The Fascia, Not the Ab Workout: How Southwest Plastic Surgery Rebuilds the Post Pregnancy Abdomen
Most abdominal consultations at Southwest Plastic Surgery start in the same place.
What is the reason of today’s visit?
“I want to look into my abdomen. I was thinking about a Lipo 360, the flanks, lower back, and abdomen. Mainly my whole midsection.”
Do you exercise?
“Four to five times a week.”
Do you have kids?
“Three, all cesarean. I did not breastfeed.”
And then, a few minutes later on the exam table: “I had three cesarean sections in different places and it bothers me.”
None of that is a discipline problem, which usually has to get said out loud, because by the time a patient books a consultation she has generally spent several years assuming it was. The workouts are real. The weight has been steady since before the last baby. The stomach still looks pregnant by evening and worse after dinner.
“So you can do as many sit ups as you want,” Dr. Frank Agullo tells patients. “This muscle will get stronger, but the fascia won’t get tight. So we’re really tightening the fascia.”
Patients tend to exhale at that point. The problem stops being their willpower and becomes a piece of tissue, which is a much easier thing to fix.
What Dr. Agullo recommended for her was not the Lipo 360 she walked in asking about:
“Your best result would be a tummy tuck. You have a lot of excess skin, but you also have a little diastasis where the muscles have separated, plus the fullness. With a tummy tuck I take away your C-section scars, the incision goes low so you can hide it with a bikini or underwear, and I remove all this skin so a lot of your stretch marks would be gone. Then I pull the skin all the way down so it is nice and tight, and even when you sit you won’t make folds. I fix your muscles up and down and your obliques, which creates a corset effect, gives you more waistline, and makes the abdomen completely flat.”
Two Different Tissues, Two Different Rules
The rectus muscles run down the front of the abdomen and the fascia is the sheet wrapped around them, joining in the middle, behaving less like a muscle than like the seam holding a hammock together.
Pregnancy loads that seam for nine months. Sometimes twice. Sometimes three times.
“What we see is after pregnancy, you have the two rectus muscles, the six pack. They separate,” Dr. Agullo explains. “And the fascia, the tissue that wraps around the muscle, stretches out. And that’s why after pregnancy, it looks like you’re still a little pregnant. Or, especially after you eat, it kinda bulges out a little bit more. It’s because the fascia has been stretched out.”
The separation is called rectus diastasis, and the reason it survives a decade of gym work is that a widened seam does not narrow because the muscle behind it got stronger. If anything the bulge gets a little more noticeable, since a bigger muscle behind a loose sheet has only one direction to go.
What the Operation Actually Repairs
A tummy tuck at Southwest Plastic Surgery is a structural repair with a skin excision attached to it, in that order of importance.
Here is Dr. Agullo walking a patient through the whole operation, in the order he does it:
“We can do a tummy tuck. We make the incision a little bit below where your scar is so we can take it away. With that, I can take all the skin from here down. If I find a hernia, I’ll fix that. And then the most important thing is putting together your muscles in the middle. And your obliques so that this ends up nice and flat. Also brings in your waist even more.”
The repair itself is done with plication sutures placed the full length of the midline and then out to the obliques at the sides. In many patients Dr. Agullo performs a triple plication, tightening the central rectus muscles and both sets of obliques, and that is what produces the internal corset effect and the narrower waist rather than just a flatter front.
For patients who delivered by cesarean there is often a second finding, and most of them have never had it named:
“I think what’s going on with the tethering is your scar is stuck to the fascia. And there’s no fat in between it. So it creates that bulge on top. So we have to release it.”
Releasing that tethering is its own step in the operation.
Patients regularly ask whether the muscle repair can be done under local anesthesia so they can skip going to sleep. It cannot, and the reason is mechanical rather than a matter of preference.
“Because when we fix the muscles, we need them to be relaxed. So even if we give local and you don’t feel anything, anytime we put a suture in the muscle, it contracts. And it can actually rip. So we wouldn’t get a good result with that one. So the best thing is for you to be relaxed. It’s completely safe.”
“Of course, we’re gonna do some lab work, make sure that everything looks good. We’ll check your heart as well before surgery. So it’s a very safe procedure.”
Liposuction is part of the plan every time.
