Belly


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.)

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.

Ah. The joys of being female.  All those lovely “woman” things, sometimes can lead you to need a hysterectomy.  Ug.  But can there be a silver lining? If you have to have a hysterectomy, can you do this with a tummy tuck?

For those with no attention span, the quick answer: Yes.

But there are conditions….

1.  Hysterectomy needs to be done for a benign condition.  If you have cancer, you need to focus on the treatment and healing for that.

2.  You need to be healthy.  Hysterectomy is a big operation, which has blood loss, healing, yadda yadda.  I had a patient who needed a hysterectomy due to intense heavy bleeding each month.  She was a great candidate for a tummy tuck.  I would have loved to do them at the same time.  But she was anemic.  NOT OKAY to do tummy tuck.  A tummy tuck is a cosmetic surgery.  It lengthens the time of surgery, causes more blood loss, and increases overall risk.  If you are anemic, you won’t heal the long incision well- you have higher risk for infection, wound dehiscence (fancy way of saying your wound opens up), poor scarring, etc.

3.  A lot of benign conditions which used to treated in the past by total hysterectomy such as heavy bleeding or fibroids, can now be done by less invasive means such as ablation.  Can’t have a tummy tuck with a hysterectomy if you don’t need a hysterectomy.

Any combined surgery has higher risk of complication, wound infection, DVT/PE, and anesthesia reactions such as nausea, etc.  In healthy women, this additional risk is low, and the benefits of one anesthetic, one surgery, and one recovery outweigh the risk.  For busy moms and working women, doing the 2 for 1 is the only way they will get to have a tummy tuck.  But we must keep in mind this is elective, cosmetic surgery.

For those who fit the criteria and are healthy, go for it! I love buy one, get one free. It’s the like tummy tuck was on sale. What girl doesn’t like that?

Yup. That’s right. Go raid your kids toys. There is a use for those marbles.marbles

The marble trick is supposed to help “round” out the belly button and/or enlarge it a bit if it is starting to constrict down too much.

Unclear how well this works, but I have had some patients with success.  Don’t make it too big- We don’t have a “shrinking” technique for belly buttons which are too big.

The marble trick:

If you have a small or slit like belly button, you can try the “marble trick.” 

Once healed (likely at least 2-3 weeks out from surgery), you put a marble into the belly button and tape it or hold it down. 

The first time do it for 15 minutes and see how you feel. Is it sore? Irritated?

Make sure the marbles are clean (alcohol or antibacterial soap)

Clean and change it out daily. You can work up to a few hours daily.

What is the thought?  The idea is the marble serves as a kind of stent to help massage the scar, soften it, enlarge the area, and round it out a little.  ? Not sure how much it works, but it’s worth a try.  Just go steal a few of your kid’s marbles of different sizes, and you can gradually upsize.  Just don’t overstretch it.  That you can’t reverse.

Mini. I love that word. Mini connotes cute. Mini skirts, the mini car, mini M&Ms. Adorable.

So who doesn’t want mini facelifts and mini tummy tucks?

A mini tummy tuck is not a tummy tuck. There is a place for it, but the application is limited. A mini tummy tuck involves removing skin and fat below the belly button only. If you have no issue with loose skin above the belly button and have tight muscles, then the mini is a good way to get rid of the extra little pooch of skin from the lower belly.

I find most of my mini patients come from two categories:
1. skinny women who get the muffin top when they wear tight lowrider jeans.
2. more overweight women who have thicker fat who need aggressive liposuction, but will end up with some loose skin in the lower belly if we don’t tighten it up a bit.

A benefit is you can position the scar as low as you want, and there is no scar at the belly button. But there is a scar, and the more skin you remove, the longer the scar will be. Sometimes the “mini” scar is not much smaller than a true tummy tuck scar.

Recovery from a mini tummy tuck is as expected- It is mini too. It is not very painful (woo hoo! Those real tummy tucks can hurt. So you Bay Area girls can get back to working out faster), because mini tummy tucks do not tighten the muscles.

So, are you a candidate for the mini? If your skin is only loose below the belly button, you don’t have much diastasis (separation of the muscles), and you scar well, it may be a good option for you.

But sometimes mini isn’t better to get what you want.

We have established it isn’t a good thing to do the tummy tuck with C section.  I know. I know.  I’d love it too.  But it just isn’t a good idea.  So when can you do it?

When is good timing? Here you will get varied answers.  Most plastic surgeons will advise 6 months or more.  Most will advise trying to get to your pre pregnancy weight.

My advice?

  1. KNOW YOU ARE DONE WITH KIDS.
  2. Wait at least 3 months: you lose blood during delivery and need to give your body time to rebuild up its blood stores.
  3. Get back to prepregnancy weight.
  4. Work out and focus on your core.
  5. Be done with breastfeeding.  I would wait a couple months after breastfeeding so you can build up your nutrition again.
  6. See a Plastic Surgeon.  Make sure you don’t see someone who can only do liposuction– you need someone to evaluate you who actually can do a tummy tuck or liposuction.
  7. Know the “price” you are willing to pay for surgery.  (For this please see my blog on the grey zone for tummy tucks at bodypostbaby on wordpress.)

