I’ve thought about a tummy tuck since I had my second child, who left me with a C-section scar, a bunch of stretch marks, and a wider mid-line between my rectus muscles, but I was warned as a female bodybuilder that I might not like the results. Why is that?

Women bodybuilders can benefit from tummy tuck (abdominoplasty) surgery, but there are a few considerations that surgeons must be aware of that are less important in many women who have this procedure. A tummy tuck usually does two things. First, it removes extra skin and stretch marks, generally including the skin between the lower abdomen (where you may find a scar from a C-section) and the belly button. To accomplish this, the skin is lifted off of the underlying muscles, exposing the rectus abdominus muscles and their overlying fascia. This allows the skin to be pulled down toward the feet, and the extra can be cut off. A mini-tummy tuck won’t remove as much skin, since it doesn’t usually do anything (or very little) for the area above the belly button.

The second thing that is done once that fascia is exposed is that the fascia can be tightened. Conditions such as pregnancy and obesity can stretch the fascia, causing the rectus muscles to be separated by more than a fairly typical centimeter. The fascia between the muscles, referred to as the “linea alba” or white line, will appear widened in bodybuilders who have experienced this sort of stretching, and you’ve certainly seen this in men and women in contest condition. This is referred to as “diastasis recti.” Tightening of this tissue can effectively narrow that midline back to a centimeter, which also flattens the stomach a bit. Most people don’t have a visible “linea alba” below the belly button, so tightening it in that area may not alter the appearance of the abdomen, but tightening it too much above the belly button can eliminate the midline and make the stomach look strange, with a wide three-pack instead of a six pack divided by the midline. In my bodybuilding patients, I narrow it specifically to just one centimeter to avoid a peculiar appearance. The other consideration comes with dealing with skin excess. As long as there is enough skin to permit a full tummy tuck, the extra skin is removed and the belly button will remain in its normal position. In patients for whom a full tummy tuck isn’t indicated based on skin laxity, a mini-tuck can be done. One technique that is sometimes used in such cases is referred to as “floating” the belly button—leaving it attached to the skin but releasing it from the abdominal wall, allowing it to reposition lower. This isn’t a great option in bodybuilding women, since it looks peculiar as well due to a lower location for the “floated” belly button.

If you’re considering a tummy tuck, you may want to make a point of these issues of normal anatomy with your surgeon in order to assure that he or she will preserve a normal appearance for you. Left to chance, you may end up with something that you don’t like, and correcting the problems (over-tightened midline and low placement of the belly button) is very difficult.

Everyone is going on and on about how great Botox is. I am a little worried about getting something that paralyzes muscles injected into me—I’m a bodybuilder and I want all of my muscles to be strong.

I have had a few bodybuilders question me about the use of Botox and more recently, Dysport (similar product, different manufacturer), since they seem to worry that the effect could go beyond the facial muscles where the product is injected. Rest assured that the effect is very local, even to the extent that adjacent facial muscles can be manipulated by injecting or not injecting in a certain spot to allow for the brows to lift, or even to correct mild facial asymmetries.

Interestingly, an observation that I’ve made is that Botox doesn’t always work maximally in bodybuilders, perhaps due to hypertrophy of facial muscles, thus requiring more than the average amount to be injected. What this means is that if you get a treatment and it doesn’t seem to do much, don’t write it off as ineffective—It will work. Instead, be sure that your provider will back up the initial treatment with a touch up to maximize the effect. I like to give the initial product at least a week to ten days, since it may just kick in slowly. After that, judicious re-injection based on persistent activity can provide a more effective treatment.

From the wrinkle perspective, the Botox stops the muscles of the face from contracting, and those contractions are what cause the wrinkles to form on the skin surface. Halting them will initially soften and often eventually eliminate the associated creases. The effect lasts three to four months in most patients, but this is another area where bodybuilders may be different, requiring a re-injection sooner than non-bodybuilders. Typically, this treatment is used for the wrinkles between the brows, wrinkles of the forehead, and the “crow’s feet” around the eyes. If these things bother you, it’s worth checking out.