Diastasis Recti: When No Amount of Crunches Will Bring Your Abs Back

Announcer (00:02):
You are listening to Alabama, the beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin (00:10):
Hey, Dr. Koehler and Dr. Gardner.

Dr. Gardner (00:12):
Hey Kirsten.

Dr. Koehler (00:14):
Hey Kirsten.

Kirstin (00:15):
Do you guys know what we are talking about today?

Dr. Koehler (00:19):
We haven't a clue. Please tell us.

Kirstin (00:22):
We're talking about diastasis recti and how we treat it.

Dr. Koehler (00:26):
Okay.

Kirstin (00:27):
What is diastasis recti?

Dr. Gardner (00:31):
So the six pack muscles are the diastasis muscles. They are longitudinal muscles that run basically from the bottom of the breast bone down to the pubic bone. And what happens during most commonly pregnancy for females, they will actually widen because as the fetus grows, the uterus enlarges, it puts a lot of pressure on the anterior abdominal wall and it stretches those muscles. So you end up with a gap between the muscles. And what happens is, is it never fully comes back together in most people. Now it could, but the bigger the baby, the more babies that people have, the more likely they are to have that widened diastasis. And so part of the procedure for a tummy tuck is the repair and bringing those muscles back together back in the midline.

Dr. Koehler (01:25):
Also, he was talking like the rectus muscles are the six pack muscles, but for men, if you go from a six pack to a keg and then you go back and you lose that weight, then you might also have some rectus diastasis.

Kirstin (01:40):
Really?

Dr. Koehler (01:41):
Yeah. So men very commonly have a problem with visceral fat. We see it in women too, but when people talk about a beer belly with a guy, well, it's that classic thing. We've probably talked about it before where it's like you push on their tummy and it's hard as a rock. Well, the reason it's so hard is because the fat that they have is not on the outside, underneath their skin. It's actually inside in their belly. And so although the men don't get pregnant, we've discussed this before, but anyhow, they put on weight and if they put on a lot of weight, then it can stretch the muscles out and so they can run into the same problem. So as part of tummy tucks, even for men will sometimes do a repair to re approximate those. And sometimes it's hard when you're doing the exam, most people, you assume if they've had pregnancies and stuff like that, that they all have muscle separation.

(02:37):
Almost every, I'd say for me, maybe one in every hundred tummy tuck, I might not do a muscle repair, but it's probably less than that. I mean, it's very infrequently we don't do the repair, but sometimes on an exam you'll have a woman who's had several children and she's got this bulging abdomen and you're like, well, it could be visceral fat, but when you push on it, it's like, eh. And so you can sometimes have a couple other things like when those muscles, when they separate, you've got a weak abdominal wall, and so it bulges just like when we see people that have that visceral fat where they've got fat on the inside. So sometimes you don't really know a hundred percent for sure until you get into surgery. Obviously it can be a combination of both. And the other thing is sometimes it's not even just muscle separation, but after maybe a pregnancy with twins or something like that, you can get what's called myofascial laxity where the muscles can be separated, but also the muscles lose their tone. So even when you try to put 'em back together, it's like sometimes they can still have a little bit of a bulge to their abdomen because everything's weak.

Dr. Gardner (03:43):
Yeah, that's a great point. And I've seen that quite a few times and it is a bit frustrating because even when you do a good solid repair, like you said, they still have a little bit of that protrusion and they can get a little frustrated with it. But yeah, I've definitely seen that the myofascial laxity, and it's hard to deal with.

Dr. Koehler (04:04):
This is a patient from in surgery, and you can see this flaps retracted and you can see, especially in the upper abdomen, there's this wide separation of those rectus muscles. And if you do a tummy tuck and you don't address this, I mean you're not going to end up with a happy patient. And typically we put those muscles right back together. I mean, in their natural state, there is a gap. I mean that is what creates the kind of groove in the middle. But sometimes we have to artificially create that with a little liposuction. We really want to repair the muscles to their full extent. We don't want to have any gap.

Dr. Gardner (04:45):
Absolutely. No, I agree a hundred percent.

Dr. Koehler (04:48):
And so the one thing, I'm sure you've heard this a lot, Vince, people are like, are you going to give me a new belly button? And I'm like, no, you get to keep your same belly button.

Dr. Gardner (04:59):
Yeah, you do get to keep your own belly button. We're going to reposition it and hopefully make it a lot cuter.