“I always combine that with liposuction. And also on the lower back, and that gives you more waist,” Dr. Agullo says. “I would recommend doing some here on the upper back and the side just so that the waist kinda goes all together. And it doesn’t leave you looking a little top heavy.”
Liposuction Alone or a Tummy Tuck
Many patients arrive asking about Lipo 360 and leave discussing something larger, because liposuction removes fat and does nothing to the fascia or to loose skin.
“If we only did lipo, we would make you thinner, but your skin would still sag,” Dr. Agullo tells patients with significant laxity. The comparison below is the one the coordinators walk through in the planning appointment.
| Liposuction Alone | Tummy Tuck With Liposuction | |
| What it treats | Fat only | Fat, loose skin, and the stretched fascia |
| Rectus diastasis | Not addressed | Repaired with plication |
| C section scar | Stays | Excised with the removed skin |
| Surgical time | About three and a half hours | About four and a half hours |
| Back to easy activity | About one week | About two weeks |
| Back to exercise | About four weeks | About six weeks |
The difference in operating time is modest. The difference in recovery is real, and the difference in the final result is substantial.
Recovery Support at Southwest Plastic Surgery
Recovery is a program here, not a handout.
A nurse visits the patient at home the day after surgery for the first shower, a review of instructions, and IV fluids if they are needed. A small drain typically stays in for seven to fourteen days. Compression garments, the fajas most patients already know by name, are worn for roughly four weeks and go on after the first massage.
Post-surgical massage is included in the surgical package and starts on the second post-operative day. Lymphatic drainage brings the swelling down faster and makes the early weeks considerably more comfortable.
Dr. Agullo’s advice for out of town patients is practical: “For the lymphatic massages, I would recommend doing at least the first two here so you get an idea of how it should feel, and then you can have anyone do the rest and tell them what it should be like.”
For patients who want additional recovery support, ElixirMD offers IV hydration and vitamin protocols that many patients schedule around the first and second post-operative weeks.
Patients traveling in from out of town are generally asked to stay two or three nights, return at about seven days for suture and drain removal, and possibly again at fourteen days. Most follow-up after that is handled by video.
Not Everyone Needs Surgery
Southwest Plastic Surgery is equally direct about the patients who do not need an abdominoplasty.
“In the right patient, one who does not have a lot of skin laxity or stretch marks and no rectus diastasis, the Renuvion J-Plasma can help keep patients away from an abdominoplasty and let them have just liposuction,” Dr. Agullo says. He is among the ten highest volume users of Renuvion J-Plasma in the world according to Apyx Medical, the manufacturer, and he is equally clear about its ceiling: “J-Plasma will not tighten extremely loose skin after pregnancy or massive weight loss.”
Skin tightening technology treats skin. Nothing delivered through a liposuction port narrows a fascial separation. That determination is made at the examination table, not from a photograph.
Patients whose breasts also changed after pregnancy usually end up discussing a mommy makeover instead of a single procedure, and patients arriving after significant weight loss are typically better served by a broader body contouring plan.
About Dr. Frank Agullo
Dr. Frank Agullo is the founder of Southwest Plastic Surgery in El Paso, Texas. He is board certified by the American Board of Plastic Surgery and the American Board of Surgery, and a Fellow of the American College of Surgeons. He completed his plastic surgery fellowship at the Mayo Clinic and his general surgery residency at Texas Tech University Health Sciences Center, where he has served as Clinical Associate Professor of Plastic Surgery at the Paul L. Foster School of Medicine since 2011. He has been named a Castle Connolly Top Doctor for thirteen consecutive years, 2014 through 2026.
Approximately sixty percent of the practice’s patients travel in from outside El Paso, which is why the recovery program is built to work for people who are not local.
Ready to Talk?
If your abdomen has not responded to the work you have been putting in, the problem is probably a layer you cannot train. Come in and let Dr. Agullo examine it. Call (915) 590-7900, text 1-866-814-0038, or book a consultation online. #StayBeautiful.
@RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook.
Companion Reads
- Dr. Agullo’s editorial version on drworldwide.com: The Sit Up Lie: Your Post Pregnancy Belly Is a Fascia Problem, Not a Muscle Problem
- The clinical patient version on agulloplasticsurgery.com: Rectus Diastasis After Pregnancy: Why Sit Ups Cannot Fix a Stretched Abdominal Wall