Life isn’t always black and white.

In fact, as we get older, I find little is black or white.  Women come in to see me after having children to look at their belly, and many expect  answer.  “You should do _______. Let’s sign you up for surgery next week.”  I’m not that kind of doctor.  Some women come in and are a clear tummy tuck candidate.  Others come and are clearly not.  And then… dum ta dum dum… there are those who fall in between.  The dreaded grey zone.

I’ve had three kids.  I know the grey zone. I’m in the dreaded grey zone. My belly used to be beautiful- not take photos of it and put them on a magazine beautiful, but flat and strong beautiful….though of course I didn’t appreciate it until I lost it. (Is there a country western song about this?)  I look at my belly, and I don’t love it, but I also don’t mind it.  There are those days where I think it looks pretty good, and those days it doesn’t.  But then I look at my kids and I know it was worth it.

So if you aren’t thrilled with your tummy, should you try to improve it?  As a woman surgeon, I think a lot about the scar of a tummy tuck.  Will you think about it? Let’s say we do the tummy tuck and the scar fades to nothingness, which is what I expect for most of my fair skinned patients.  So you have a teeny tiny line of scar across your belly and around your belly button.  Now you get dressed.  Are you going to think about the scar? Will you be concerned it shows? Will you reposition your underwear? With all of our tiny underwear and low rider jeans and running around all summer in a bathing suit chasing kids.  I think about the scar with every patient.

Many women I see fall into a grey zone- They aren’t what they were before kids (sigh.) but they aren’t bad.  If you stand up really super straight the belly skin looks okay. (don’t slouch!)  So should these women do a tummy tuck?

My advice for women waffling in the grey zone?  Wait.  Wait a couple years. Work out.  Do core training.  See what you can do.  Then evaluate if a tummy tuck is the right surgery for you.  When these patients come in for a consultation, I take out my very sophisticated advanced medical tool: a black sharpie pen.  And I draw (shhhh. don’t tell my kids) on your skin where I think your scar will go.  Then you go home and try on your clothes and stare at yourself in the mirror.  Imagine your skin is tighter; your belly flatter; and ohmy you have a waist again.  How do you feel about the scar?

Tummy tucks are big surgeries with a high “price”- they are painful, have bigger scars, and longer recoveries.  Don’t do it unless you need to.  Some women are just plain blown out after babies- hanging skin, stretch marks, or they look 5 months pregnant all the time.  These women really benefit from a tummy tuck.  But these women are not in the grey zone.

I get asked this question a lot.  “Why can’t I do a tummy tuck when I get a Csection?” Sounds good. Some people look at me like, duh, why haven’t you thought of this?

Anyone who has been pregnant knows their body is not normal at the end of pregnancy. During pregnancy your blood volume grows by 50%. If you labor hard, everything down south is swollen. Your body has been dedicated to creating a healthy baby, depleting your body of some nutrition. If you breastfeed, that continues. Your weight is not normal. Most of us have not worked out for months, and even for you uber Bay area athletes- admit it: you can’t really get a good core workout with a giant baby in your belly.

We plastic surgeons have thought about it. You are in surgery, anesthesia, everything is stretched out….. But a true tummy tuck is a big surgery. It is two layers- the bottom layer tightens your muscles at the midline where you formed the diastasis. The second layer is the excess skin. When we mobilize the skin, we undermine it from the pubic bone all the way up to the ribcage.

Many Csections are after laboring and failing vaginal delivery. The patients are exhausted and swollen, and so is their tissue. You have significant blood loss during delivery. There have been studies in the past which linked combined surgery to higher complications. Please reread paragraph one again.

Elective cosmetic surgery is that. Elective. Cosmetic. It must be SAFE. You need to be well, healthy, energetic. You have a newborn to feed and care for and lift. Blood loss, poor wound healing, opening of your incision, bleeding, inability to lift heavy objects, staying bent at the waist, drains, liquids only for the first few days- it is too much.

What about the people who advertise “Tummy tuck with C section, Get a 2 for 1!” Those are not true tummy tucks. That is usually a little wedge of extra skin off the lower belly. A small skin wedge is akin to a miniabdominoplasty and adds little extra risk. This is not a tummy tuck. During this procedure they are not tightening the underlying muscles, nor are they addressing any of the loose skin or muscle above the belly button.  But if you have to have the C section, why not take a little extra skin? I am not against it.  Removing a wedge of skin will lengthen your C section scar, but it may be worth it.

As for the real tummy tuck with the C section…. I get it.  I would love the two for one.  I would love to have been done with my third kid and come out looking like a movie star.  But it is surgery.  A big surgery.  And to do it right, your body needs to be normal.  You need to be healthy.  You need to have normal blood levels and nutrition.  And you need to be able to focus on YOU.

You just gave birth.  You are lucky.  Focus on your beautiful baby.  Trust me, your baby isn’t looking at your belly….  They have other parts of you they want.

