Last week HuffPost ran a personal essay from a mother of three who paid out of pocket to repair what three pregnancies had done to her abdominal wall. The headline did the heavy lifting. The story underneath it landed because the experience is common, the operation that fixes it is well understood, and the reason it gets paid out of pocket has very little to do with medicine.
The editor reached out to Dr. Frank Agullo, the medical director at Southwest Plastic Surgery and a double board-certified plastic surgeon in El Paso, for a surgeon’s read on why these repairs are so often denied. His answer, as he puts it, is the one he gives every postpartum patient who walks into his consult room with a soft belly, a sore lower back, and a primary-care note that says “core work.”
“The word cosmetic is doing a lot of work in that sentence,” Dr. Agullo says. “Most of it is wrong.”
This piece walks through what diastasis recti actually is, how the team at Southwest Plastic Surgery diagnoses it, what the operation involves, where physical therapy fits, where the MedSpa fits, and why insurance still treats a structural problem as if it were a vanity one.
What Diastasis Recti Actually Is
The rectus abdominis is the long paired muscle running down the front of the torso, one belly on each side of the midline. The thin sheet of connective tissue between them, the linea alba, is what keeps the two bellies tethered at the midline so the abdominal wall behaves as a single pressurized box. Pregnancy stretches that sheet. Sometimes it stretches and recovers. Sometimes it stretches and stays stretched. When it stays stretched, the two rectus bellies sit further apart than they did before. The abdominal wall has lost the closed front it had.
That is diastasis recti. The muscles are not injured. The wall between them is.
“Look, the rectus muscles are fine,” Dr. Agullo tells patients on the table during the exam. “The tissue between them is what gave. And tissue that has lost its length does not get it back from a workout.”
The Symptoms That Are Not Cosmetic
When the abdominal wall loses its tension, the lower back takes more of the load. Pelvic floor symptoms get worse, because the abdomen and pelvic floor work as a coordinated pressure system, and the box only holds pressure if every side of the box is doing its job. Some patients develop a visible dome when they sit up from lying flat, where the contents of the abdomen push into the space between the separated muscle bellies. Some develop a true umbilical or ventral hernia.
“I’ll see a patient who’s been on muscle relaxants and anti-inflammatories for years,” Dr. Agullo says. “She’s been to a chiropractor. She’s been to pelvic floor PT. She’s leaking when she runs with her kids. Her primary care doctor never put her flat on the table and asked her to lift her head. So nobody ever told her that her abdominal wall is open.”
That last sentence is, by his read, the central clinical failure. Diastasis is a bedside diagnosis. It is not subtle once you look for it. And it almost never makes it into the postpartum visit.
How the Team Tells Diastasis Recti From the Things It Gets Confused With
There are three different problems that all show up as a soft belly after pregnancy. They get conflated constantly. Southwest Plastic Surgery uses a quick comparison to separate them:
| Diastasis Recti | Loose Skin Only | Soft Postpartum Belly | |
|---|---|---|---|
| What is separated | Linea alba is stretched, rectus muscles sit apart | Nothing structural | Nothing structural |
| Visible sign | A dome or ridge when sitting up from lying flat | Skin laxity, stretch marks | Soft fullness that responds to weight loss |
| Back pain pattern | Common, often years of it | Uncommon | Uncommon |
| Pelvic floor symptoms | Common | Uncommon | Uncommon |
| Hernia risk | Real | Low | Low |
| Helped by core PT alone | Sometimes, sometimes not | No | Yes |
| What a real repair requires | Plicating the rectus muscles back to midline, surgically | Skin excision | No surgery at all |
| Typical insurance label | “Cosmetic” | “Cosmetic” | N/A |
“PT works for the patient who has a small residual gap and good motor control,” Dr. Agullo notes. “It does not work for the patient whose linea alba is permanently stretched. PT cannot close a hernia. It cannot reattach a sheet of collagen that has lost its length. When PT is the answer, we send the patient to PT. When it is not, we say so.”
How Dr. Agullo Plans a Repair
The consultation starts with the patient supine, head off the table, like she is mid curl-up. Dr. Agullo measures the inter-rectus distance at three levels: above the navel, at the navel, and below. He notes the depth of the gap as well as the width. He looks for a coexisting hernia at the umbilicus, because a small one is easy to miss and changes the operation.
For complex cases (prior abdominal surgery, very obese patients, atypical pain), he orders an abdominal ultrasound or a CT before he books anything. He wants to know whether what he is feeling is a pure diastasis or a diastasis hiding a hernia inside it.
“Different operation, different conversation,” he says. “I want to know before I plan, not in the OR.”
When repair is the right answer, it is most often done as the muscle component of a tummy tuck. The skin and subcutaneous tissue of the lower abdomen are elevated off the muscle layer. The rectus sheath is exposed from the xiphoid all the way to the pubis. The plication runs the full length of the diastasis. The closure is layered: long-acting absorbable suture on the inner layer, permanent suture on the outer layer. A hernia, if there is one, is repaired in the same operation, with mesh in selected cases. The umbilicus is released and reset through the new midline.
