The "Mommy make-over"

Here at our Orlando plastic surgery practice, it's very common for me to see women in their 30's and 40's who would like to restore their body to the "way it used to be", back before pregnancy. Typically, the body parts most affected by the wear and tear of pregnancy are the tummy and breasts.

A tummy tuck and breast augmentation or breast lift can work wonders for these patients. We call this combination the "Mommy Makeover". Often, a proportionately-sized breast implant will restore the volume and fullness that was lost as a result of pregnancy. We might additionally suggest a breast lift, if the nipple position is low.

A tummy tuck can get rid of stretched out skin, and lower abdominal stretch marks - and can also repair separated abdominal muscles. If needed, we also do a little liposuction around the waist, which helps to give a youthful figure.

And we do our special belly button technique, that we've discussed in an earlier chapter of PSB, as part of our tummy tuck.

The Mommy Makeover can sometimes be done during one surgery, depending on the length of anesthesia needed. Other times it is best to divide the procedures up over more than one day. (It's really all about doing what is safest.)

The results have been very gratifying. When your patients say, "Doctor, I never looked this good, even before I was pregnant!" - you know you're really on to something.

Thromboembolism risk and tummy tucks

There's a good review article on the risk of blood clotting problems known as "VTE's" and their relationship to abdominoplasty surgery in this months issue of Plastic and Reconstructive Surgery. VTE is the abbreviation for venous thrombo-embolism, and it includes such problems as deep vein thrombosis of the leg and pulmonary embolism.

Although this topic may sound obscure, pulmonary embolism can be fatal, and it can sneak up and strike suddenly after major surgery, without warning symptoms. My friend, Dr. Paul Vanek, once described VTE's as a "scud missile striking randomly in the middle of the night" - and that's a good way to think about it. So, anything we can learn to understand and prevent this problem better is really very important.

The authors reviewed the plastic surgery literature on VTE's, and their analysis revealed some findings that should make surgeons sit up and take notice.

In particular:

Risk of VTE with standard tummy tuck: 0.34% (= 1 / 300)

Risk of VTE when tummy tuck is combined with an intra-abdominal procedure (e.g. hysterectomy) 2.17% = 6 x risk

Risk of VTE when tummy tuck is combined with lower body lift (circumferential tummy tuck) 3.40% = 10 x risk.


Both of these findings were highly statistically significant.

Of course, wise surgeons do everything possible to prevent this problem. Using pneumatic compression leggings, which massage the calf area, keeping blood moving during surgery helps. Giving Lovenox, the medication which treats blood clots, helps significantly. And getting people moving as soon as possible after surgery helps too. But the risk of developing a VTE is still not eliminated.

So, what can we learn from this paper?

Personally, I think surgeons should give up doing the procedures that are high risk for these complications, until a proven strategy to prevent these potentially life-threatening problems can be developed and tested.

That mean no "circumferential" tummy tucks, and not doing tummy tucks at the same time as other operations inside the abdomen.

Just my two cents.

Exercise after abdominoplasty

Many patients who have lost significant amounts of weight through either diet, exercise or gastric surgery are very interested to know when they can resume their work-out routines after having a tummy tuck (abdominoplasty). They have made exercise an important part of their lifestyle, and miss it during the immediate postoperative time period.

While there is no scientific paper on this, and each surgeon's recommendations may be slightly different, we recommend a step-by-step return to activities using the following schedule.

3-4 weeks post-op: begin low intensity walking / treadmill / stationary bicycle

8 weeks post-op: may return to work-outs, except for abdominal exercises and activities that require strong twisting motions (e.g. golf, tennis, pilates)

12 weeks post-op: may return to full activities - no restrictions

In my experience from literally hundreds of abdominoplasty patients, we have not seen any problems from this exercise protocol, given an otherwise uncomplicated recovery.

Mini tummy tucks - are you a candidate?

"Doctor, will a mini tummy tuck fix my tummy or do I need the full tummy tuck?"

The mini tummy tuck (abdominoplasty) is the smaller cousin of both the "regular" or the "extended" abdominoplasty. These latter two operations do have a longer incisional length, but are much more powerful in terms of skin tightening and muscle repair, so they give a bigger degree of improvement.

Like many things in life, it's a matter of "choosing the right tool for the job".

A mini-tummy tuck incorporates:
- a small amount of skin removal from the lower abdomen, with a scar similar to a caesarian section incision;
- repair of the lower half of the rectus muscles;
- possibility for some abdominal liposuction, if needed.

Unlike it's bigger cousins, a mini tummy tuck does not:
- move the umbilicus (navel). This means that tightening of the upper abdominal skin is limited.
- doesn't repair the upper half of the rectus muscles, so bulging in this area will remain.
- take care of loose skin near the hip bones.

So, if you have a small problem area of loose skin or separated abdominal muscles in just the lower, central zone of the abdomen, then a mini tummy tuck might work for you.

If, however, you have a lot of loose skin that you can pinch when you bend forward, and that loose skin extends towards the sides of your waist line, then you really do need a more involved surgery, because a mini tummy tuck will not correct these problems. It's just not powerful enough. You would be left with a tightened zone in the middle of the abdomen, but loose zones on each side if you had the mini abdominoplasty - which wouldn't look good.

About one or two patients out of every ten that I see are good candidates for a mini tummy tuck. The other eight or nine people need more work to get a nice looking result.

