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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 know I am not a pediatrician or a family practice doctor, so some may wonder why I am so focused on breastfeeding.   I am a surgeon who deals a ton with the breasts and the effects of breastfeeding.  I have heard rumblings while being a mom-around-town of women who are choosing not to breastfeed their children because they are concerned about the cosmetic effect it will have on their breasts.  I am a fan of breastfeeding.  Please see the other blogs prior to this and the results of a study which just came out.

For the hypereducated Bay Area women reading my blog, here is another pro for breastfeeding:

MUCH lower risk of SIDS.

SIDS is sudden infant death syndrome.  It affects 2,300 babies a year.  The cause is unknown.  From the sids.org site, risk factors include having a baby as a teen, less than one year between pregnancies, tobacco/cocaine/heroin use during pregnancy, and premature birth.  After the baby is born: have the crib in your room, no bedding/pillows, sleep on the back, use a pacifier, avoid respiratory infections, and do not overheat the baby.  The risk is highest between 2-4 months of age.  90% of SIDS occur in babies less than 6 months.

In Pediatrics June 2011 online edition, Hauck and researchers at University of Virgina did metaanalysis of 18 studies looking at breastfeeding and risk of SIDS.  Findings:

  • 73% reduction in risk if exclusively breastfed
  • 60% reduction in risk if breastfed for any time period
  • 45% reduction when other factors known to increase SIDS were factored out, like smoking, socioeconomic status, and sleep position.

 

Why does breastfeeding lead to lower risk?  Thoughts vary.  Hypothesis include:

  • Breastfed babies are more arousable during sleep
  • Fewer issues with diarrhea and respiratory infections, which may predispose to SIDS
  • Possible boost of their immunity from the breastmilk.

So, pediatricians recommend breastfeeding exclusively for 6 months and then continue to nurse for the first year, as you introduce solid foods.  So bond with your child, lose weight (anyone for an extra slice of cheesecake?), and protect them from SIDS…. Breastfeeding is sounding pretty good.

Abdominoplasties come in all shapes and sizes, just like the women who need them.  This blog will be a glossary of some of the common terms.  From biggest surgery to smallest:

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.

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.

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.

As you are on this site, body post baby, I know a very important thing about you.

You are a mom.

The most wonderful, challenging, unpaid job in the world.  So cheers to you!  May your children appreciate you and all  you have done….

For charting and ovulation predictor kits and putting legs up in the air hoping to conceive, surviving the two week wait between ovulation and getting the positive test, to waiting to see the first heartbeat, and being scared any time you had a cramp or tinge of blood when you wiped that  something bad could be happening, to not having diet coke while pregnant, or alcohol, or advil, or blue cheese or one of the countless other no nos….

For birthing a 10 pound baby, or a baby with a big head, or enduring 24 hours of labor….

For the countless feedings, lack of sleep, lack of shower, and lack of everything for you, for breastfeeding, and pumping in cars and wedding reception changing rooms all for the health of your baby, for breasts which were sucked dry and now look sad, or breasts which now droop to your waist….

For not being able to suck it in anymore, or for having to suck it in all the time, or wearing your baby in a bjorn like a necklace so no one will make the mistake of asking you, the newborn mother, “remind me when you are due again?”

To motherhood.

We are a very very blessed bunch. I salute you.

I know this isn’t really about plastic surgery.  But being a working mom, I loved this study which looked at kids and obesity.  One of the questions raised in recent times is whether childhood obesity rates going up has something to do with more mothers having to work.  In 2000, the New York Times reported for the first time since the Census Bureau began tracking numbers, families in which both parents are working is the majority, including the traditional married with children group.  Here in the Bay Area we know most of us can’t afford our house without two working parents.  

This study out of Australia, to be published in the Journal of Social Science and Medicine, looked at 2500 children at two different points- ages 4/5 and again at 6/7.  There were three groups of moms: stay at home, full time working, and part time working. 

