garments, and neck pillows.

Beyond the first two months

The body will continue to heal and adapt for the next 6 months to a year after surgery. Surgery cannot return a patient to their pre pregnancy state but it can really improve both the functional and aesthetic appearance of the abdomen.

There are many conditions associated with diastasis recti, and it is difficult to separate the direct contribution of the muscle separation to these conditions. However, many patients have expressed a significant improvement in their symptoms, overall happiness and self-confidence. Once fully recovered they comment on how much fitter they feel.

The chance of recurrence of the muscle separation is low. Generally patients who are able to maintain good form get stronger and fitter.