Pre pregnancy advice from a plastic surgeon


I can’t help but write a blog about this.

There was an article in the New York Times about a month ago written by a female doctor with four kids and she stated no woman should go to medical school if they are not going to work full time when they are done.  I won’t get into the arguments for and against her, but I applaud her for bringing up the conversation.  Needless to say, my hypereducated Bay Area group of female friends, many of whom are lawyers, doctors, and business school types, have had lively discussions about this.  And it prompted us to make a book club, and our first assignment?  To read “Torn, True stories of Kids, Career, and the conflict of modern motherhood,”  edited by Samantha Walravens, with chapters by some fantastic writers, career and noncareer women, who share their stories.

The crux?

Working mom, Part time working mom, Stay at home moms.  There are many different paths we can take, and since you are on this website entitled body post baby, you have already made the one common choice- to have a child (or many children).

So then you get to the this thing they talk about … “BALANCE.”  What is that?

The stories are well written, insightful, and open.  I found it refreshing to see women really talk about their lives and the complexities.  And it writes about both sides of the fence: those who are working with kids, and those who “opted out” and are stay at home moms.  Both groups have issues with balance.  Both groups have issues with navigating our current world and how to mother in it.

I’ll update you on the gist of my book club meeting.  Should be interesting.  But for any of you who want a good read in tiny bite sized pieces (the only kind of book to read when you have the craziness of kids), I like this one.

I am a mom.  I gained weight with pregnancy.  How much is “me” and how much is my new baby?  When I gave birth to my first child, I couldn’t stop thinking about it.  As much as I did not want to give birth to a 30 pound baby (OUCH), somewhere lurking in my mind, I thought, “of course this baby must weigh 30 pounds!”  So in my little dreamworld, I thought I would painlessly deliver my 30 pound baby and leave the hospital zipped up in my favorite pre-pregnancy jeans, back to my normal little self.

ha ha.

Most babies don’t weigh 20-40 p0unds, and no one tells you the dirty little secret that those maternity clothes should be called maternity and mother-with-newborn-can’t-wear-normal-clothes-yet clothes.  Most of us take months to get smaller.  When we gain weight with pregnancy where is it?  Is it water weight? Fat? Blood volume?  Why do some lose it so quickly and others don’t?

When you gain weight with pregnancy, some of it is clearly the weight of the baby.  I have researched many sources, and the consensus of a typical pregnancy is:

Baby – 7½ pounds
Enlargement of uterus – 2 pounds
Placenta – 1½ pounds
Amniotic fluid – 2 pounds
Breast enlargement – 2 pounds
Extra blood and fluid volume – 8 pounds
Extra fat stores – 7 pounds
Total – 30 pounds

If you are gaining more, then the question comes, which of these is it?  Babies, placentas, amniotic fluid, and breasts likely aren’t going to be a big contributor.  So when you see women who really balloon up, the likely cause is extra fluid or extra fat.  The women who lose a ton of weight in the first week likely are those who carried a lot of extra fluid, and lose it right after birth.  The others… well those are women who likely have extra fat.  This is much harder to lose, and a common reason why I see women plateau at a higher weight than their prepregnancy weight.

So look at the blogs on the guidelines of how much weight to gain during pregnancy.  For a normal BMI woman with a healthy pregnancy,  you should gain 25-35 pounds.

wish I had a crystal ball.

Every person is different with how their breasts change with pregnancy. Some barely look different, some go up 3 cup sizes.

Breastfeeding adds another layer of change. Are you a producer? Do you favor one side? How big do you get? How long do you breastfeed for?  If you had surgery with an incision at the nipple areola, your milk production may be affected.  I have many blogs on breast milk production after breast surgery.

Each pregnancy is different. As for the droop, it depends on your skin tone, how many pregnancies, how old you are, what your size changes are, and the above.  Keep your fingers crossed.

