A lot of us have back pain.  And kids, in addition to being a pain in the neck at times :), can also lead to a pain in your back.  

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 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.

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.

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.

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

We have established it isn’t a good thing to do the tummy tuck with C section.  I know. I know.  I’d love it too.  But it just isn’t a good idea.  So when can you do it?

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.)

Life isn’t always black and white.

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.

I get asked this question a lot.  “Why can’t I do a tummy tuck when I get a Csection?” Sounds good. Some people look at me like, duh, why haven’t you thought of this?

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.

There is a price for plastic surgery.   (yes. yes. I am a plastic surgeon who will not give you a hard sell to do surgery do surgery do surgery.)  Because plastic surgery, the yummy mummy, mommy makeover is not for everyone.

When you get done having your beautiful babies, you wait a bit.  I strongly recommend you wait a bit.  What will your post baby body be like? Will your breasts stay full or will they deflate? Will they be anywhere near your neck or will they touch your waist? Will your belly look like you are permanently 4 months pregnant or will it get back into an okay territory?  How bad does it look when you sit down? And most importantly, does it bother you?

We all have these thoughts.  No woman goes through labor and gets done and doesn’t think UGGH when they see their belly skin flop over when they lie on their side that first day. Thank heavens we are ramped up on adrenaline looking at the beautiful new baby next to us, and then sleep deprived and can’t see straight for the next few months.  When women show up in my office, they have thought about doing surgery for months, sometimes years.  They are not happy.  On a frequent basis some thought haunts them.  “I can’t buy a bathing suit.”  “I was dancing and my bra padding migrated down my dress.”  “I look like a boy.”  “I look four months pregnant all the time.”  “I can’t do sit ups.”  “I have to always take in my jeans at the waist, because when I buy pants to fit my thighs the waist is too big.”  “I look like I hopped out of National Geographic.”

If you are happy with your body, don’t do anything.

Seeking advice from a plastic surgeon is the next step.  You have thought about it, talked to your friends perhaps, and read too much on the internet.  You need a doctor to evaluate you.  Please here take my advice:

  • See a Board Certified Plastic Surgeon.  Anyone can call themselves a plastic surgeon.  True plastic surgeons are trained as general surgeons first.  We are well trained to do all breast and body surgery.  I keep seeing women who have the wrong surgery done (especially liposuction when they needed a tummy tuck) because the doctor is not a real plastic surgeon.
  • See more than one doctor.  I joke if you see three plastic surgeons, you’ll get at least two different answers on how to do something.  Many patients fall into what I call a grey area: no surgery is perfect, but all will improve the situation.  An example:  You have lost breast volume and are mildly droopy.  Do you do a breast implant alone? Do you do an implant with a lift?  Do you just do a breast lift? Every woman is unique in what they look like and what they want to look like.  My Palo Alto patients are smart women.  They know their body, they know what amount of scar is okay, they know what look is okay.  I educate them, so they can make the right choice for them.

So, getting back to my original point, you pay a price for surgery. The price is not actual money (though yes, you do need to pay actual money too).  There are some procedures where the “price” is low: the surgery is easy, short, fast recovery, little downtime, small scar, scars heal well.  There are other surgeries where the price is higher: longer, bigger surgery, longer recovery, larger scar, higher chance of other things.