Pre pregnancy advice from a plastic surgeon


I saw a patient today in clinic who wants to change her breasts.  She has been unhappy with their size and shape as long as she can remember. 

Perfect candidate for breast surgery! Sign her up?!

Not quite.  She should consider waiting.

Why?  She is in her mid thirties. She wants to have kids.  Even when she said, “I won’t breastfeed because I want to minimize changes in the breast” (which I don’t recommend due to the overwhelming evidence of the benefit of breastfeeding, but those are topics for other blogs), your breasts still change.  She is not a 20 year old who has a good decade before having children.  She is in her mid 30s and will have them in the next year or two.  I could make her breasts perfect- exactly what she wants- and pregnancy and/or breastfeeding will change them. 

What do we see?

  • Loss of volume (Rarely increase in volume)
  • Skin laxity/droop
  • Stretch marks
  • Sensory change
  • Shape change

 

Other thoughts…

Pregnancy is tough.  It is hard to work on making your body look good for decades and then lose control of it in pregnancy.  I don’t want you to ever regret or have negative feelings about having a child and breastfeeding because it is doing “damage” to your breast.  If you are in my office you are not adverse to doing surgery to improve things.  Great! So time your surgery well.  If you are on the cusp of your babymaking years, go have that baby. Breastfeed.  Enjoy it.  When you are done with all your kids, your issues with your breast will have changed.  Your breasts will be different.  Let’s address it then.

If you live in Northern California as I do, women breastfeed.  I would even venture to say there is peer pressure to breastfeed.  When I had my first child I went to a mommy and me gathering for new moms at Stanford.  All these moms from Palo Alto, Menlo Park, Atherton, and Woodside gathered in a circle to discuss their babies.   A mom took out a bottle to feed her child. As people looked, there was almost a hush in the room.  I could feel her discomfort- she wasn’t breastfeeding her baby.  My girlfriend advice (I’m putting on my girlfriend hat, not my doctor hat) is to see how you feel when you have your baby, perhaps even try breastfeeding, before you decide you will or will not do it.

Now if you are 20, flat chested, and self conscious about your breasts, I would advise differently.  For you  it makes a lot more sense.  You could easily have a decade until you even think about babies.  And I have women who understand everything I mentioned above but still want the breast augmentation now.  That is fine. 

I believe in choice.  I am here to educate you and to help you understand the issues.  I will support you (and be honored to be your surgeon) regardless of your choice.

California is having an epidemic of whooping cough.  I just got a memo from Sequoia Hospital, which followed my memo from Stanford.  This is real.

The number of cases is at the highest level since 1958.

Why do we care?

  • Case rates are highest in infants
  • Adolescent and teens follow close behind
  • 12% of cases required hospitalization
  • 8 deaths have been reported, all in babies less than 2 months of age, and none had been vaccinated yet.

 

Whooping cough is spread by inhaling respiratory droplets (ie it gets into the air you are breathing) and is highly contagious.  On average they think most patients infect 12 other people!  Whooping cough in adults does not have the severe whooping cough characteristic of infants and young children, therefore it frequently goes undiagnosed.

Infants are very vulnerable.

Infants are protected for the first few months of life from maternal antibodies during gestation.  Unless recently immunized though, most pregnant women have little immunity to pertussis, so they are not giving sufficient protective antibodies to their fetus.  As a result, the California Department of Public Health is recommending

  • all women of childbearing years be vaccinated with Tdap. (Tetanus, Diptheria, Acellular Pertussis) Pregnancy is not a contraindication to vaccination, though usually women are vaccinated in the 2nd /3rd trimester or postpartum. 
  • Anyone in close contact with infants– family members, caregivers, and health workers– should be vaccinated at least 2 weeks before contact.

 

Provide a cocoon of safety for your infant and your family. The first dose of DTaP is given at 2 months of age, but may be given as early as 6 weeks to provide protection earlier in life.

Who doesn’t love that glucose tolerance test? Who can forget the “cola” flavor which 1. does not taste like cola, and 2. does not taste better when chilled.   Did you wonder why you had to do that? What is gestational diabetes?

Gestational diabetes is when you develop diabetes (high blood sugar) while pregnant.  You don’t want your blood sugar to be too high.  People with long term diabetes have issues all over their body due to problems with blood flow- heart disease, loss of sensation, loss of limbs, higher infection rates, vision issues to name a few.  In pregnancy, diabetes is associated with higher birth weight of your baby, early delivery, higher C section rates, diabetes in the mom, and future diabetes and obesity in your child. 

A study came out in the American Journal of Obstetrics and Gynecology of 65,000 women studied from 1991-2008 at Kaiser.  It showed for recurrent gestational diabetes:

  • if you have gestational diabetes with your first child, you are 6x more likely to have it again with your second pregnancy
  • if you have it with your first two pregancies, you hae a 26X risk for having it with your third pregancy
  • higher rates found in Hispanic women, and Asian/Pacific Islander women
  • higher recurrence in women over age 30
  • higher recurrence when bigger time gap between pregnancies

This may seem like a “of course that makes sense” kind of thing.   But for those women who have had gestational diabetes, are older, or are certain ethnicities, that glucose tolerance test is extra important.

Fat.

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.

Being overweight isn’t good for pregnancy. We all “know” this, but a study in the British Journal of Obstetrics and Gynecology came out which looked at 23,000+ women in different countries.  They showed weight is an issue by itself.

We know obese and overweight women have a higher rate of pregnancy related gestational diabetes.  Gestational diabetes can lead to larger babies.  Larger babies are harder to deliver, causing more issues during delivery, including injury to the baby like shoulder dislocation.