I was recently the featured interview for an online magazine for busy moms to talk about the mommy makeover.

http://bizymoms.com/palo-alto/surgery/mommy-makeover-palo-alto.php

Oh my.  How confusing all this liposuction stuff is, even for me, a Board Certified Plastic Surgeon. If it confuses me, I can only imagine how it must confuse others. So here is a quick and dirty breakdown of what is out there, and my opinion of what it does…

UAL, ultrasonic, Vaser liposuction

  • UAL is ultrasonic liposuction.  It uses ultrasonic energy to help fat cavitate, or liquefy/break up.  It has been around since the mid 1990s.  It is wonderful at breaking up fibrous fat, and is thought to potentially tighten the skin a bit.  It never caught on as much as some other methods. Why if it is so good did it not catch on?  The machine was expensive.  They marketed mostly to true plastic surgeons (there aren’t many of us), so they didn’t sell many machines.  Some people who didn’t know how to use it well would get skin burns and issues with seromas, so they would bad mouth it.  After all this time, I am still a huge fan.  I find it is a good caliber, it really breaks up fibrous fat (which all you athletic people have, and you men, and anyone with any prior surgery and internal scar), and it helps create a smooth even result.  I still love it.
  • Vaser is ultrasonic liposuction.  A slightly smaller caliber, not quite as strong an energy as UAL.  Still effective at breaking up fat.  Good.

Laser liposuction, Slim lipo, Smart lipo

  • Laser liposuction uses laser energy to break up the fat.  Again, just like ultrasonic liposuction, the energy can potentially cause burns.  If you liquefy the fat and don’t remove it with traditional liposuction, you will get seromas.  My biggest issue with laser liposuction is the marketing.  They purposefully lead patients to believe there is no anesthesia needed, it retracts the skin well, no traditional liposuction is needed, and you will be back at normal life in a day or two.  ANY TIME YOU DO A SMALL AREA THESE THINGS ARE TRUE.  When you do any larger area, which even here with my uber atheletic Palo Alto patient population most of my patients need, they still use ultrasonic liposuction FIRST and then the laser second.  For normal sized cases where they only use the laser, it takes forever.  Because the laser is such a small caliber, it is like painting a room with a small paintbrush, not a roller.  Time on the operating room table is a risk factor for complications.  Smoothness of fat removal is important as well, and painting a room with a small brush doesn’t give that smooth airbrushed quality which a roller can.  Again, I think energy to break up fat is a good thing for most liposuction patients.  When I went to the seminar where they tried to sell me these machines, the instructors admitted for most cases they used ultrasonic first and finished the patients with the laser.  I don’t think lasers are bad.  My issue is with their misleading marketing.  Also these companies are focused on selling machines.  I am concerned about their integrity because they specifically target nonplastic surgeons to do the procedure.
  • Smart lipo. Brand of laser liposuction
  • Slim lipo. Another brand.  They argue they are faster than Smart Lipo. ??

Noninvasive liposuction.

  • No incisions. Not a surgery.  External machines which “melt” the fat, which is then absorbed into your body.   Sonosculpt, Zerona, Cryolipolysis, Ultrashape are some of the machines touted.  There is also mesotherapy and lipodissolve, where you inject fluids under the skin to melt the fat.  I was on the board of directors for a fledgling company which was trying to address noninvasive liposuction.  I think it is a fantastic idea, but has many issues still.  Most of the companies which show true reduction in fat volume could not control the smoothness and amount of fat removal.  And it was painful.
  • The goal with liposuction is not just the amount of fat removed.  You want the contour to look smooth.  I had a patient who came to me from Wyoming who had mesotherapy.  It has never really taken off for a reason.  There is no “standard” solution.  For my patient, the solution injected caused her to go into liver failure, and she was taken by emergency helicopter to Salt Lake City and was in the ICU for a week.

When fat is liquefied, it gets absorbed into your bloodstream, so safety and health issues to consider:

  • ?Change in blood triglyceride and cholesterol levels?  I recently went to a talk for a noninvasive liposuction machine.  They said the triglyceride and cholesterol levels were fine after the procedure.  When I asked for more detail (I was curious), they had only taken a single blood test six weeks after the procedure to look at levels.  That does not tell me the safety at all!  What was the level in the blood during the procedure? An hour after? 6 hours after? 24 hours?  I need to know my patients who are doing elective procedures for cosmetic reasons are safe.  If your blood stream is flooded with fat, can it cause organ damage? etc etc.
  • ?How much fat can you safely remove at a time?
  • ?Smoothness and evenness of fat removal?
  • ?Fat emboli in your blood stream?
  • ?Is the size reduction long lasting?  We all have seen massage and body wraps “take off inches” which we know will come right back after a few days.

So. I have gone into this on my website with liposuction pitfalls: I and II.  I may repeat myself a bit, but I hope to educate you and demystify the madness a little.  I like to think of myself as a girlfriend’s guide to plastic surgery.

Tell a friend.  I am always so sad when I meet a patient after they have been snookered into surgery by promises of a rainbow: no pain, no surgery, no scars, no downtime.  And some things I can’t fix.

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