Advice?
1. SUPPORT SUPPORT SUPPORT. Sleep in a bra. Wear it 24 hours a day.  Wear a good one which looks like Fort Knox.
2. When breastfeeding, alternate (don’t favor one side).  See other tips on my blog.
3. If you see any kind of infection, mastitis, rash, etc, JUMP ON IT EARLY.  Most implants are submuscular, so there is a nice muscle between your implant and the breast.  Most implants have formed a capsule, which protects your implant from your breast.  What you don’t want though is an issue with your breast causing a breast implant infection.  It is rare… but if you are worried about any breast redness, tenderness, or discharge, see a doctor sooner as opposed to later.

And remember to focus on the big picture! CONGRATULATIONS!  Most implants do just fine with pregnancy.

The institute of medicine is widely recognized as setting guidelines for pregnancy.  The last time they revised their estimates was in 1990.  Since then the obesity epidemic has boomed.  Kathleen Rasmussen, ScD, PhD, and IOM committee chairwoman expressed “during pregnancy many women gain substantially more than we would like.”  The new guidelines are similar to the past, but now the obese women have an upper limit.  No one should lose weight while pregnant.

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.

Yes, yes.  We have all heard it.  “Have another piece of cake.  You are eating for TWO.” 

Egads.  Back in my mom’s day, women didn’t gain much weight with pregnancy.  15 pounds was likely normal.  I know a woman who was told by her doctor (remember this is a long time ago…) to start smoking (!!) as she was gaining too much weight with one of her pregnancies.

You don’t need many extra calories for your little bun in the oven.  According to a nutritionist, you need more nutrients during pregnancy, but not more calories. In the first trimester you need no extra calories.  In the second trimester you should have an extra 350 cals/day,  and in the third 450 cals/day. 

Which nutrients? Protein (recommendation is an extra 20g/day), folate (extra 50% of normal rec), iron (50% more than normal, so about 27mg/day total), and zinc. Don’t take any supplements though without checking with a doctor or registered dietitian because too much of certain vitamins is bad.

As far as weight gain, according to guidelines, you should gain 25-35 pounds if you are a normal “healthy” weight when  you begin your pregnancy.  If you are 5’6″, to be at a healthy weight when you start means you should weigh 118-148 pounds.  If you weigh over 150 pounds you are “overweight.”  If you weigh 186 pounds you are obese.

See my blog on BMI and weight gain recommendations by the IOM.

This is the beginning of a series of blogs about pregnancy and weight gain.  Pregnancy is not a time to go hog wild eating whatever you want.  There are guidelines to how much weight you should gain, and they vary with what your pre pregnancy weight is.

For those with no attention span (and can’t read past a twitter title), the findings were 

  • the higher your BMI, (underweight–>normal–>overweight–>obese), and
  • the more your weight gain past recommendations during pregnancy,

the higher your chance of high blood pressure during pregnancy. (High blood pressure during pregnancy is bad.)

Terms:

BMI= Body mass index. To calculate yours, here is a link from the US department of health  :http://www.nhlbisupport.com/bmi/bminojs.htm

PPBMI= Your prepregnancy BMI

IOM= Institute of Medicine.  It has guidelines recommending how much you should gain.  Those will be posted in another blog, but if you are normal weight, you average weight gain during pregnancy should be around 30 pounds, if obese around 15 pounds.

Study: American Journal of Perinatology Jan 2011

  • Evaluated new Institute of Medicine weight gain guidelines within each PPBMI category
  • Patients with singleton term deliveries
  • Women without history of  heart disease, diabetes, or pregnancy high blood pressure
  • Pregnancy high blood pressure rates were compared overall and within each PPBMI group
  • Looked at women gaining less than recommendations, within recommendations, and above recommendations

 

FINDINGS:

  • High blood pressure during pregnancy was higher when your prepregancy BMI was higher (5.0%, 5.4%, and 10.8% for less than, within, and above recommendation groups, respectively ( P < 0.001).
  • Above recommended weight gain resulted in higher high blood pressure incidence within each PPBMI category (underweight 7.6%, normal weight 6.2%, overweight 12.4%, and obese 17.0%), reaching statistical significance in all but the underweight PPBMI group.
  • Excessive weight gain above established guidelines was associated with increased rates of high blood pressure. 
  • Regardless of PPBMI, women should be counseled to avoid excessive weight gain during pregnancy.