So this study wanted to look at is it the weight? Or is it the gestational diabetes?

The women in the study all had oral glucose tolerance tests, height, and weight measurements.   Metzger and his colleagues looked at whether body mass index (BMI) influences pregnancy risks and fetal and newborn health unrelated to gestational diabetes.

Women with BMI of 42 or greater (severely obese) had triple the risk of an excessively large baby.  The risk of having a C section was doubled.  Preeclamisa risk was 14 times greater.

In an interview Metzger stated, “We’re pretty confident that treating gestational diabetes going forward is going to continue to be beneficial,” “We have much less evidence at this point as to how to neutralize or reduce the impact of overweight on pregnancy outcome.”  “What is becoming clear is that it’s probably a woman’s weight before she gets pregnant, rather than how much she gains during pregnancy, that’s important in determining risk.”

SOURCE: BJOG, online January 20, 2010.

Obstetrics and Gynecology, Feb 2010 published a study out of Norway looking at exercise, BMI, and baby birth weight.

Findings?

They looked at 43000+ women aged 15-49 who were pregnant with a single fetus.  The women’s exercise was walking jogging, biking, weight training, aerobics, etc.  They averaged 6 times a month for the first half of pregnancy, and then once a week until week 30. 

The average weight of the infants at birth was 3,677 grams (8 pounds. Ouch!), and those who exercised during pregnancy did not have a significant effect on birth weight.

BUT, they did find an association with BMI. 

What is BMI? BMI is body mass index, to do it in US measurements, it is 703 x weight (lb)/ height (inches) squared.  BMI 18.5-23.9 is normal, 24-29.9 is overweight, and greater than 30 is obese.

The prepregnancy average BMI of the women in the study was 24. Fleten’s team found each unit increase in the mother’s BMI was associated with 20 grams (0.70 ounces) heavier birth weight.  So an increase in BMI of 5 units — 29 versus 24 — would cause a birth weight increase of 103 grams (3.63 ounces).

The Norwegian doctors suggest doctors focus on preventing or treating overweight and obese women of childbearing age to help reduce the risk of giving birth to babies who weigh too much. (OUCH!)

SOURCE: Obstetrics and Gynecology, February 2010

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.

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

So you are going to take the plunge. I think it is fantastic.  There is nothing I have done as moving and rewarding as having children.  Pregnancy is hard on the body.  Common changes occur.  Here is a brief overview of some things to do before you get knocked up.

1. Exercise.  A healthy body does better with pregnancy.  A lot of the women I see with great figures after pregnancy had them before pregnancy.  So improve your muscle tone, particularly your core muscles (especially the rectus muscles and oblique muscles which you use to do pilates/the plank/sit ups).

2. Healthy skin.  The “rosy skin” of pregnancy sounds great. And many women do get it.  They also get a lot of pigmentation.  The sun spots, age spots, freckling- call it what you will- worsens with pregnancy.  So prior to pregnancy, try to reverse any skin pigmentation you have.  Hydroquinone and Retin A are great for pigmentation, but they are NOT baby safe.  There are products with Vitamin C and E which are okay while pregnant and breast feeding.  And the key to pigment? SUNSCREEN and the big floppy sun hat. You should apply sunscreen daily.  Try to find a moisturizer or makeup base with sunscreen in it.  When doing activities in the sun, apply sunscreen 20 minutes before going outside, reapply every 45 minutes in water, reapply every 2 hours regardless, and use sunscreen less than a year old.  I am a fan of the clear zinc based sunscreens.  They are mechanical blockers, not chemical, so they are likely less absorbed in the skin.  Very effective and thought to be a little more baby safe.

3. Ideal weight.  You will gain weight with pregnancy.  (Oh my!? shocking.) The amount of weight you gain varies, but the usual recommendation is 25 pounds.  There is a correlation with weight gain and body changes- stretch marks, loose skin, diastasis, and higher post pregnancy weight.  There are studies which link obese children to mothers who were obese before pregnancy.  (The amount of weight gain has been revised to 11-20 pounds for women with a BMI of 30 or more.)

4. Stop smoking.  I could go on for ages on this one.  It affects every body system; increases your chance of heart attacks, stroke, and cancer; along with sun exposure it is the biggest ager of the skin, and does things I can’t fix with products and peels; no surgeon will do a tummy tuck or a breast lift on a smoker, so you might as well stop now; it is expensive; you can’t do it in restaurants; it yellows your teeth.

The health effects on the baby: it lowers the amount of oxygen they get in utero, increases heart rate, and increases rate of miscarriage and low birth weight.  There are other studies indicating after birth these babies have issues with asthma, behaviorial issues, and higher SIDS. For more information go to: http://cerhr.niehs.nih.gov/common/smoking.html.

5. Surgeries. The one surgery I like before pregnancy is liposuction.  If you have a discrete problem area, like “my outer thighs,” or are an exaggerated pear or apple shape, your shape will not improve with pregnancy.  Particularly for those women who are teeny tiny up top and carry all their weight in their thighs/hips, when you put on baby weight it will all go there.  Fast forward: you are now 10 years older and have stretched that skin more, for a longer time, and your skin is older- it won’t bounce back after liposuction like it would at age 25. Skin tone is key to liposuction, and young skin is better.

I do not like to do abdominoplasty (tummy tuck) or breast surgery right before babies.  If your breasts really bother you and you will not have babies for 5-10 years, then it may be worth it to do now. But pregnancy and breast feeding affect the belly and the breast the most.  If you can, wait to fix up those areas until after you have kids.

So,

Exercise. Wear sunscreen. Eat well/be your ideal weight. Don’t smoke.  Sounds simple, eh?

Now go get practicing to have that baby.

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