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If you have even heard of a rectus diastasis or its repair, you have likely heard of it in conjunction with the larger topic of a tummy tuck plastic surgery procedure. While this is a key association, as traditionally a diastasis repair is performed simultaneously with a tummy tuck, a rectus diastasis is a condition deserving of its own conversation. More than our mothers or grandmothers before us, we have access to more information about and pay more attention to the changes that a woman's body endures during pregnancy and postpartum. This does not, however, mean we have learned it all and sadly, most women are not given the resources they need to understand these changes, identify them or correct them (when possible). In this blog post, I take a deeper look at a rectus diastasis– a condition I see often when I have postpartum moms seeking procedures like a “mommy makeover” in my plastic surgery practice. While traditionally thought of as a more aesthetic concern– leading to widening of the waist or expansion of the core– a rectus diastasis is now being recognized as a key component of chronic, postpartum symptoms such as weakened core, lower back pain and pelvic floor dysfunction. While a rectus diastasis is often not the sole contributor to these issues, it may play a larger role than conventionally thought.
WHAT IS A RECTUS DIASTASIS AND WHY DO WE GET IT?
The most common reason for a rectus diastasis in pregnancy, though it technically can occur with anything that causes chronic increased intra-abdominal pressure such as weight gain or with genetic predisposition. During pregnancy, the paired rectus muscles migrate laterally from their midline position to accommodate the increasing size of the fetus and uterus. In the weeks and months postpartum, the muscles can slowly move back to their original midline position. Oftentimes, the muscles either entirely fail to return to their midline position or only partially return to the midline leaving a palpable and/or visible gap either above, below or at the belly button. This gap is what we refer to as a ‘diastasis’.
ARE THERE SYMPTOMS OF A RECTUS DIASTASIS?
Symptoms occurring secondary to a rectus diastasis are wide-ranging and sadly both under-examined and poorly understood. As a key stabilizer of the “core” muscles of the abdomen, the effects of these muscles being out of alignment are often wide-ranging and can include the lower back and pelvic floor. Most patients report a bulge of the abdomen due to weakened fascia. In extreme cases, this can give the appearance of residual pregnancy even though a patient is postpartum. I have even had patients report elimination of their abnormal GI symptoms (mainly constipation) after a tummy tuck and diastasis repair. Now while this might feel like a stretch, the fact that there is no evidence to support such a benefit could simply mean it hasn’t been studied yet. And when it comes to women's anatomy and health, there is a lot that hasn’t been studied.
Many women who come to see me in my Seattle-based plastic surgery practice for procedures like tummy tucks or a “mommy makeover” have no idea they even have muscle separation. During all my consultations regarding abdominal plastic surgery procedures, muscle separation is examined with the patient lying down and lifting both their legs simultaneously. This flexes those rectus muscles and allows me to directly feel their positioning relative to the midline and to one another.
NON-SURGICAL CORRECTION:
Not everyone has to jump right into plastic surgery if they suspect or discover they have a rectus diastasis. In fact, 60-90% of postpartum women will have muscle separation that lasts for months after giving birth before things start to improve. Despite time and some intervention, namely schlepping a baby around and returning to as normal an exercise routine as one can with a new human around, a little less than half of women will have a persistent rectus diastasis that extends past 6 months postpartum.
Non-surgical interventions are the best way to start, irrespective of the cause or duration of your rectus diastasis. Physical therapy is a great resource for patients to help guide them through exercises that will target their specific anatomy and meet them at their specific physical abilities. The best place to start is by finding a PT that has experience in postpartum women, the pelvic floor and rectus diastasis (literally just Google these and add a ‘near me’). Definitely make sure to cross-reference this with your health insurance provider to see if any specialized providers are covered under your healthcare plan as physical therapy can be expensive and time-consuming. If no physical therapist is covered under your plan, consider going once or twice in order to learn the exercises and tools that can be implemented at home in a self-directed manner.
The way we think about abdominal exercises as it relates to the deep core muscles is often completely misunderstood. Your abdominal wall is constructed in 4 layers: the rectus muscles running vertically in the midline, and deeper to this are the external oblique, internal oblique and transversus abdominis muscles that circle around your abdomen in layers and build your “core”. When we think about abdominal exercises, we mainly refer to exercises that work your rectus muscles or your obliques. And for a rectus diastasis, it makes sense to want to work those muscles that are involved. The key muscles to work for rebuilding your core after pregnancy and correcting a rectus diastasis, however, are actually your “deep core” involving your transversus abdominis, the muscles of your pelvic floor, the diaphragm and deep and tiny back muscles. Targeting your deep core takes practice and patience, but there are an emerging and ever-growing number of resources available online.
WHEN TO CONSIDER PLASTIC SURGERY:
As a female plastic surgeon, the patient’s I see have either maxed out non-surgical methods for rectus diastasis correction or are seeing me for procedures such as a tummy tuck or breast lift. More often than not, however, women don’t even realize they have a rectus diastasis until I have examined them during consultation. I see this as an obvious consequence of our lack of care and education for the postpartum woman and her body, but I will leave my two cents there. A rectus diastasis repair can be performed simultaneously during most types of tummy tucks but is not performed (at least in my practice) as a stand alone procedure.
HOW A RECTUS DIASTASIS IS CORRECTED:
As stated above, a rectus diastasis can be repaired during a tummy tuck plastic surgery procedure. During a tummy tuck, the skin on the abdomen is lifted up in order to stretch it downwards and remove the extra, loose skin. During elevation, we are able to directly visualize the rectus muscles, their position, and the fascial layer between them. Layers of stitches are then placed to close the fascial gap between the muscles and realign them in their original, anatomic position. I will generally place two layers of sutures during this procedure to increase the strength of my repair. In very wide diastasis repairs, our suture repair can also be reinforced by the placement of mesh. The stitches are permanent, but we also rely on the body’s ability to create its own layer of scar which only serves to strengthen the repair over time.
It is important to remember that separation of the rectus muscles can occur anywhere along the muscles, and may not occur over the entire length of them. In a traditional tummy tuck or a fleur de lis tummy tuck, the entire length of the muscles are exposed, and thus a repair anywhere along the length of the muscle is possible. In some women though, there is an isolated diastasis above the belly button. If a mini tummy tuck is performed in these patients (which generally does not expose the upper portions of the muscles), repair may not be possible. Ultimately, you and your plastic surgeon will decide upon the most appropriate procedure for your needs and aesthetic goals during your plastic surgery consultation.
CONCLUSIONS:
Traditionally thought of only as an aesthetic adjunct to help narrow the waist during a tummy tuck surgery, rectus diastasis repair is now recognized as an important restoration of function to the female core following pregnancy. The symptoms of a rectus diastasis can be wide-ranging and insidious, as they often overlap with many other fallouts from pregnancy such as pelvic floor dysfunction and urinary incontinence. If you are considering a tummy tuck plastic surgery procedure, that is the ideal time to pursue a rectus diastasis repair. To learn more about the types of tummy tuck procedures available and to discuss if a rectus diastasis repair is right for you, schedule your consultation today.
Dr. Megan Dreveskracht is a Female Plastic Surgeon in Seattle, Washington who specializes in Aesthetic Surgeries of the Breast, Body & Face. To schedule your consultation, call 206.860.5582 or fill out a contact form here.
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