So if you are considering getting pregnant, or you are pregnant, look at your BMI and weight gain.  It is important for your health and your pregnancy.  In general, as a plastic surgeon who specializes in the mommy makeover, I see women who don’t fare well with pregnancy.  Weight gain is part of that issue.

I am a plastic surgeon.  I perform a lot of breast augmentations.  I am lucky- most of my patients come to me after they have children and are done with breastfeeding. 

Any surgery to the breast will affect the breast.  This seems obvious, but it is something I always discuss with patients, particularly if they have not had children yet. 

If someone comes to me in their mid 30s and wants to have kids, I will counsel them to wait to have surgery until they are done having kids.  Your breasts get larger when you are pregnant and breastfeeding anyway.  Your breast changes with pregnancy and breastfeeding–after you are done with kids most women end up smaller in volume, so the size they would choose would change. (Some women do end up larger in breast size after kids, but don’t hold your breath for that one- it isn’t as common.)

So. Back to the title of this blog- if you have a breast augmentation, does it affect your future ability to lactate (ie breastfeed)?

Yes.

A study came out in Breast Journal, Jan-Feb 2007 out of the UK.  I have a few issues with the study, particularly one of their opening lines which I think is really untrue, “It does not occur to most women to consider the possible effects of breast augmentation surgery may have on their future ability to exclusively breastfeed their baby.”  Maybe it is because I live in the hypereducated Silicon Valley Palo Alto area, but I think all of my patients consider the effect of any breast surgery on their future ability to breastfeed, and it is part of my usual discussion, particularly with regards to incision site. 

But back to the study, which I am citing because it did bring out some interesting facts. 

  • Women who have breast augmentation surgery have a greater   lactation insufficiency.  NOTE: This does not mean they do not produce milk, but they may not be able to exclusively feed their child by breast milk alone to meet their parameters of weight gain.
  • Factors related to surgery include impairment/loss of nerves to the nipple areola complex, which lead to reduced sensation and loss of the suckling reflex resulting in decreased milk production.
  • complications in surgery (hematoma, need for additional surgery, capsular contracture, etc) can lead to impairment.

Their conclusion? “With good surgical technique and proper postoperative management, most of the complications associated with surgery that may result in insufficient milk production can be minimized but not always avoided.”

So what does this mean? This study would not change my general advice to women, which is:

  • If you are in your early 20s and have a good decade before having kids, in the pros/cons of deciding to do breast surgery, you need to factor in potential decrease in your ability to breastfeed.
  • I have had many patients who have successfully breastfed after breast augmentation.  This study shows a decreased amount of milk production, and it varied due to multiple factors.  Their final statement was that good technique and proper postop management you can minimize the impairment.
  • IF YOU ARE WITHIN A YEAR OR TWO OF HAVING A BABY, WAIT.  I counsel women to do this all the time. I get that having larger breasts will make your wedding dress fit better, but if your plan is to get married and then start a family right after, wait to do the surgery.
  • IF BREASTFEEDING IS OF PARAMOUNT IMPORTANCE and you would be upset to supplement with formula if needed, WAIT.  I know this is controversial in my plastic surgery world where many doctors have become salesmen for procedures, but you have to look at your life big picture when looking at these things.

Remember also, some women can’t breastfeed for whatever reason who have never had breast surgery.  There are no guarantees.

I love science.

I do a ton of breast surgery.  I have 3 kids.  I am a huge fan of breastfeeding.  How can I advise my patients about breast surgery and the relationship to breastfeeding?   I know a lot from being in practice for over a decade, and I read a lot of studies.  Every piece of information helps in the decision making.

There are women who are going to have a hard time breastfeeding.  Some of these women have had breast surgery, others did not.  Is there some way to predict who is whom?  Who will have a harder time?

A study came out in Birth, Sept 1990 looking at the influence of different factors on your ability to breastfeed a baby.  The study followed 319 women who were pregnant with their first baby who intended to breastfeed.  These women were evaluated in their last trimester for their initial measurements.  They looked at:

  • surgical incisions
  • size
  • symmetry
  • nipple protuberance (do you have inverted nipples?)
  • and the woman’s estimate of their breast increase during the pregnancy

At two visits after the first 2 weeks postpartum (all were term babies), the infants were weighed and the moms estimated how big their breasts got when their milk came in.  Breastfeeding was evaluated and help was given when there were problems, looking particularly at how to maximize the amount of milk made.

