This is the beginning of a series of blogs about pregnancy and weight gain.  Pregnancy is not a time to go hog wild eating whatever you want.  There are guidelines to how much weight you should gain, and they vary with what your pre pregnancy weight is.

For those with no attention span (and can’t read past a twitter title), the findings were 

  • the higher your BMI, (underweight–>normal–>overweight–>obese), and
  • the more your weight gain past recommendations during pregnancy,

the higher your chance of high blood pressure during pregnancy. (High blood pressure during pregnancy is bad.)

Terms:

BMI= Body mass index. To calculate yours, here is a link from the US department of health  :http://www.nhlbisupport.com/bmi/bminojs.htm

PPBMI= Your prepregnancy BMI

IOM= Institute of Medicine.  It has guidelines recommending how much you should gain.  Those will be posted in another blog, but if you are normal weight, you average weight gain during pregnancy should be around 30 pounds, if obese around 15 pounds.

Study: American Journal of Perinatology Jan 2011

  • Evaluated new Institute of Medicine weight gain guidelines within each PPBMI category
  • Patients with singleton term deliveries
  • Women without history of  heart disease, diabetes, or pregnancy high blood pressure
  • Pregnancy high blood pressure rates were compared overall and within each PPBMI group
  • Looked at women gaining less than recommendations, within recommendations, and above recommendations

 

FINDINGS:

  • High blood pressure during pregnancy was higher when your prepregancy BMI was higher (5.0%, 5.4%, and 10.8% for less than, within, and above recommendation groups, respectively ( P < 0.001).
  • Above recommended weight gain resulted in higher high blood pressure incidence within each PPBMI category (underweight 7.6%, normal weight 6.2%, overweight 12.4%, and obese 17.0%), reaching statistical significance in all but the underweight PPBMI group.
  • Excessive weight gain above established guidelines was associated with increased rates of high blood pressure. 
  • Regardless of PPBMI, women should be counseled to avoid excessive weight gain during pregnancy.

So if you are considering getting pregnant, or you are pregnant, look at your BMI and weight gain.  It is important for your health and your pregnancy.  In general, as a plastic surgeon who specializes in the mommy makeover, I see women who don’t fare well with pregnancy.  Weight gain is part of that issue.

I am a plastic surgeon.  I perform a lot of breast augmentations.  I am lucky- most of my patients come to me after they have children and are done with breastfeeding. 

Any surgery to the breast will affect the breast.  This seems obvious, but it is something I always discuss with patients, particularly if they have not had children yet. 

If someone comes to me in their mid 30s and wants to have kids, I will counsel them to wait to have surgery until they are done having kids.  Your breasts get larger when you are pregnant and breastfeeding anyway.  Your breast changes with pregnancy and breastfeeding–after you are done with kids most women end up smaller in volume, so the size they would choose would change. (Some women do end up larger in breast size after kids, but don’t hold your breath for that one- it isn’t as common.)

So. Back to the title of this blog- if you have a breast augmentation, does it affect your future ability to lactate (ie breastfeed)?

Yes.

A study came out in Breast Journal, Jan-Feb 2007 out of the UK.  I have a few issues with the study, particularly one of their opening lines which I think is really untrue, “It does not occur to most women to consider the possible effects of breast augmentation surgery may have on their future ability to exclusively breastfeed their baby.”  Maybe it is because I live in the hypereducated Silicon Valley Palo Alto area, but I think all of my patients consider the effect of any breast surgery on their future ability to breastfeed, and it is part of my usual discussion, particularly with regards to incision site. 

But back to the study, which I am citing because it did bring out some interesting facts. 

  • Women who have breast augmentation surgery have a greater   lactation insufficiency.  NOTE: This does not mean they do not produce milk, but they may not be able to exclusively feed their child by breast milk alone to meet their parameters of weight gain.
  • Factors related to surgery include impairment/loss of nerves to the nipple areola complex, which lead to reduced sensation and loss of the suckling reflex resulting in decreased milk production.
  • complications in surgery (hematoma, need for additional surgery, capsular contracture, etc) can lead to impairment.

Their conclusion? “With good surgical technique and proper postoperative management, most of the complications associated with surgery that may result in insufficient milk production can be minimized but not always avoided.”

So what does this mean? This study would not change my general advice to women, which is:

  • If you are in your early 20s and have a good decade before having kids, in the pros/cons of deciding to do breast surgery, you need to factor in potential decrease in your ability to breastfeed.
  • I have had many patients who have successfully breastfed after breast augmentation.  This study shows a decreased amount of milk production, and it varied due to multiple factors.  Their final statement was that good technique and proper postop management you can minimize the impairment.
  • IF YOU ARE WITHIN A YEAR OR TWO OF HAVING A BABY, WAIT.  I counsel women to do this all the time. I get that having larger breasts will make your wedding dress fit better, but if your plan is to get married and then start a family right after, wait to do the surgery.
  • IF BREASTFEEDING IS OF PARAMOUNT IMPORTANCE and you would be upset to supplement with formula if needed, WAIT.  I know this is controversial in my plastic surgery world where many doctors have become salesmen for procedures, but you have to look at your life big picture when looking at these things.

Remember also, some women can’t breastfeed for whatever reason who have never had breast surgery.  There are no guarantees.

I love science.

I do a ton of breast surgery.  I have 3 kids.  I am a huge fan of breastfeeding.  How can I advise my patients about breast surgery and the relationship to breastfeeding?   I know a lot from being in practice for over a decade, and I read a lot of studies.  Every piece of information helps in the decision making.

