I have a friend who lives in LA who just had a tummy tuck and breast augmentation.  She is on her first day after surgery.  She is a tough cookie, and her words to me today were, “This really hurts!!”

One of the most common mommy makeover surgeries is breast augmentation and tummy tuck.   These by themselves are the two most painful surgeries we do as plastic surgeons.  These surgeries hurt because of the muscle.  For tummy tucks, I like to put in a pain pump which drips numbing medication internally to help.  In addition we give you pain medication and some of us use muscle relaxants as well.  Even with all of this, it still hurts.

For planning how to deal with your family life (as you are a mom, hence the mommy makeover):

• the first 2-3 days you are OUT. You will be on medication round the clock.  Someone else should care for your kids.  And you. 
• The first one to two weeks you will be very sore.  No driving until you are off pain medication.  As for when you will feel normal again and be doing your daily life things, people vary.  Every person is different as to when they get over the “hump” and feel better. 
• No heavy lifting (yes, this includes your adorable children) until much farther out.  Exactly when you can lift something over 5-10 pounds is not a hard rule.  Some of it depends on you and your tissue.  Your doctor will know what that means.  Here plastic surgeons differ on their recommendations for activity level, so defer to your doctor.  Tensile strength of your wound (how strong your repair is) is weakest at three weeks out from surgery.  Usually you can’t do any exercise until at least 6 weeks out.  For core body exercise (pilates, crunches, that favorite daily method place in menlo park, etc) I extend that until 3 months.

Give yourself time.  It took you 9 months (and for those of you with multiple kids, multiply that time) to get into this mess, it will take you a while until you feel normal again.  This is normal.

But she has been reading my blog (Go Bay Area blog reading mommies!) and said, “I know I should wait for 2-3 years until I do surgery, but I don’t want to wait.”   I realized I have not been clear.  It is true, the most common time I see women after babies is about 2-3 years out.  I think that timing is good- you have gotten out of the fog of babydom and given yourself a chance to get back into shape and see what comes back … and what doesn’t.  So the flip of that…

When is the soonest? Should you wait?

• Normal blood level.  You lose a fair amount of blood after birth.  You need 3 months to rebuild your blood store.
• Nutrition.  Your baby has spent the last 10 months preferentially getting your nutrients.  You need time to restore. 
• Sleep.  Surgery is a stress on the body.  I liken it to running a marathon.  If you are sleep deprived you won’t have the reserve to help you heal well.
• Breastfeeding.  Breastfeeding continues to take calories, energy, and nutrition for your newborn.  I am a HUGE breastfeeding fan.  The benefits to you and your child are immense.  If doing breast surgery, you need the breasts to be empty of milk, which takes about 3-6 months after you stop breastfeeding.  If doing other surgery, you can’t breastfeed at the same time- it would be too tough on your body to devote energy to healing and to your baby, and the medications needed for surgery and healing would get in your milk.  Also, see the nutrition point- breastfeeding can deplete you, so you need time after you stop to rebuild your internal stores.

My two to three year window is for women in the dreaded grey zone.  The grey zone? Those women who’s breasts and bellies aren’t like they were before babies, but they aren’t so bad.  In the right time of day, right angle, or if you stand up straight (posture girls!) you look okay.  Those are the women who should wait. 

But some women have things time will not help.  Particularly for the abdomen, horrible stretch marks, a wide diastasis (separation of the muscles), hernias, and hanging skin won’t go away with time and exercise.  Two years will not make these better.

So see your doctor.  Every patient and situation is different.  I get timing is tricky.  Many of you work, have multiple kids, and husbands schedules and other things you juggle.  But this is elective surgery.  And I know, from the title of this blog, you have an incredible responsibility- you are a mom. 

Elective surgery needs to be safe. 

There is a time and place for everything. Talk to your doctor.

It is one of those things we discuss for our entire lives.  Watching what we eat, trying to fit into jeans, comparing ourselves to others while changing in the locker room.

A recent study in Nature magazine showed some interesting facts.  The basic jist:  the number of fat cells you have as an adult remains constant through your adult life.  They postulate that number is formed by the amount of fat cells you have in childhood and adolescence.  When you gain weight as an adult, you are enlarging the fat cells you already have.  When you lose weight, you are shrinking them.  As a kid though, when you put on weight, you add fat cells. 

Their thought? If you gained weight in childhood, you have more fat cells, and it is harder for you to lose weight as an adult.  For those who gained as adults, their fat cell number was determined when they were kids, so they don’t have as many cells, therefore  it may be easier for them to lose weight.  (Maybe this has something to do why some can lose the baby weight easier than others?)