“Sufficient” milk production related to an average weight gain daily of 28.5g between visits.  If they had to supplement with formula this was noted as well. 

What was related?                                                              

  • 85% of mothers had sufficient lactation
  • 15% had insufficient lactation, despite intervention
  • 7% had some kind of breast surgery prior to their first pregnancy.  If a periareolar incision was used, these women had a 5x rate of lactation insufficiency compared to those without any surgery.
  • Insufficient lactation was significantly associated with minimal prenatal breast enlargement
  • Insufficient lactation was significantly associated with minimal postpartum breast enlargement when the milk came in
  • Inverted nipples were more likely to have lactation insufficiency (not statistically significant)

 

So. How can you anticipate?  If you have inverted nipples, or prior breast surgery with an incision in the periareolar area, you may have decreased milk production.  15% of women in this study had insufficient milk production, and many did not have any prior surgery or inverted nipples.  If your breasts get much larger with pregnancy and when your milk comes in, signs are good you will produce enough milk. 

What I have seen in my plastic surgery practice here in Palo Alto, where there is positive peer pressure to breastfeed, is prior surgery does not mean you can’t breastfeed.  What I found in practice and these studies is your milk production may be lower.  But any breast milk is good for you, your baby, and your bond.

This will be the first in a line of blogs about this topic.

Let me start first with an email I received from a patient,  “I just want let you know that I have had no problem breastfeeding.  I am grateful that nothing was damaged during my breast lift surgery.  Nice job to you!!  We had a beautiful girl.  I was worried about breastfeeding but it is going great.  I have a ton of milk supply on both breasts.   I just wanted to let you know. “

All breast surgery affects the breast.  Seems like a simple concept, but we forget it sometimes.  A 20 year old woman who wants a breast reduction may be more focused on getting her breasts smaller and somewhere above her waist, not the bonding and nutrition she may give with breastfeeding 10 years down the road when she decides to have kids. 

So I discuss it. 

Any woman who has not had children and wants to do any surgery of the breast needs to consider the effect surgery will have on the breast and your ability to breastfeed.  Thankfully, for most women, they are able to make milk.  The studies show there may be a decreased amount of milk, but I have had many patients who have had breast augmentation or breast reductions and lifts who have successfully gone on to breastfeed.

If you are a decade away from thinking about kids or you have a lot of issues with your breasts (backpain, droop, asymmetry, etc), then know there are techniques which help maximize your future ability to breastfeed.  If you are on the verge of having kids, wait to do the surgery.   It will totally preserve your ability to breastfeed among other advantages:
Anectode:  I had a friend who was 38, newly married, who wanted a breast augmentation.  I am a straight shooter, so I told her, “You are older.  You can’t wait to have kids.  Have your kids.  You’ll need to have them in the next year or two.  Your breasts will get bigger with pregnancy.  Your breasts will get bigger while breastfeeding.  When you know you are done, then do the surgery.  Pregnancy and breastfeeding changes the breasts a lot- shape, volume, symmetry.”  She did not listen, and went to someone else for surgery.  She has now had two surgeries within 3 years.  Had she waited until done with kids, she might have had just one surgery, and the results could have been better. 
 
I am a huge fan of breastfeeding.  I am not saying to do surgery or not do surgery.  I am not dictating the timing of your surgery.  This is all about educating you to make the right choices for you.

Many women who come to me have gained weight.  Particularly after babies, and the more babies the merrier, you may not be able to get back down to the svelte self you once were.  Some of it is from pregnancy- did you overeat? not exercise? Some of it is from young motherhood- are you sleep deprived? eating to stay awake? nibbling on all of the goldfish and mac n cheese? going to the umpteen million kiddie parties with cupcakes? or finishing the tidbits on your kids plates while cleaning the dishes (guilty as charged)?

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.

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