“Tension balance is the whole game,” Dr. Agullo says. “Close it too tight in one segment and that segment fails. Close it correctly across the full length and it holds for decades. The peer-reviewed durability data is on the side of the technique. The technique just has to be right.”
What Recovery Looks Like (Honestly)
The first week is the hardest. The repair is tight, the patient is flexed at the waist to protect the closure, and pain management is the main job. Walking starts day one (short flat-footed steps) and expands every day. Drains, if used, typically come out somewhere in week two. By week three the swelling has peaked and is starting to come down. By weeks four to six, the patient is on light cardio. Core work waits until Dr. Agullo clears it, usually around eight to twelve weeks, and resistance training expands from there.
Pelvic floor symptoms often improve within the first three months. Some patients report immediate relief from urinary leakage on the first cough after waking up from anesthesia. Back pain driven by the lost abdominal tension generally improves on the same schedule as the closure heals.
“By a year, the scar has matured and the result is the result,” he says. “A repair done well lasts. A repair done poorly is a redo with a scar she did not have before.”
Where the MedSpa Fits, and Where It Does Not
The MedSpa team at Southwest Plastic Surgery does not treat diastasis recti. Nothing at the MedSpa closes an open midline. There is no laser, no radiofrequency device, no peptide that reattaches a sheet of stretched collagen. Patients who hear otherwise are being misled.
Where the MedSpa is genuinely useful is around the surgery, not instead of it.
- Stretch marks. Patients who have stretch marks across the lower abdomen often want them addressed at the same time. Most of the obvious stretch marks are excised along with the lower-abdominal skin during the tummy tuck itself. Residual marks above the umbilicus are candidates for fractional laser or RF microneedling (Morpheus8) at the MedSpa once healing is complete.
- Scar care. Once the tummy tuck scar matures, usually six months out, RF microneedling can soften it and improve texture. Topical silicone and a few months of disciplined scar care from the post-op nursing team usually does most of the work, and the MedSpa picks up the rest.
- Skin tone and texture. Patients who want their abdominal skin to look like the rest of their body book the occasional radiofrequency or laser session at the MedSpa. None of this is required. All of it is optional.
- Post-op recovery support. The practice offers structured post-op recovery protocols, post-surgical lymphatic massage where indicated, and access to the in-house nursing team for the first six weeks. The ElixirMD regimen is available for patients who want a structured post-op skincare protocol layered on top.
“The MedSpa cannot fix a diastasis,” Dr. Agullo puts it flatly. “Anyone who tells you it can is selling you something. What it can do is take care of the patient after the repair, so the result feels complete. That is its job. We do not blur the two.”
Why Insurance Still Calls It Cosmetic
The pattern is consistent. Insurance pays for years of physical therapy that did not solve the problem, for the medications that managed the back pain instead of treating the cause, for the pelvic floor consults, and eventually for the hernia repair when the umbilical hernia finally herniates badly enough that the structural argument is impossible to dismiss.
What insurance will not pay for is the single operation that closes the wall before all of that.
“That is not medical sense,” Dr. Agullo told HuffPost. “That is accounting. The word cosmetic is being used as an exclusion code, not a clinical description. There is a real peer-reviewed body of work on the functional outcomes of diastasis repair. A handful of insurers are catching up. Most are not. And so the patient pays out of pocket for the operation that should have been covered the day she presented with documented symptoms.”
The practice does not pretend insurance will pay for these repairs. It quotes the surgery transparently up front, finances responsibly through the practice’s standard programs, and makes sure the patient understands the operation she is signing for. Where there is a clear hernia component, the team does help patients document the medical case for partial coverage. Sometimes that works. Often it does not.
Two More Reads, Both Written by Dr. Agullo Himself
For a shorter editorial take on the same HuffPost conversation, see Dr. Agullo’s piece on drworldwide.com: The Repair Your Insurance Calls Cosmetic: Diastasis Recti After Three Babies.
For a longer clinical walkthrough (diagnosis, surgical technique, recovery week by week), see the agulloplasticsurgery.com version: Diastasis Recti Repair: What Pregnancy Stretches, What PT Can and Cannot Fix, and Why Insurance Still Calls It Cosmetic.
Why Southwest Plastic Surgery
Dr. Frank Agullo is double board-certified by the American Board of Plastic Surgery and the American Board of Surgery. He completed his plastic surgery fellowship at Mayo Clinic. He is a Fellow of the American College of Surgeons, a Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, and an Affiliate Professor at the University of Texas at El Paso. He has been named a Castle Connolly Top Doctor for thirteen consecutive years, from 2014 through 2026. Southwest Plastic Surgery is the practice he founded in El Paso, with a busy surgical practice and a full-service MedSpa under the same roof.
Schedule a Tummy Tuck Consultation at Southwest Plastic Surgery
If you have been carrying around five years of “just being a mom” and a primary-care file that never mentioned the words diastasis recti, come in. Dr. Agullo and the Southwest Plastic Surgery team will examine you, document what they find, and tell you honestly whether you need surgery, whether physical therapy is still your best move, or whether the answer is somewhere in between.
Call (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com/appointments. Follow along at @RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook. #StayBeautiful.