Dr. Koehler (05:04):
Yeah, there's a lot of art form to the belly button part. I really feel like for tummy tucks, there was a surgeon, you know him, I'm not going to mention the name, but he was visiting my practice and I could tell it was absolutely painfully killing him, watching me do the belly button. I take a little extra time there and I do some things. He commented on it. I said, well, you know what, to me, this is what the patients see. If you're in a bathing suit, the incision's covered except for the belly button. And so I've worked on it for a lot of years, still haven't perfected it, but I'm getting better with time. But to me, it's a really important part of a tummy tuck.

Dr. Gardner (05:41):
Yeah, absolutely. You're right. That's what they're going to notice and that's what they're going to comment on.

Kirstin (05:47):
Does fixing diastasis recti change things functionally? Does it improve posture or core strength or anything like that? Or is it just strictly something to make you look better?

Dr. Gardner (06:00):
No, I think it absolutely can help with core, because when you think about it, when people complain of back pain, what do they tell you to do? Strengthen your core. And so you can have issues with back pain for sure. You can have issues with posture. And so correcting the diastasis can definitely help in other areas. And I think you hit the nail on the head.

Dr. Koehler (06:22):
Now once you've had a tummy tuck and a rectus repair, we're not going to let you start doing a lot of core stuff right away. And we're going to tell you that's the one thing at six weeks, I tell people, oh, you can go back to doing exercise. But I'm always very clear to say, but maybe don't start with core. Start with your other stuff. And then as you start to incorporate core, you got to listen your body, because sometimes, yeah, you're probably not going to rip my repair. It's not going to fall apart. But if your body's hurting, it's not quite ready for that level of exercise just yet. But yeah, I think absolutely, it definitely improves a lot of areas when the muscles are in their proper alignment, that's when they work the best.

Kirstin (07:06):
One thing that we get questions about sometimes is does muscle repair cost more? And we kind of talked about it a little bit already, that pretty much everybody in a tummy tuck is going to have some sort of muscle repair. So do you want to talk a little bit about that?

Dr. Gardner (07:23):
Like I said, it's rare that I don't do a muscle repair, but sometimes in a mini tuck where we're only going to free up the skin from the pubic bone up to the belly button. So if we're doing that, then those patients typically are not going to get a muscle repair. But those are carefully selected preoperatively because we don't necessarily think they're going to need a repair. But if somebody truly needs a repair, they're going to need a traditional full tuck where you mobilize from the pubic bone all the way up to the xiphoid or the breastplate, and you're going to repair those muscles. You're looking right at 'em. This is your shot to repair it. It should be part of every, unless ahead of time, like a mini tuck.

Dr. Koehler (08:07):
Yeah, there's a few cases that just don't need it. And I mean, those are few and far between, but there are cases, but it's absolutely considered part of it. It's more of a, it's an exclusion like, okay, I didn't have to do this part because it was fine. But you would go in with every case, assuming there'll be a muscle repair. So we don't charge more for it because it's just part of the procedure. And one of the things that Vince said about many tummy tucks, just to clarify why we wouldn't do a muscle repair, but first of all, very few people are good candidates for many tummy tuck anyhow. If it's just a little loose skin above a C-section scar and that's the only thing that's bothering them, then okay, a mini tummy tuck will be fine. But a lot of times it won't fix any laxity in the upper abdomen. And if you do muscle repair, the belly button and the pubic, what you end up doing is you flatten the bottom and you've just pushed everything up. And now the upper abdomen can bulge and look. It doesn't look right because there's still diastasis above and you've corrected only the below. Those patients are selected very carefully. So

Kirstin (09:11):
Let's talk about, can we tuck recovery, especially when you have to do muscle repair? What does that look like?

Dr. Gardner (09:18):
That obviously, and I tell patients, the most painful part of the procedure is the muscle repair. We put typically three layers of stitches, big stitches to pull those muscles together. And like Dr. Koehler said, what we don't want to do is have them challenge that prematurely. And what I tell patients is, you don't want to pop or separate those sutures to where we have to go back and re repair it.

Dr. Koehler (09:45):
My patients are recovered fully in about one week

Kirstin (09:49):
As a patient, that's a lie.

Dr. Koehler (09:54):
Alright, maybe it's six, but still No.

Kirstin (09:56):
I did come back to work in one week, but I was hobbling.

Dr. Koehler (09:59):
Yeah, you're a superstar. I will say.

Kirstin (10:01):
One week. That's impressive.

(10:04):
Wow.

Dr. Gardner (10:05):
Yeah.

