For many years, diastasis of the rectus abdominis muscles, especially in women after pregnancy, has been considered a purely aesthetic problem, and that is why its approach has been carried out by plastic surgeons as another step in an abdominoplasty.
Fortunately, the understanding of this issue has evolved and it is time for a paradigm shift, since diastasis can lead to certain physical problems that elevate it to the category of pathology.
To address this topic rigorously, we must first understand that we speak of diastasis when there is a separation between the rectus abdominis muscles in the midline of the abdomen of at least 3 cm, which leaves the central area of the abdominal wall more weakened and us It gives a bulging sensation that can be confused with a hernia. It is relatively common for a diastasis and a midline abdominal hernia to coexist when there is also a fascial defect, especially an umbilical hernia.
We do not know the real frequency of diastasis in the general population, but some studies place it around 70%. Its incidence increases with age and obesity, although it does not usually cause symptoms in the vast majority of cases and no treatment is necessary.
When symptoms occur, they are usually: difficulty getting up, chronic lower back pain, abdominal bloating, constipation or urinary incontinence. Symptomatic diastasis usually occurs after childbirth, which is why it must be assessed differently and individually.
During pregnancy, the rapid increase in volume that occurs in the abdomen not only produces excessive tension and, consequently, stretching of the tissues with the consequent loss of elasticity thereof, but also causes elongation and loss of of strength of all the muscles in the area.
The abdominal wall must be understood as a tubular belt that is formed by the rectus anterior muscles (the “chocolate bar”), the lateral muscles (of which there are 3), the lumbar muscles, as well as the pelvic floor muscles. They form a whole that we call the core. When in a diastasis one or more of these elements are too weak and do not perform their function correctly, that is when symptoms may appear and action must be taken to correct the problem.
Understanding why and how a diastasis is established is vital to understand the treatment to follow and to achieve an optimal result, not only aesthetic, but also functional. Classically it has been treated solely with cosmetic surgery, sewing to reduce the distance between the rectus muscles and eliminating excess skin if necessary, but ignoring the fundamental problem of core weakness.
That is why the ideal approach to diastasis has to include treatment of the core, to achieve the best functional results and minimize the risk of recurrence. To do this, I apply a complete program, which I have called the ECR Program (from the acronym Training, Surgery and Rehabilitation).
Firstly, we started a training plan led by a physiotherapist specialized in core and pelvic floor for 6 months before considering surgery. This phase requires consistency and effort to perform the exercises every day. Sometimes, only training can correct the symptoms and there is no need to undergo surgery.
Once the training phase is over, if the problem has not yet been corrected, it is time to talk about surgery, and we have two ways to approach it.
The first is the abdominoplasty. We indicate it when there is excess skin, which means making an extensive scar in the lower part of the abdomen due to the need to remove the “skin”. This surgery combines rectus plication (the bringing together of the rectus muscles using sutures) and a dermolipectomy, which consists of removing excess skin. In most cases it is necessary to reimplant the navel so that it remains in its initial position.
The second way to approach it is minimally invasive rectus plication, which is performed by laparoscopy and is the most aesthetic option possible since we only make three small incisions of between 5 and 10 millimeters, which are hidden by underwear. It can only be done when there is no excess skin. The most widespread technique is what we call REPA (Endoscopic Preaponeurotic Repair). An extended modality is the technique called MILA (Minimally Invasive LipoAbdominoplasty), which includes liposuction in the same act, but is only recommended if this surgery is performed for purely aesthetic reasons.
Once the surgical phase is completed, the program is completed with 6 months of rehabilitation to finish strengthening the muscles and learn which exercises we should do and which we should avoid.
The big question is always what is the best time to assess the status of a diastasis, so some advice for those of you who have just become mothers: be patient. Until at least 6 months have passed after childbirth, it cannot be truly assessed whether you have a diastasis or not. If after that time you think you may have it, and you do not want to be mothers again, it is time to consult with an abdominal wall surgeon to talk about how to treat it. The specialist will guide you throughout the decision-making process and will offer you the most appropriate treatment in each case.
In summary, a diastasis is not a merely aesthetic problem and can be cured, but it is not an easy path that requires commitment, effort and perseverance.
