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.

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.

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.

Who doesn’t love that glucose tolerance test? Who can forget the “cola” flavor which 1. does not taste like cola, and 2. does not taste better when chilled.   Did you wonder why you had to do that? What is gestational diabetes?

Gestational diabetes is when you develop diabetes (high blood sugar) while pregnant.  You don’t want your blood sugar to be too high.  People with long term diabetes have issues all over their body due to problems with blood flow- heart disease, loss of sensation, loss of limbs, higher infection rates, vision issues to name a few.  In pregnancy, diabetes is associated with higher birth weight of your baby, early delivery, higher C section rates, diabetes in the mom, and future diabetes and obesity in your child. 

A study came out in the American Journal of Obstetrics and Gynecology of 65,000 women studied from 1991-2008 at Kaiser.  It showed for recurrent gestational diabetes:

  • if you have gestational diabetes with your first child, you are 6x more likely to have it again with your second pregnancy
  • if you have it with your first two pregancies, you hae a 26X risk for having it with your third pregancy
  • higher rates found in Hispanic women, and Asian/Pacific Islander women
  • higher recurrence in women over age 30
  • higher recurrence when bigger time gap between pregnancies

This may seem like a “of course that makes sense” kind of thing.   But for those women who have had gestational diabetes, are older, or are certain ethnicities, that glucose tolerance test is extra important.

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.

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.

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.

Babies.

I am a plastic surgeon.

I am a mother of three.

This site stems from my desire to educate women about changes in our bodies from babies. My practice focuses on fixing what babies do to women. I want to share what I know from treating hundreds of women and from my own experience about what you can do to prepare, prevent, and fix what pregnancy does.

Why do some women look better than others? When I had my first pregnancy I asked my colleagues for helpful hints to survive the pregnancy changes.  I know what happens, how it happens, what it looks like.  Could I stop it from happening to me?  It is like standing on the beach in front of a giant wave, knowing it is going to knock you over, but you can’t get out of the way

There are themes and trends… things you can do before becoming pregnant, things during pregnancy, and then things after. And there are some things you just can’t fix on your own. Please feel free to email me questions through my website at www.laurengreenbergmd.com