Kirstin (10:06):
I sit in this chair for eight hours a day. I think the thing that helped me the most is obviously you give a numbing shot in the muscle intraoperatively and you feel really good for 24, 48, 72 hours maybe. So I always tell everybody that questions it, get up that night, come home, you're a little bit sleepy, but by evening time, by dinnertime, you're probably ready to get out of that bed. So make a short lap around your island or around your couch in your living room just so you're up and moving. And those muscles aren't just sitting still for two days until you feel like getting out of bed. I really think that was probably the biggest thing that helped me. Everybody always says get up and walk, but nobody wants to. So I think the most crucial time is when you have that numbing medicine in your muscles and you don't feel anything. Get up and take a lap around your kitchen. That way you're moving and kind of getting going a little bit.

Dr. Koehler (11:04):
Yeah, I think it's good. You just got to be careful. Sometimes when you feel good, that's a mistake sometimes it can be made. It's like, oh, I'm not hurting at all. I can do this. I can do that.

Kirstin (11:13):
Well, not cartwheels.

Dr. Koehler (11:14):
No, I know, but you can't do one. Anyhow, I saw you guys out on the back lawn trying to do that a few weeks back. I don't know

Kirstin (11:20):
Actually. It's true.

Dr. Koehler (11:23):
You were,

Kirstin (11:24):
I was going to say at the Christmas party that year, but that's true. We were doing it sober a few weeks ago.

Dr. Koehler (11:30):
Yeah. I'm like, what are you guys doing out there in the back lawn? And you're like trying to do cartwheels. I'm like, I don't know what's happening around here.

Kirstin (11:37):
But oh, I forgot about that.

Dr. Koehler (11:39):
Yeah. Anyhow. But yes, I mean, definitely you want to do it, but with common sense, be careful, but get up and move is good.

Kirstin (11:47):
How long do results last? Are they forever? And what happens if you have another baby after a tummy tuck?

Dr. Gardner (11:54):
They last a long time. Again, it's kind of how do you treat your car? Do you speed? Do you slam on the brakes? Do you abuse your car? Well, it's not going to last that long if you abuse your car. Same thing if you're abusing your body and you're not doing the things that you need to do. And I always say, protect your investment. Cosmetic surgery is an investment in you. And so if you want to protect that investment, what do you want to do? Well, you want to eat clean. You want to exercise, watch your weight, do all the things that you need to do to keep your body in good working condition. And by doing that, you're going to probably extend the repair and the results that you're going to get from surgery. But if you go out and you say, well, my tummy tuck, I lost weight with my tummy tuck, and now I'm just throwing caution to the wind and I'm eating whatever, and you gain and lose and gain and lose, well, you're going to stretch skin out. You're not going to have the same results that you did right after surgery. So yeah, I think that there are things that you can do to end up keeping your results much longer.

Dr. Koehler (13:01):
Yeah, I mean, I would agree with that. The question I get, not with tummy tuck, but with facelifts, the common things, well, how long will this last? How long will my facelift last? And I'm like, it's the most impossible question in the world to answer because first of all, there's things like Vince said, diet, exercise, and then there's habits like if you're a smoker or not a smoker, if you're abusing your body. And then there's your genetics. I mean, just your genetics. I mean, some people, you look at Tina Turner, I mean, she looks the same now as she did when she was popular in the eighties. I mean, her legs are the same, but some people genetically are just kind of lucky that way. And that's great. Also, it depends on when you do it. So tummy tuck are typically done women in their twenties, thirties, forties maybe. But facelift surgery is usually 50, 60 seventies. And I go, well, if you do a facelift at 50 and then look at, see where you are in 10 years time. I mean, you're 10 years older, we didn't stop the aging process.

(14:05):
But if you did that same facelift on a person that's 70, and then look at them at 80, yeah, it looks like it's relapsed a whole lot more. So where you are in the aging process, your skin elasticity, all these things. In fact, that is something I would maybe want to get your comments on, Vince. I know we've talked about it because a frustrating thing that we deal with. And although the massive weight loss patients, which I love those patients, they're great patients and they're often so very grateful. But they do deal with a difficult problem that our typical abdominoplasty patients don't deal with, which is just the trouble of skin elasticity after surgery or just the fact of massive weight loss in general, and a lot of times nutritional type stuff. So why don't you talk about that, Vince?

Dr. Gardner (14:57):
Yeah, yeah. I think that's a great observation is the skin is not the same once it's been stretched out. And again, we see patients all the time that have lost a hundred, a hundred thirty, a hundred fifty, two hundred pounds or more, and that skin is just not good quality skin. And so like you said, the elasticity and the collagen are stretched out. They have stretch marks, and we're going to cut as much of that off as we can. But I tell every one of those patients, look, no matter how tight I pull it in the or next day, it's not going to look as tight and in two years, five years later, it's not going to be as tight. And so I always tell those patients, there's always a chance that you're going to need some revision work. And what I mean by that is maybe go back and take a little more skin and they're like, well just do it right the first time.

