January 2010


I answered a question recently about timing of a mommy makeover.  The person was traveling out of state via plane to have the surgery done.  I tried to redirect her to the real issue: how safe is travel to have surgery?

plane

Mommy makeover is a combined surgery of breast and body.  Her question was when to do surgery after you stop nursing (I would wait 3-6 months, and be close to your ideal weight if possible).  The bigger issue I saw was her travel from New York (place with many great doctors) to Florida for surgery.

There are short surgeries with easy recoveries, and there are long surgeries with long recoveries.

Mommy makeovers are usually two surgeries done at one sitting.  In most healthy women, it is safe.  But combined surgeries have higher risk of bleeding, anesthesia complications, DVT, infection, and other issues.  You are at higher risk for a DVT for 3-4 weeks after surgery, making airline travel riskier.  If you do a tummy tuck, you will have a drain.  In heavier women, that drain can stay in for 3-5 weeks after surgery.

If you have a complication, it will be difficult to get to your doctor.  A local doctor will be hesitant to treat you.

Find someone close to where you live.  If you live in a small town, then go to a nearby larger town.  For a qualified surgeon near you, find someone board certified by the American Board of Plastic Surgery.  Meet a few doctors.  You’ll know the right one when you meet them and see their photo books.

(I do have patients travel to have me do surgery.  Usually though they have family or friends near me, and I require they stay around for 2-3 weeks depending on the scope of surgery.  It is not ideal.)

When I started my practice a decade ago, most of my breast reductions were covered by insurance.  I think they are a great surgery, improving posture, neck pain, back pain, shoulder notching, and the ability to go jogging.

Things have changed.

Now almost none of my reductions can get covered. It is frustrating for me and my patients, as I see many large breasted women who can’t get covered.  What changed?

First, I now do a short scar breast reduction technique, called a vertical breast reduction.  I “cut out” less breast tissue with this technique.  Why did I change?  First and foremost: much shorter scar.  Also, I find this breast reduction better at shaping, with a longer lasting result.  I love it.  But with this technique I do liposuction of the lateral breast in the armpit area.  Insurance won’t include this fat as part of my “breast tissue removed” total.

Second, the amounts they require have gotten higher.  Not a good combo with my short scar technique where the amounts I directly cut out went down anyway.

scaleThe Schnur scale came out of a study in the plastic surgery literature.  They did the study to prove breast reductions objectively, medically IMPROVE symptoms. During the 1980s plastic surgeons started to see insurance companies refusing to pay for breast reductions, calling them “cosmetic.”  So multiple studies followed, documenting scientifically that back pain, neck pain, and breast pain had about an 80% improvement after surgery.  (And patient satisfaction was around 90%.  Pretty fantastic, particularly given those were the days of the longer anchor scar.)

The Schnur study came up with a scale used to show the volume which needed to be removed for breast reductions done for medical reasons only.  The issue is the Schnur study had a mean height of patients being 5’4″, 163 pounds, and a mean total amount of breast tissue being removed was 1515g. (That is over 3 pounds per breast.)

Ug.  When I started my practice, if a woman was going down about 2 cup sizes, they would get covered.  I used to have to remove about 300g for insurance coverage.  Now it is adjusted to the body surface area, and the required amounts have gone up.  With current recommendations, a 5′6″ woman who weighs 140 pounds needs a reduction of 370-400 grams per breast to be covered.  If she weighs 160, she would need about 450 grams per breast.  Liposuctioned fat cannot be applied to this total.  In my office I can show you visually what “volume” (using an implant sizer) this would be.  Many times the amount looks like the total of the entire breast, essentially being a mastectomy.

You don’t need to convince me a breast reduction and lift is a good idea. Insurance is another story though.

BODY SURFACE AREA CALCULATOR at http://www.bcbst.com/providers/calculator.asp

SCHNUR SLIDING SCALE at http://www.bcbst.com/mpmanual/The_Schnur_Sliding_Scale_chart.htm

Short answer: Yes. You can get pregnant after a tummy tuck.  That being said, every plastic surgeon you meet will tell you to tuck after babies.  Why?

Well, what makes you want to get a tummy tuck now? You are likely

stretched out,

hanging or loose skin,

loosened muscles,

and maybe stretch marks.

When we do a tummy tuck we 1. tighten the muscles and 2. tighten the skin.  Another pregnancy will do the opposite.  Your muscles and skin will stretch to accomodate the pregnancy.  Your internal stitches to tighten the muscles will likely loosen or rip.  Your skin will stretch  and if you are prone to stretch marks, you will likely form new ones.

STORYTIME:

I had a patient who had major weight loss. 100 pounds.  She came to me for a tummy tuck.  She also was 30 ish, and when I asked, she said she wanted children in the future.  She was a great tummy tuck candidate- she had horrible stretch marks and hanging skin.  But I told her to wait.  Why? She is 30.  She can’t wait too long to have kids due to that darn fertility time clock.  She formed bad stretch marks from her weight gain.  People who form bad stretch marks tend to do it again.  The stretch marks now are mostly on her lower belly, and I will remove them when I tummy tuck her.  If I tuck her now and tighten the skin, when she gets pregnant she will form new stretch marks.  These stretch marks will go where she stretches, which includes above the belly button.  I most likely won’t be able to cut these out after her pregnancy.

IF she waits, she is “prestretched” for her pregnancy (from her prior 100 pounds of weight.) She will likely look just like she does now after the baby.  I can then tuck her after the baby, and likely get rid of her stretch marks.  It is also one less surgery.

And, something doctors don’t talk about, but being pregnant can be tough.  Watching your flat belly stretch… and stretch…and stretch is hard to do.  When you”fixed” your belly with a tummy tuck and your new pregnancy and baby is now “ruining” it – that is not a good dynamic.

If life throws you a curve ball, then it happens.  But if you are planning things out, think of your body for the long haul- what will be the best result 10 years down the road.