Findings (Dum ta dum dum drumroll): Mothers who worked part time were more likely to have healthier children than either of the other groups.  They found those children watched an hour less of TV per week and had a healthier lifestyle. 

Full time career women had higher rates of overweight children.  The thoughts were they had fewer home cooked meals and less time to encourage active, physical play.

Stay at home moms? Unclear why they were more likely to have overweight kids, but they postulated the part time working mom might balance work and family demands better. “They reschedule activities, sleep less, and allocate less time to personal care and leisure to ensure that time with children is protected.”

Regardless, it was good for me to read.  It is nice to know stay at home moms and full time working moms were in the same boat, and part time working moms fared the best.  So working isn’t the issue.  Balancing and scheduling well seems to be the ticket.

Ooooh.  Or perhaps this means we all need a day or two off a week.  As the study shows,  it is better for our kid’s health and weight….

Yup.
The Senate, at the 11th hour, on a Saturday night while no one was watching tacked on a cosmetic procedure tax.

5%.

On every cosmetic surgery, botox injection, filler injection, and ??? what else.

The issues are multiple:
1. Never has the government taxed a patient for a medical procedure.
2. 90% of all “cosmetic” procedures are done by women.
3. This tax applies to procedures paid for by insurance, as well as by the patient. So if your insurance considers your breast reduction “medically necessary” (no small hurdle- see my blog on getting insurance to cover a breast reduction. It is as difficult as getting a child to eat broccoli over ice cream), the government will still consider it “cosmetic” and walah! You get to pay 5% more.  On a breast reduction surgery, this could amount to an additional $400-500.

4. The majority of plastic surgery patients are not the rich and famous.  They are, as I see in my practice, the soccer mom and the working mom.

This tax is effectively a “Soccer Mom” tax that will adversely impact mainstream American wives and mothers, who are the majority of plastic surgery patients,” said Renato Saltz, MD, President of ASAPS. “As doctors, we understand and appreciate the need for health care reform, but taxing physicians and cosmetic surgery procedures to pay for the reform is not realistic or beneficial,”

In a 2005 ASPS survey of people planning to have cosmetic surgery within the next two years, 60% of respondents reported an annual household income of $30,000-$90,000 a year. Most importantly, 40% of those reported a household income of only $30,000-$60,000. Only 10% of respondents reported a household income of over $90,000, which clearly refutes the suggestion that elective surgery taxes are “luxury” or”sin” taxes affecting a privileged few.

eeeek! I have on my website gone through the specific issues: breast reduction, diastasis after babies, botox.  And my biggest issue is why women.  WHY?  Let’s look at pure botox for wrinkles, pure elective cosmetic botox.  Why is my desire for botox as a 40 year old woman taxed, but a man’s desire for medications for his “erectile dysfunction” not taxed? Are there too few women making laws on Capitol Hill? Is it that doctors and women have poorer lobbies than men and pharmaceutical companies?

This is a broadly worded way for the government to try to get revenue.  If you think this is not a slippery slope to taxing more medical procedures and medications, think again.  Their definition is :

COSMETIC SURGERY AND MEDICAL PROCEDURE-  ”1. is performed by a licensed medical professional and 2. is not necessary to ameliorate a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or disfiguring disease.”

Many many surgeries are not congenital, related to injury from accident or trauma (though can I argue having an 8 pound baby constitutes trauma?), or disfiguring disease.  Mole removal? Hernia repair? Breast cancer reconstruction? Breast reduction? Under this broad definition, who determines what is “necessary”?

A tax was done on cosmetic procedures in New Jersey.  It has proved arbitrary and difficult to administer.  And the “projected revenue” was 59% lower than expected.  Eight other states have looked at taxing these procedures, and all did not do it.

As I said before, EEEEK.

If you would like to know what to do, go to my website. Why can’t medicine be about medicine? I am not a politician, nor a tax collector.  I really love being what I do best- a surgeon and doctor to my patients.

Where to cut?

