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.

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.

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 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.

OUCH!

I have a friend who lives in LA who just had a tummy tuck and breast augmentation.  She is on her first day after surgery.  She is a tough cookie, and her words to me today were, “This really hurts!!”

One of the most common mommy makeover surgeries is breast augmentation and tummy tuck.   These by themselves are the two most painful surgeries we do as plastic surgeons.  These surgeries hurt because of the muscle.  For tummy tucks, I like to put in a pain pump which drips numbing medication internally to help.  In addition we give you pain medication and some of us use muscle relaxants as well.  Even with all of this, it still hurts.

For planning how to deal with your family life (as you are a mom, hence the mommy makeover):

  • the first 2-3 days you are OUT. You will be on medication round the clock.  Someone else should care for your kids.  And you. 
  • The first one to two weeks you will be very sore.  No driving until you are off pain medication.  As for when you will feel normal again and be doing your daily life things, people vary.  Every person is different as to when they get over the “hump” and feel better. 
  • No heavy lifting (yes, this includes your adorable children) until much farther out.  Exactly when you can lift something over 5-10 pounds is not a hard rule.  Some of it depends on you and your tissue.  Your doctor will know what that means.  Here plastic surgeons differ on their recommendations for activity level, so defer to your doctor.  Tensile strength of your wound (how strong your repair is) is weakest at three weeks out from surgery.  Usually you can’t do any exercise until at least 6 weeks out.  For core body exercise (pilates, crunches, that favorite daily method place in menlo park, etc) I extend that until 3 months.

Give yourself time.  It took you 9 months (and for those of you with multiple kids, multiply that time) to get into this mess, it will take you a while until you feel normal again.  This is normal.

I had a patient who after three kids wants a tummy tuck.  Her belly was blown out after her second child, and she has back pain, so we knew a tummy tuck was in her future to repair it all after her third child.  She wants to do it when her baby turns one.

But she has been reading my blog (Go Bay Area blog reading mommies!) and said, “I know I should wait for 2-3 years until I do surgery, but I don’t want to wait.”   I realized I have not been clear.  It is true, the most common time I see women after babies is about 2-3 years out.  I think that timing is good- you have gotten out of the fog of babydom and given yourself a chance to get back into shape and see what comes back … and what doesn’t.  So the flip of that…

When is the soonest? Should you wait?

  • Normal blood level.  You lose a fair amount of blood after birth.  You need 3 months to rebuild your blood store.
  • Nutrition.  Your baby has spent the last 10 months preferentially getting your nutrients.  You need time to restore. 
  • Sleep.  Surgery is a stress on the body.  I liken it to running a marathon.  If you are sleep deprived you won’t have the reserve to help you heal well.
  • Breastfeeding.  Breastfeeding continues to take calories, energy, and nutrition for your newborn.  I am a HUGE breastfeeding fan.  The benefits to you and your child are immense.  If doing breast surgery, you need the breasts to be empty of milk, which takes about 3-6 months after you stop breastfeeding.  If doing other surgery, you can’t breastfeed at the same time- it would be too tough on your body to devote energy to healing and to your baby, and the medications needed for surgery and healing would get in your milk.  Also, see the nutrition point- breastfeeding can deplete you, so you need time after you stop to rebuild your internal stores.

 

My two to three year window is for women in the dreaded grey zone.  The grey zone? Those women who’s breasts and bellies aren’t like they were before babies, but they aren’t so bad.  In the right time of day, right angle, or if you stand up straight (posture girls!) you look okay.  Those are the women who should wait. 

But some women have things time will not help.  Particularly for the abdomen, horrible stretch marks, a wide diastasis (separation of the muscles), hernias, and hanging skin won’t go away with time and exercise.  Two years will not make these better.

So see your doctor.  Every patient and situation is different.  I get timing is tricky.  Many of you work, have multiple kids, and husbands schedules and other things you juggle.  But this is elective surgery.  And I know, from the title of this blog, you have an incredible responsibility- you are a mom. 

Elective surgery needs to be safe. 

There is a time and place for everything. Talk to your doctor.

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 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.

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?

plane

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.)

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