There are women who are going to have a hard time breastfeeding.  Some of these women have had breast surgery, others did not.  Is there some way to predict who is whom?  Who will have a harder time?

A study came out in Birth, Sept 1990 looking at the influence of different factors on your ability to breastfeed a baby.  The study followed 319 women who were pregnant with their first baby who intended to breastfeed.  These women were evaluated in their last trimester for their initial measurements.  They looked at:

  • surgical incisions
  • size
  • symmetry
  • nipple protuberance (do you have inverted nipples?)
  • and the woman’s estimate of their breast increase during the pregnancy

At two visits after the first 2 weeks postpartum (all were term babies), the infants were weighed and the moms estimated how big their breasts got when their milk came in.  Breastfeeding was evaluated and help was given when there were problems, looking particularly at how to maximize the amount of milk made.

“Sufficient” milk production related to an average weight gain daily of 28.5g between visits.  If they had to supplement with formula this was noted as well. 

What was related?                                                              

  • 85% of mothers had sufficient lactation
  • 15% had insufficient lactation, despite intervention
  • 7% had some kind of breast surgery prior to their first pregnancy.  If a periareolar incision was used, these women had a 5x rate of lactation insufficiency compared to those without any surgery.
  • Insufficient lactation was significantly associated with minimal prenatal breast enlargement
  • Insufficient lactation was significantly associated with minimal postpartum breast enlargement when the milk came in
  • Inverted nipples were more likely to have lactation insufficiency (not statistically significant)

 

So. How can you anticipate?  If you have inverted nipples, or prior breast surgery with an incision in the periareolar area, you may have decreased milk production.  15% of women in this study had insufficient milk production, and many did not have any prior surgery or inverted nipples.  If your breasts get much larger with pregnancy and when your milk comes in, signs are good you will produce enough milk. 

What I have seen in my plastic surgery practice here in Palo Alto, where there is positive peer pressure to breastfeed, is prior surgery does not mean you can’t breastfeed.  What I found in practice and these studies is your milk production may be lower.  But any breast milk is good for you, your baby, and your bond.

This will be the first in a line of blogs about this topic.

Let me start first with an email I received from a patient,  “I just want let you know that I have had no problem breastfeeding.  I am grateful that nothing was damaged during my breast lift surgery.  Nice job to you!!  We had a beautiful girl.  I was worried about breastfeeding but it is going great.  I have a ton of milk supply on both breasts.   I just wanted to let you know. “

All breast surgery affects the breast.  Seems like a simple concept, but we forget it sometimes.  A 20 year old woman who wants a breast reduction may be more focused on getting her breasts smaller and somewhere above her waist, not the bonding and nutrition she may give with breastfeeding 10 years down the road when she decides to have kids. 

So I discuss it. 

Any woman who has not had children and wants to do any surgery of the breast needs to consider the effect surgery will have on the breast and your ability to breastfeed.  Thankfully, for most women, they are able to make milk.  The studies show there may be a decreased amount of milk, but I have had many patients who have had breast augmentation or breast reductions and lifts who have successfully gone on to breastfeed.

If you are a decade away from thinking about kids or you have a lot of issues with your breasts (backpain, droop, asymmetry, etc), then know there are techniques which help maximize your future ability to breastfeed.  If you are on the verge of having kids, wait to do the surgery.   It will totally preserve your ability to breastfeed among other advantages:
Anectode:  I had a friend who was 38, newly married, who wanted a breast augmentation.  I am a straight shooter, so I told her, “You are older.  You can’t wait to have kids.  Have your kids.  You’ll need to have them in the next year or two.  Your breasts will get bigger with pregnancy.  Your breasts will get bigger while breastfeeding.  When you know you are done, then do the surgery.  Pregnancy and breastfeeding changes the breasts a lot- shape, volume, symmetry.”  She did not listen, and went to someone else for surgery.  She has now had two surgeries within 3 years.  Had she waited until done with kids, she might have had just one surgery, and the results could have been better. 
 
I am a huge fan of breastfeeding.  I am not saying to do surgery or not do surgery.  I am not dictating the timing of your surgery.  This is all about educating you to make the right choices for you.

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.

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.

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.

Yes, yes.  I am a true believer in the benefits of breast feeding. 

I do not go into this starry eyed.  I know there is a cosmetic hit we breast feeding moms take (it is a lot of what I fix doing my mommy makeover work.)  But if you aren’t going to do it for your child’s health (less infections, etc), or for your health (lowers the rate of diabetes and heart risk), then do it for your country.

Medical costs are soaring.  The government is becoming increasingly involved in medicine.  I saw a recent study published in the news about how breastfeeding for six months could save 13 billion dollars. (!!)  You mean I can make a dent in America’s staggering spending by breastfeeding my baby?

Yes.

This is not new news.  In March 2001, a study of “The Economic Benefits of Breastfeeding: A Review and Analysis” was published for the USDA  (Food Assistance and Nutrition Report (FANRR13):

“A minimum of $3.6 billion would be saved if breastfeeding were increased from current levels (64 percent in-hospital, 29 percent at 6 months) to those recommended by the U.S. Surgeon General (75 and 50 percent). This figure is likely an underestimation of the total savings because it represents cost savings from the treatment of only three childhood illnesses: otitis media, gastroenteritis, and necrotizing enterocolitis. This report reviews breastfeeding trends and previous studies that assessed the economic benefits of breastfeeding”

http://www.ers.usda.gov/Publications/FANRR13/

The recent numbers are an extension of the original study, which only looked at three major illnesses, and wasn’t corrected for today’s economics. 

So.  Breastfeed- For your baby, for your health, and for your country.

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