When you choose to do a breast augmentation, we must get the breast implant inside. (Unfortuantely, it is not magic.)  This is the scar you will see when you are done.  There are pros and cons to each incision.

There are three basic common incisions:

  • Armpit (also known as axilla)
  • Periareolar (at the bottom of the areola, the colored portion of the breast skin)
  • Inframammary fold (also called IMF, the under part of your breast where an underwire goes)

There are other incisions  you hear about such as through the umbilicus (TUBA), through an abdominoplasty incision, and through the base of the  nipple. These are not as common (for real reasons).

IMF: This is the most common incision used.  The scar can go in the crease of the underwire or just above the crease on the bottom curve of the breast.  PROS: On the breast, so only someone seeing you naked will see it.  Preserves ability to breastfeed.  Can use as an open door- when you need a revision surgery due to deflation or capsular contracture, you can fix it through the old scar.  CONS: If you wear a bikini which doesn’t hug your underwire, you may see the scar.  For patients who don’t scar well (read: hyperpigment, keloid, hypertrophic scar) you can see the scar.

AXILLA: Scar goes into the armpit.  PROS: Preserves ability to breastfeed.  No scar on the breast.  CONS:  Scar in a place visible when you wear tank tops or bathing suits.  Usually more of the pocket is done by blunt dissection, so may get more bruise.  More difficult pocket dissection, may lead to implant malposition and upward migration of implant.  Difficult to place gel implants.  Usually need to make a second incision when you need revision surgery for implant replacement.  For patients who don’t scar well (read: hyperpigment, keloid, hypertrophic scar) you can see the scar.

PERIAREOLAR: Scar is at the transition between the areola and the breast skin.  It does NOT go all the way around the areola.  It is at the bottom of the semicircle.  If you see a scar going 360 around the areola, then a breast lift was done.  PROS: I find this incision hides the scar the best, particularly in my patients with darker skin tones: Asian, Phillipino,  Latina,  and Black.  If your scar turns darker / brown, then it tends to blend with the areola.  It is an open door- you can reuse the old scar for any revision surgery.  It does NOT interfere with sensation. (Will go into sensation details below.) The scar is on the breast, so only someone seeing you naked will see it.  It gives the best access to making an accurate pocket dissection, important for smaller implant sizes, which is important for my natural aesthetic in my Bay Area patients.  It allows access to have meticulous bleeding control, important to limit bruising and potentially capsular contracture.  This is my favorite incision as I find the scar fades in most patients to nothingness.  I like it particularly for women who are done with pregnancy and breastfeeding, women with constricted or tubular breasts, and women who may need a lift down the road, so you limit future scars.  CONS: It does cut through some of the breast ducts, so for women who have not had children yet and want to breastfeed, it may impair breastfeeding.

The biggest issue women bring up when discussing breast augmentation incisions, tends to be sensation.  Will my breast sensation change? What affects it?  There is a common perception that cutting at the areola will cause more sensory change.  This is not true.  Funny.  It seems like if you cut at the areola then the nipple sensation should change more than if you cut at the armpit, eh?  A study published in our white journal (the plastic and reconstructive surgery journal- a big deal in my world) showed there was no difference in sensation based on where you cut, but there was a difference based on how big you go.  The sensory nerves come up from the sides.  As you stretch the skin the nerves stretch.  This is what causes the sensory change.  Think about how your breasts feel when you are pregnant- or better yet -when your milk comes in.  That tingly, numb, or hypersensitive-don’t-touch-my-breasts sensation.  Many women report right after augmentation feeling like they did when their milk came in.  This feeling goes away, though your final sensation may be the same, less, or more than prior to surgery. I tend to find sensory change is less for women after having kids, and my thought is they have essentially “prestretched” their breast skin.

SO. Bottom line on sensation? The bigger you go, particularly if you are stretching the skin, the more sensory change you will get.

For photos, check out my gallery.  Most of the incisions you see are periareolar, and most photos are 6 weeks out.