Full abdominoplasty.  Also called Tummy tuck. Two scars: one incision from about hip to hip and one around the belly button.  The muscles are tightened and usually all of the skin between the pubic area and belly button is removed. This can be combined with other procedures like liposuction of the flanks.  Cannot be combined with liposuction of the belly itself.  If you have hanging skin, volumes of loose skin, or loose skin above the belly button, this may be what you need.

Mini abdominoplasty.  Also called a mini tummy tuck.  The incision for a mini can be placed as low as you want to go.  The scar length can vary– from short like a C-section to longer from hip to hip.  The longer the scar, the more skin is removed.  (and most are not the short C-section kind.  Sorry.) Does not have an incision at the belly button. (Good for bikinis and low rider jeans) Does minimal to no tightening of the skin above the belly button.  It does tighten the skin of the lower belly. You can combine with liposuction of anywhere you want.  You can also combine with tightening of the muscle, though it can be difficult to reach the upper muscle near the ribcage if you are long waisted.

Floating belly button.  This is not a common surgery.  It involves no scar on the skin of the belly button, just one in the lower abdomen.  Your belly button is like a mushroom.  During a normal tummy tuck the belly button does not move- the skin does.  In this surgery, the stalk of the belly button is cut, and the belly button floats down toward the pubic area attached only to the skin.  This allows tightening of the upper abdomen and lower abdomen skin.  The issue is it lowers the position of the belly button, so it is only good for those with high belly buttons to begin with, and the belly button is no longer connected to the stalk.  If you ever need a laproscopic procedure, they cannot use the port through the belly button as this connection is gone. 

Muscle tightening only.  This is for the women who have good skin tone, no fat, but have loosened muscles after babies. (When you aren’t sucking it in you look 5 months pregnant, and when you suck it in you go FLAT.)  A lot of my Bay Area women fall into this category.  The skin incision can be short when you do this.  NOTE:  If when you suck in your belly the skin hangs and is wrinkled, then you likely need some form of skin tightening.  The more skin tightening, the longer the scar.  See mini tummy tuck description above.

The hybrid adominoplasty is a trademarked name of a procedure done by Dr. Moelleken from Southern California.  It is most like the muscle tightening only procedure listed above.

So what is the magic answer?

First, figure out your BMI.  Body mass index.   weight (pounds) / [height (ininches)]² x 703.  For those who don’t want to do the math, go to the calculator here: http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html  This is a fairly reliable way of figuring out body “fatness” in most people. It doesn’t directly measure your fat, but research has shown BMI correlates with accurate measurements of body fat.

What are the categories?

• If your BMI is less than 18.5= underweight
• BMI is 18.5 to 24.9= normal or healthy
• BMI is 25.0 to 29.9= overweight
• BMI is 30.0 or higher= obese

SO. the IOM guidelines?

If you are pregnant with ONE child:

• Underweight: Gain 28-40 pounds
• Normal weight: Gain 25-35 pounds
• Overweight: Gain 15-25 pounds
• Obese: Gain 11-20 pounds

If you are pregnant with TWINS :

• Underweight: no guidelines due to insufficient data
• Normal weight: Gain 37-54 pounds
• Overweight: Gain 31-50 pounds
• Obese: Gain 25-42 pounds

So most likely,  to do this, you need to eat basically what is your normal.  Exercise.  Don’t think of this time as “eating for two.”  If you do, in addition to gaining more weight than you should (which leads to a host of other issues), you will be hurting your body’s ability to bounce back after pregnancy.  Trust me- as a plastic surgeon, I see it all the time.

So what am i going to say?  Eat broiled fish and salad?  Lose the weight by “chasing your children” and breastfeeding??

NO!

I love to read Men’s Health magazine.  The articles are great.  Here are some good rules of thumb, and he focuses on the tiny changes- not the “I am going to exercise for 2 hours every day” kind of programs, but the “I am going to not put the extra food on the table” kind of things. So I am not going to write this article again- I think he did a great job.  But I will post it here because he cites some interesting studies.  And much of the body work I do as a plastic surgeon has everything to do with weight.