Anchor / fleur-de-lys abdominoplasty

One variation of the usual abdominoplasty (tummy-tuck) is known variously as the "anchor", the "vertical" or "Fleur-de-lys" abdominoplasty. This involves removing not only the lower abdominal skin and fat, but also adding a vertically-oriented segment shaped like an inverted "V" in the upper midline. When the surgery is completed, this leaves a T-shaped or "anchor" shaped incision, but it is a very effective tightening operation for those who need it.

It's usually only performed for our patients that have lost a major amount of weight (>100 lbs), and who have obvious fullness or laxity in that upper midline zone of the abdomen. Standard abdominoplasty techniques don't correct horizontal laxity of the upper abdomen very well, so this technique may be useful for patients with that particular issue.

Also, for patients that have had a previous traditional open-style gastric bypass operation, and who have a scar there already, the fleur-de-lys approach is a reasonable option, as we are not adding any new scars, and are merely using the pre-existing midline incision to take out a little more skin there.

As is commonly the case in excisional body lifting surgery, this operation is a trade-off: more scars, but better tightening.


Advantages of the fleur-de-lys approach:
- better tightening of upper abdominal zone when obvious laxity is present
- may permit excision of previous old-fashioned gall-bladder surgery scars
- gives horizontal tightening, unlike a standard abdominoplasty

Disadvantages:
- more scars, which are not as well hidden as a standard abdominoplasty
- has potential for wound healing problems at intersection of incisions
- umbilicus shaping is more complex, prone to post-operative shape changes

When Abdominal Fat can be deadly - "Metabolic Syndrome"

It's well known that America has an obesity epidemic, which affects both adults and children alike. But what's not as well known, even in the medical community, is the rapid rise in an obesity-related problem called "Metabolic Syndrome".

Metabolic Syndrome is diagnosed if you have 3 or more of:
- increased waist size (>40 inches for men, 34.6 inches for women
- elevated blood sugars or known Type II diabetes
- elevated blood pressure (> 130/85) or known hypertension
- decreased good cholesterol (HDL)
- increased triglycerides

Why is Metabolic Syndrome important? Because it causes a huge increase in the risks for heart attack and stroke. According to a 2002 article in the Journal of the American Medical Association ("JAMA"), middle aged men with Metabolic Syndrome are three to four times more likely to die of coronary artery disease, and have double the all-cause mortality rate. It affects women similarly, too.

About 47 million people in the United States are believed to have the syndrome, or about one-fourth of the population. It's common here due to our sedentary lifestyle and overall level of obesity.

It's probably more even common than that at my office, because the patients I see for liposuction and tummy tucks are often self-selected; they are seeing me specifically because they have an increased waist size, which is the most obvious part of the syndrome. I now routinely check these patients for the other parts of the syndrome.... Almost every month, we find men and women who never knew they had untreated diabetes, or cholesterol abnormalities, or the whole package -- Metabolic Syndrome. And let me tell you, are they ever thankful we discovered the problem early, rather than after a heart attack! "Doc, I came in for a tummy tuck, and you saved my life!"

It turns out that the fat inside the abdomen, the so-called "visceral fat" (as opposed to the fat that is immediately underneath the skin - "subcutaneous fat") is the chief culprit, together with insulin resistance. Visceral fat is not the harmless layer of insulation we used to think it was - it is metabolically active, giving off hormonal messenger compounds that affect our body. The thicker the visceral fat is, the more health problems are seen. Unfortunately, this internal fat can not be removed by way of liposuction or tummy tuck, so there's no quick fix.

There is an answer, though, and hope for those with the syndrome. Insulin sensitizing medications such as metformin can be used to help with the insulin resistance. Blood pressure and cholesterol medication can help, too, controlling those parts of the syndrome.

Probably the most important treatment, though, is the one that takes the most determination and effort - diet and excercise, particularly aerobic fitness. Several studies show that aerobically fit people with Metabolic Syndrome improve their odds substantially, reducing their risks by a factor of three. Furthermore, overweight people who are aerobically fit have a lower risk of cardiovascular mortality than those who are lean but unfit.

It's time to turn off the TV's and computers, America, and go get some exercise! (And that includes me, too!) Your heart will thank you for it.

Making a beautiful belly-button

It seems like a small thing, but many of my prospective tummy tuck patients mention how they like our photos, especially the nice looking belly buttons.

During a full abdominoplasty, we re-use the original umbilicus, but we have to make a new cut-out in the skin for it, once the upper abdominal skin has been shifted downwards and pulled snug. It's much like making a new button-hole for a button on a shirt.

Here are some of my "surgical secrets" for making pretty belly-buttons:

1) the right size: when you trim the original umbilicus, and when you make the new cut-out, the sizes must match. Don't make the new cut out either too large nor too small...

2) the right location: the umbilicus needs to be in the midline, at the correct height, which is on a line at the top of the so-called "iliac crest" - that bony bit on the top of the hip you can feel on your side. Try it for yourself, and see. By putting the skin incision at the correct location, you avoid tension on the closure, which could lead to a distorted shape later.

3) the right shape: don't make the new umbilical cut-out perfectly round - or else it will tend to shrink / scar down later. There are multiple techniques for this; I prefer the "tulip" or "pac-man" methods, in which the pre-existing umbilicus is converted to a "tulip" or "pac-man" shape. A small V-shaped flap of tummy skin is designed to fit neatly into the top of the "tulip" portion of the umbilicus, re-creating the hooded configuration of the upper part of the belly button. This method looks nice, and reduces the risk of a scarring problem known as umbilical stenosis.

4) tailor the underlying fat: After all, you don't want to have any puffy fat around the umbilicus...

5) Perform a tidy layered closure.

And now you know most of how it's done. It's really not magic, after all. Just like schoolwork, points are awarded for neatness!