For many women, pregnancy and breast-feeding combine to create significant changes to the breasts and abdomen, often accompanied by increased fat deposition in the flanks, abdomen, and thighs.
This process is the “mommy makeover”—what the public and the media often call the combination of procedures to reshape the breasts and abdomen, and to liposculpt the abdomen, flanks, and thighs.
In practice, women will undergo one or more of these procedures depending on their overall goals for their appearance, postpregnancy and beyond. Because of their social and sexual significance, it is often the changes in her breasts that first lead a woman to seek a consultation.
The changes women undergo after having children include ptosis (which is the most common), breast involution, and occasionally persistent hypertrophy. Breast-reshaping procedures to address these changes include breast augmentation, mastopexy, and reduction.
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With recent advances in surgical techniques and improvements in the materials used for augmentation, surgeons and patients have more options now than ever before.
SILICONE, ANYONE?
Silicone implants have become much more widely used again in the last few years. These implants have a demonstrated safety record and offer patients an improved feel and, often, a more natural shape.
Different implant diameters and projections give aesthetic surgeons greater ability to create an individualized result. For example, take a woman with pseudoptosis or Grade 1 ptosis who is a candidate for augmentation. She will want to minimize incisions but also will desire subtle augmentation results. A low-profile implant often allows filling of the breast envelope and some nipple elevation with minimal incision and a minimal increase in breast projection.
A word of caution: For most women who have borne children and, in particular, those who have nursed, high-profile implants are to be avoided in most cases unless a mastopexy is also performed. Otherwise, the lax skin envelope quickly lets the remaining breast tissue fall off the implant.
In my practice, incisions used for mastopexy (and reduction) commonly include a simple crescent, a circumareolar incision, a vertical incision, and the inverted T incision. The incision choice is determined by the degree of ptosis, whether an implant also will be used, and after talking with the patient and determining her goals and desires.
When counseling patients it is important for you to make every effort to minimize talk about incisions—ultimately, breast shape takes precedence.
Fortunately, most scars fade well over time, while breast shape after mastopexy tends to be very long-lasting.
For mastopexy/reduction cases in which no implant is to be used, the degree of nipple-areola elevation required provides a general guideline for the optimal technique.
Incisions used to address ptosis include a simple superior crescent excision (when 1 cm to 2 cm of elevation is required), a circumareolar incision (for 2 cm to 4 cm of ptosis), a vertical mastopexy (3 cm to 6 cm), and an inverted T incision (for 6 cm or more of ptosis).
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| The changes women undergo after having children include ptosis (which is the most common), breast involution, and occasionally persistent hypertrophy. Breast-reshaping procedures to address these changes include breast augmentation, mastopexy, and reduction. |
Patients with good skin quality can add a few more centimeters of ptosis to each category and obtain a good result.
Patients receiving an implant, particularly with a circumareolar approach, can also stand a few more centimeters of ptosis and obtain a good result.
It is worth reemphasizing that every effort must be made to obtain the optimal shape, with incision length an important secondary consideration.
COMBINING PROCEDURES
The changes to a woman’s body caused by pregnancy and aging are not limited to the breast. You must often address the abdomen, flanks, and thighs in order to obtain optimal results.
Furthermore, once the breasts are lifted, the upper abdomen and waist often become more visible, which makes flaws in these areas more apparent. Combining breast reshaping with abdominal recontouring and/or liposuction procedures has become increasingly popular in the past few years.
For the past 10 years in my practice, these procedures are usually combined. I have performed more than 500 such combined procedures. This approach offers patients the potential for optimal results in all of their “problem areas,” and also minimizes recovery time and cost.
Perhaps most important, after this single procedure and recovery a woman can achieve her desired body shape, thereby enhancing her appearance and self-esteem. Many of my patients have referred to this simply as “getting my body back.”
A number of studies have now demonstrated that such procedures can safely be combined, as long as certain safety requirements are followed.1-3
OPTIMIZING SAFETY, RESULTS, AND RECOVERY
Patient safety begins with patient selection. In my practice, preoperative testing is done according to American Society of Anesthesia guidelines, in conjunction with the anesthesiologist and the patient’s primary care physician.
All preoperative markings are done with the patient both standing and lying down—done properly and thoroughly, this step can dramatically decrease intra-operative time since all the decision-making is largely done prior to the procedure.
Incisions can be checked for symmetry, dog-ears can be anticipated and corrected, etc. Whereas the surgeon can sit the patient up to confirm the results (that is, following mastopexy), I very rarely deviate from these markings or have to make intraoperative adjustments.
All patients receive intraoperative compression stockings and sequential pneumatic compression, which can dramatically decrease the incidence of deep vein thrombosis—which is probably the most significant cause of morbidity in these procedures.
I have not used Lovenox (low molecular weight heparin), because it increases the risk of hematoma formation, though some physicians have used it routinely.3 Its place in the perioperative care of these patients is not yet established. A Bair Hugger is used to minimize heat loss and increase patient comfort before, during, and after the procedure.
When liposuction of the flanks, back, and thighs is performed, the patient is in a prone position at the outset of the procedure. Additional liposuction of the lateral chest, inner thighs, and abdomen is performed with the patient supine.
Additional considerations accompany routine liposuction—for example, limiting aspirate volume and ensuring proper perioperative hydration becomes increasingly important in combined procedures.
Patients who undergo combined procedures are frequently the primary caregivers of one or more small children, and these moms truly benefit from a shorter recovery time. With these patients, I adjust my intraoperative and postoperative approach to abdominal procedures.
In order to help offset the increased abdominal pressure, which may be associated with muscle plication during abdominoplasty, I make minimal use of the flexed position during these procedures.
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| See also “More Than Skin Deep” by Skip Freedman, MD, in the April 2005 issue of PSP. |
The breast portion of the procedure is completed first, and only minimal (or no) flexion is used during the abdominoplasty closure. There is seldom a need to make the skin closure in the midline so tight that a significant degree of tension is needed to allow skin closure.
Adhering to this principle keeps scars low and thin, may minimize the risk of pelvic vein thrombosis, and allows a quicker, less painful recovery period.
Postoperative use of pain pumps also seems to speed recovery and minimizes the need for narcotics to control pain. Similarly, compression garments are used judiciously in order to avoid decreased pulmonary compliance and functional residual capacity.
Following an abdominoplasty (with or without liposuction), I use only an adjustable wrap binder for a few weeks instead of the tighter compression garments.
James Anthony, MD, FACS, received his MD from Stony Brook University and completed his general surgery residency at the New York Hospital-Cornell Medical Center and his plastic surgery residency at the University of California, San Francisco. He has developed and improved several techniques for facial and breast reconstruction. He can be reached at (415) 395-7323.
PHOTOS COURTESY OF JAMES ANTHONY, MD, FACS
REFERENCES
- Stevens WG, Cohen RM, Vath SD, Stoker DA, Hirsch EM. Is it safe to combine abdominoplasty with elective breast surgery? A review of 151 consecutive cases. Plast Reconstr Surg 2006;118:207-212.
- Stevens WG, Vath SD, Stoker DA. “Extreme” cosmetic surgery: a retrospective study of morbidity in patients undergoing combined procedures. Aesthetic SurgJ 2004;24:314-319.
- Stokes RB, Williams S. Does concomitant breast surgery add morbidity to Abdominoplasty? Aesthetic Surg J 2007;27: 612-615.