7 Habits That Make You Fat
By David Zinczenko of Men’s Health

FAT HABIT #1: Putting the Serving Dishes on the Table
Researchers at Cornell University found that when people served themselves from the kitchen counter or the stove, they ate up to 35 percent less food than they did when the grub was on the kitchen or dining room table. When there’s distance between us and our food, the scientists theorize, we think harder about whether we’re really hungry for more.

FAT HABIT #2: Getting Too Little (or Too Much) Sleep

A sleep schedule is vital to any weight-loss plan, say Wake Forest University researchers who tracked study participants for 5 years. In the under-40 age group, people who slept 5 hours or less each night gained nearly 2½ times as much abdominal fat as those who logged 6 to 7 hours; also, those who slept 8 hours or longer added nearly twice as much belly fat as the 6- to 7-hour group. People with sleep deficits tend to eat more (and use less energy) because they’re tired, says study coauthor Kristen Hairston, M.D., while those who sleep longer than 8 hours a night tend to be less active.

FAT HABIT #3: Not Multitasking While Watching TV
We don’t need to tell you that too much TV has been linked to weight gain. But here’s what you may not realize: You can have your TV and watch it, too. Just do something else at the same time. Washing dishes burns 70 calories every 30 minutes. So does ironing. Here’s another thing to keep in mind: Cutting TV time even a little helps you burn calories, say researchers at the University of Vermont. In their study, overweight participants who cut their viewing time in half (from an average of 5 hours to 2.5) burned an extra 119 calories a day. “Nearly anything you do—even reading—uses more energy than watching TV,” says study author Jennifer J. Otten, Ph.D.

FAT HABIT #4: Drinking Soda
Researchers say you can measure a person’s risk of obesity by measuring his or her soda intake. Versus people who don’t drink sweetened sodas, here’s what your daily intake means:

½ can = 26 percent increased risk of being overweight or obese

½ to 1 can = 30.4 percent increased risk

1 to 2 cans = 32.8 percent increased risk

More than 2 cans = 47.2 percent increased risk

That’s a pretty remarkable set of stats. You don’t have to guzzle Double Gulps from 7-Eleven to put yourself at risk—you just need to indulge in one or two cans a day. Wow. And because high-fructose corn syrup is so cheap, food marketers keep making serving sizes bigger (even the “small” at most movie theaters is enough to drown a raccoon). That means we’re drinking more than ever and don’t even realize it: In the 1950s, the average person drank 11 gallons of soda a year. By the mid-2000s, we were drinking 46 gallons a year. A Center for Science in the Public Interest report contained this shocking sentence: “Carbonated soft drinks are the single biggest source of calories in the American diet.”

FAT HABIT #5: Taking Big Bites
Dutch researchers recently found that big bites and fast chewing can lead to overeating. In the study, people who chewed large bites of food for 3 seconds consumed 52 percent more food before feeling full than those who chewed small bites for 9 seconds. The reason: Tasting food for a longer period of time (no matter how much of it you bite off) signals your brain to make you feel full sooner, say the scientists.

Fat Habit #6: Not Eating Enough Fat
You don’t have to go whole hog on a low-carb diet to see results. Simply swapping a few hundred calories of carbs for a little fat may help you lose weight and reduce your blood-insulin levels, according to researchers from the University of Alabama at Birmingham. People in their study who consumed just 43 percent of their calories from carbohydrates felt fuller after 4 hours and maintained their blood-sugar levels longer than those who ate 55 percent carbs. Carbs can cause blood-sugar levels to spike and then crash, leading to hunger and overeating, says study author Barbara Gower, Ph.D. Fat, on the other hand, keeps you satiated longer. Some easy swaps: butter instead of jam on toast; bacon instead of potatoes; low-fat milk instead of a sports drink.

FAT HABIT #7: Not Getting the Best Guidance!
Signing up for e-mails (or tweets) that contain weight-loss advice can help you drop pounds, a new study reveals. When researchers from Canada sent diet and exercise advice to more than 1,000 working adults weekly, they discovered that the recipients boosted their physical activity and ate smarter. People who didn’t receive the reminders didn’t change.

EAT RIGHT RULE: If your food can go bad, it’s good for you. If it can’t go bad, it’s bad for you.