• The number of fat cells rises until age 20
• The number then remains constant
• The number of fat cells is linked to BMI (your body mass index)

They found patients who had stomach stapling had no change in the fat cell number despite losing 18% of their weight.

Bottom line: Keep your kids healthy during adolescence.  Their fat cell number is set as an adolescent for the rest of their life.

Give yourself a break.

I know it is tough.  We see magazine articles of “how famous so and so actress lost her baby weight in three months!”  And there will be some lovely article about broiled chicken and fish and salad and yoga.  Or better yet, “I lost the weight just chasing after my kids.” Oh how lovely.  Here in the Bay Area there are many uber athletic thin women.  Some women I know look smaller when they are 9 months pregnant than the average American woman is non pregnant. 

Give yourself a break.

There are those genetically blessed women who “pop” right back into form quickly.  Yes, it isn’t all genes.  Keeping in shape while you are pregnant, not gaining more than the baby weight, not using pregnancy as carte blanche to try all the flavors of Ben and Jerrys … these all are important. 

But at six months out with a new baby, particularly if you have other children, and are breastfeeding/ working/ making dinners/ laundry/ cleaning up/ making lunches/ bathtimes/ buying diapers/ afterschool activities/ playgroups/ clean the house again…

There is a time and place for everything.  Sometime not so far away, your baby won’t be a baby.  He will be sleeping through the night.  YOU will be sleeping through the night.  I see the majority of my mommy makeover patients 2-3 years after their last child.  I think that timing is good.  It gives you time…. time to enjoy being a mother.  Time to breastfeed.  Time to give your body a chance to get back to normal.   Then you can work out.  Diet.  Exercise hard.  See where you can get to on your own.   

So give yourself a break.  Your baby won’t be a baby for long.  Savor every moment while you can.

Yes, yes. I admit.  I flip through it.  A guilty pleasure I am sure.  It is a bit of “plastic surgery” research though as well.

This will be a quick post, but The March 8 2010 issue had on the front cover, Nicole Eggert. “How I lost 15 pounds!” So I read the article.  I saw the photos.

She did lose weight.  She does look better.  But I have a strong suspicion this was not just her eating plan of not skipping breakfast, eating a large salad for lunch, and broiling fish for dinner.  So I searched online to see if anyone has the scoop on what she did.  In looking at her photos, I can’t quite see her moles on her 2009 photo to compare to her current one.  In her 2010 photos she is lifting her hands above her head (we all look better that way), so I can’t quite tell how tight her skin really is.  Why would I look for moles and skin tightness? My strong suspicion is she had liposuction, a tummy tuck, or a mini tummy tuck. When you have a tuck, your skin is tightened and walah, your moles would move.

So why am I writing about this? Trust me, I am a busy surgeon.  I am not searching gossip columns to dish on celebrity surgery.  But this People magazine article makes me mad.  Women who have children frequently don’t have the bodies they did before having children.  And for many, it is not eating too many hamburgers and being a couch potato which causes it.  I have many patients at their ideal weight, who do work out daily and eat well, and “can’t tone things up.”  They can’t tone it up because their muscles are separated and their skin is stretched. 

I don’t want people to read this article and think “If I just eat broiled fish for dinner, I can look like that too…”  This is misleading.  This is not the whole story.

So I don’t know what she did.  I am glad she feels better and is in the best shape of her life.  She looks great.  But we mortal women who have had children should not read these magazine articles and think they are reality.

Though maybe we should all raise our arms over our head when we take photos.  It is a simple thing to do.  And that will make our bellies look better.

I hear patients say all the time “I can tone that skin up later when I start to exercise again.”  Ug.  I am the poor girl who has to correct them.  I have to tell them that unicorns and faries are not real.  I wish you could retighten the skin.

Things that do not tighten the skin:

• exercise
• improving the underlying muscles “toning”
• creams
• lasers
• massage

Wouldn’t it be great if we could just take off our skin and throw it in the dryer? Shrink it right back up like those jeans you can barely get on after the wash?

But alas, it does not work like that.

Skin is like a bathing suit.  Skin tone is like the elastic in the suit.  When the elastic is gone, it is gone.  The only way we have of tightening skin is to cut it out.   Volume makes skin look better (ie fat under the skin), as it puffs out the skin.  Hydration keeps skin better, though drinking lots of water doesn’t go to the skin- you likely pee most of it out.  I do see lasers which improve the look of the skin for a short time- 3-4 weeks- due to the swelling following the procedure.  When the swelling goes, so does the “improvment.”

Don’t let someone sell you a rainbow.  Many people use tricks with photography to try to convince you.

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.

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?

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.

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.