(15:48):
What has nothing to do with that? I'm going to pull it as tight as I can that's safe. But because of the quality of the skin, that stretched out skin, a lot of times we do have to come back and do some revisions and take more skin. And it's unfortunately just part of that patient population. And the other thing you hit was the genetics. And genetics I think plays a huge role. And we just don't know what really your skin quality is. And we see people that smoke and they still have great skin, and it's mainly because their genetics are so good. And then we see other people that do everything and they just have poor quality skin. So like you said, it's just the genetics. As far as post-op nutrition, when we did a gastric bypass procedure, our goal was to get that patient to hit 60 grams of protein post op.

(16:40):
And that was nearly impossible for them to do because when you've got the stomach, the size of an egg, getting 60 grams of protein in a day is really difficult. So I harp on patients post-op that you really need to be getting 90 to a hundred or more grams of protein a day. And sometimes that can be difficult, especially if you've had a weight loss surgical procedure and you have a small gastric pouch. But again, we push that because those patients just tend to heal better. And I can usually tell the ones that have issues with wounds and wounds not healing correctly or incisions not healing, they need to, it's probably because it's a nutritional issue.

Dr. Koehler (17:21):
We definitely see that. And obviously if they had the full roux en y gastric bypass, I mean, their absorption of certain vitamins and other things gets affected. And so, yeah, there's a lot of things that go into it, but you get it as tight as you can in the I know when I'm not going to hold back. I want to be here once and out. And it's like you pull it as tight as you can. And I've even said myself, I look at it and I'm like, God, I know I pulled it tighter than that. I know. I know. I had t clamps holding everything together. I know it was tight. So anyhow, it is a bit of a challenge for some of those people. But still, I think in the end, when you look at some of the amounts of skin, I think I was talking to you the other day and you're like, yeah, I had a patient. We just did 20 pounds of skin. That's a lot of skin to take off. It is.

Dr. Gardner (18:11):
It is. And that's the other funny thing that I always like, how much did it weigh? How much did it weigh, doc? How much was it? And I always tell 'em, it's not going to be as much as you think, but on that rare occasion where you have somebody who still has a little bit of a higher BMI, you can end up getting 20, sometimes more than 20 pounds off. It's interesting.

Dr. Koehler (18:32):
Yeah. And when you do, that's a phenomenal amount. I am sure you've done this before. We've talked about it on our podcast before when we're at the hospital sometimes, and you take off this big thing and you hand it to the scrub tech to put on the back table or whatever, and it's covering the entire back table. And everybody's like, oh my God. And you're like, well, you want to guess how much that weighs? And everybody's making their guesses and they're like, oh, that's got to be 20 pounds, 30 pounds, whatever it is. And I'm like eight. I think eight. So it looks so much bigger than what it ends up actually being half the time. And it does bring up a point. We did talk about this a little bit earlier, but I remember this one patient, I was so frustrated because I came for her, and we noticed she'd put on quite a bit of weight. It wasn't a little bit, it was like maybe 10 or more pounds. It was a lot from her consult. And I was like, Hey, I just noticed you've put on actually quite a bit of weight since your consult. She goes, oh, I know. She goes, but I love ice cream, and I've been eating so much of it lately because you're going to cut it all off. And I'm like, oh my gosh. It's not a weight loss program. It's a body contouring program. But anyhow, be frustrating.

Kirstin (19:52):
Do you have a burning question for our doctors or me? You can leave us a voicemail on our podcast website at AlabamatheBeautifulpodcast.com. We'd love to hear from you.

Dr. Koehler (20:01):
No, actually, I talked to Vince earlier. He said he'll take all the questions about burning. I'll take the other ones.

Kirstin (20:10):
We talked about this before. We're not OBGYNs here.

Dr. Gardner (20:13):
Exactly.

Kirstin (20:14):
It's all right. Thanks, Kirstin.

(20:17):
All right. Thanks, Dr. Koehler and Dr. Gardner.

Dr. Koehler (20:20):
Thanks, Kirsten.

Kirstin (20:21):
Go back to making Alabama beautiful.

Dr. Koehler (20:23):
All right, will do. See you. Bye.

Announcer (20:26):
Got a question for Dr. Koehler. Leave us a voicemail at Alabamathebeautifulpodcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, apple Podcast, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram @EasternShoreCosmeticSurgery. Alabama the Beautiful is a production of The Axis, theaxis.io.