That tummy tucks help with back pain is not new news.  When you have babies you will stretch out your abdominal muscles.  Frequently this leads to separation of the rectus muscles, what is called a diastasis.  This midline separation cannot be fixed with situps.  The only way we have of fixing it is to corset the muscles back together during a tummy tuck. 

So why would fixing your belly help your back?  Your back and your abdominal muscles work to stabilize your body and help you stand up straight.  If your abdomen is blown out or loosey goosey (I know, highly technical terms here), then your back must work overtime to stabilize your body.  This can lead to pain.

What is common folk wisdom in plastic surgery often leads to scientific papers which support it.  A multitude of papers have emerged which support that tummy tucks are not a just-to-make-you-look-pretty surgery, but a functional one.  The latest appeared in the January 2011 issue of Plastic & Reconstructive Surgery Journal .  It is a study out of the University of Michigan, “Wide Abdominal Rectus Plication Abdominoplasty for the Treatment of Chronic Intractable Low Back Pain.” 

In it, they point out some ideas I would like to reiterate:

• Most surgical treatment for chronic back pain is directed at the spine.  In a study by Toranto, who first championed the wide abdominal rectus plication, he gave relief to chronic back pain in 24 of 25 patients by addressing the belly, not the back.
• A tummy tuck for back pain is only useful in patients who present with significant abdominal wall weakness and laxity.  All of the patients in this study had one or more pregnancies. 
• Conservative treatment is always good first. 
• For those with neurologic damage of the spine, you need to make sure there is no radiographic or clinical evidence of the damage being caused by an identifiable structural lesion in the spine.

The study postulates that the rectus muscle forms a “sheath” of tissue connecting to the thoracolumbar fascia.  “This forms a structure that biomechanically influences the mechanics and stability of the lumbar spine.”  The “wide” abdominal plication doesn’t just realign the rectus muscles, it brings it in tighter.  The thought is to increase the intraabdominal pressure and put the muscles at a more efficient place in the force-length curve to increase their force generating capacity. In this small study of 8 patients, all were improved. 

Small studies can be discounted, but this study had a very thorough evaluation preoperative and postoperatively by a physical medicine and rehabilitation specialist with specific expertise in management of chronic low back pain.  100% of them were better.

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.

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.)

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.

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.

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

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.

So that age old question: “How does that giant baby fit into my belly?”  It does so by moving the other things around and stretching your muscles and skin.  Your abdominal muscles are the rectus muscles (the “six pack”) and oblique muscles.  The muscles of the abdomen do not cross the midline.  This central line is called the linea alba.  It is made of a leathery substance called fascia.  When you are pregnant, your muscles separate in the middle.  This separation between the muscles is the diastasis.  Everyone who has had a pregnancy has some separation.  This is the reason you can’t “suck it in” as tightly as you did before pregnancy.  This is also part of why your waist gets wider.

The amount of separation varies.  Some people have a small amount, some a wide.  It tends to get worse with the number of pregnancies and the amount of weight you gain.  (Another reason that large babies should give their moms large presents on mother’s day.) Some women have poor genetics though and get a lot of loosening with their first child.  If your diastasis is bad, you will have a flat belly lying down, and then look pregnant when you stand up.  When your abdominal muscles are loose, you may have back pain due to weak abdominal strength.

Since no muscles cross this midline, you can’t tighten it up again with exercise. (To many a husband’s chagrin. So tell him that his “honey you just need to do more sit ups” will not work.) A diastasis is fixed with a tummy tuck.

A tummy tuck is two parts.  That bottom part is internal and fixes the diastasis separation.  You can’t see it.  It is a corset which brings those muscles back together.  I use a two layer muscle tightening approach; both layers are permenant sutures.  This will tighten your core again as it brings the muscles together.

The second layer to a tummy tuck is removing excess skin. 

A hernia is a true hole in the abdominal wall.  This commonly occurs at the belly button, and is why some women are no longer an “innie” after pregnancy.  Sometimes people will call a diastasis a “ventral hernia.”  Most women have a simple separation where the sheet of tissue keeping the “insides in” is still intact, not a hole.