bodypostbaby's blog

I just got back from a playgroup. There was a mom who just had twins 6 months ago and has another child who is 2.  She had tried to do an intense exercise and diet program to get back into shape.  Here is a woman who has three kids within 2 years, the twins are boys, she is not sleeping through the night.  I was looking at her thinking, “You showered!” “Your shoes match!” “You aren’t wearing sweats!”  So I will repeat what I, the plastic surgeon and mother of three said to her:

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.

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….

I get People magazine at my office. 

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.

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

If only unicorns were real. 

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.

I answered a question recently about timing of a mommy makeover.  The person was traveling out of state via plane to have the surgery done.  I tried to redirect her to the real issue: how safe is travel to have surgery?

Mommy makeover is a combined surgery of breast and body.  Her question was when to do surgery after you stop nursing (I would wait 3-6 months, and be close to your ideal weight if possible).  The bigger issue I saw was her travel from New York (place with many great doctors) to Florida for surgery.

There are short surgeries with easy recoveries, and there are long surgeries with long recoveries.

Mommy makeovers are usually two surgeries done at one sitting.  In most healthy women, it is safe.  But combined surgeries have higher risk of bleeding, anesthesia complications, DVT, infection, and other issues.  You are at higher risk for a DVT for 3-4 weeks after surgery, making airline travel riskier.  If you do a tummy tuck, you will have a drain.  In heavier women, that drain can stay in for 3-5 weeks after surgery.

If you have a complication, it will be difficult to get to your doctor.  A local doctor will be hesitant to treat you.

Find someone close to where you live.  If you live in a small town, then go to a nearby larger town.  For a qualified surgeon near you, find someone board certified by the American Board of Plastic Surgery.  Meet a few doctors.  You’ll know the right one when you meet them and see their photo books.

(I do have patients travel to have me do surgery.  Usually though they have family or friends near me, and I require they stay around for 2-3 weeks depending on the scope of surgery.  It is not ideal.)

When I started my practice a decade ago, most of my breast reductions were covered by insurance.  I think they are a great surgery, improving posture, neck pain, back pain, shoulder notching, and the ability to go jogging.

Things have changed.

Now almost none of my reductions can get covered. It is frustrating for me and my patients, as I see many large breasted women who can’t get covered.  What changed?

First, I now do a short scar breast reduction technique, called a vertical breast reduction.  I “cut out” less breast tissue with this technique.  Why did I change?  First and foremost: much shorter scar.  Also, I find this breast reduction better at shaping, with a longer lasting result.  I love it.  But with this technique I do liposuction of the lateral breast in the armpit area.  Insurance won’t include this fat as part of my “breast tissue removed” total.

Second, the amounts they require have gotten higher.  Not a good combo with my short scar technique where the amounts I directly cut out went down anyway.

The Schnur scale came out of a study in the plastic surgery literature.  They did the study to prove breast reductions objectively, medically IMPROVE symptoms. During the 1980s plastic surgeons started to see insurance companies refusing to pay for breast reductions, calling them “cosmetic.”  So multiple studies followed, documenting scientifically that back pain, neck pain, and breast pain had about an 80% improvement after surgery.  (And patient satisfaction was around 90%.  Pretty fantastic, particularly given those were the days of the longer anchor scar.)

The Schnur study came up with a scale used to show the volume which needed to be removed for breast reductions done for medical reasons only.  The issue is the Schnur study had a mean height of patients being 5’4″, 163 pounds, and a mean total amount of breast tissue being removed was 1515g. (That is over 3 pounds per breast.)

Ug.  When I started my practice, if a woman was going down about 2 cup sizes, they would get covered.  I used to have to remove about 300g for insurance coverage.  Now it is adjusted to the body surface area, and the required amounts have gone up.  With current recommendations, a 5′6″ woman who weighs 140 pounds needs a reduction of 370-400 grams per breast to be covered.  If she weighs 160, she would need about 450 grams per breast.  Liposuctioned fat cannot be applied to this total.  In my office I can show you visually what “volume” (using an implant sizer) this would be.  Many times the amount looks like the total of the entire breast, essentially being a mastectomy.

You don’t need to convince me a breast reduction and lift is a good idea. Insurance is another story though.

BODY SURFACE AREA CALCULATOR at http://www.bcbst.com/providers/calculator.asp

SCHNUR SLIDING SCALE at http://www.bcbst.com/mpmanual/The_Schnur_Sliding_Scale_chart.htm

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.

Ah. The joys of being female.  All those lovely “woman” things, sometimes can lead you to need a hysterectomy.  Ug.  But can there be a silver lining? If you have to have a hysterectomy, can you do this with a tummy tuck?

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?

Yup. That’s right. Go raid your kids toys. There is a use for those marbles.

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.