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.

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 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.

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.

I was recently the featured interview for an online magazine for busy moms to talk about the mommy makeover.

http://bizymoms.com/palo-alto/surgery/mommy-makeover-palo-alto.php

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