Port-partum Rejuvenation (Mommy Makeover)
Introduction
Motherhood is a blessing but it can also wreak havoc on a body. Pregnancy is nothing short of a traumatic process that can permanently alter the structure, shape, and often times, function of the female body. Additionally, the psychological effects of seeing a body ravaged by the process of childbirth can leave a women feeling unattractive and self-conscious, particularly during sexual relations . Because these changes are structural, no amount of exercise or diet will alter these physical deformations; only a surgical intervention can reshape and reform the post-partum body.
Mechanisms of change
During pregnancy, the enlarging breasts stretch the skin as well as the interior suspensory ligaments. Once the hormonal influences are withdrawn, the glandular elements atrophy, the skin retains a measure of laxity, and the suspensory ligaments remain lengthened. The result is smaller breasts that sag, with the bulk of the gland redistributed to the lower pole (figure).
Changes to the trunk are even more dramatic and predictable in women that do not have adequate pelvic/abdominal volume for late term fetal development. These women are typically shorter in stature, possess narrow hips, or are “short waisted" having a diminished pubic to xiphoid measurement. The predictable result is outward growth of the fetus with overstretching of the skin and the fascial elements of the abdominal wall, most notably at, but not limited to, the linea alba. As the linea alba stretches, the rectus abominus muscles move laterally into an anatomically more relaxed state. With less tension now exerted on the lower abdominal wall there is predictable expansion and protrusion of the lower abdominal wall. This also occurs in the upper abdominal quadrants, but to a lesser extent owing to the presence of the structural support of the lower rib cage .
Statistics Females of child-bearing age, as well as those who are beyond that stage, have a growing need and interest in post-partum procedures; especially the tummy tuck and breast lift/ augmentation. In 2005, more than 20% of the surgical procedures performed were to lift or augment the breast. If you include abdominoplasty this number rises to 30%. The majority of these patients fell in the 30 to 55 age group. This follows the growing trend of young adults who are exercising, eating well, and want to look as good as they feel. Not to be discounted is the feeling of empowerment and self confidence that physical appearance creates in the individual.
Objectives
Rejuvenation of the anterior abdomen should strive to achieve the following: Inconspicuous incisions within the bikini line; reduction of abdominal stria; flattening of the abdominal contour; reduction in the waistline measurements; tightening of the skin about the hips, thighs and groin areas; rejuvenation and tightening of the pubis; improvement of body posture; relief of back pain if related to body posture and lower abdominal laxity.
Rejuvenation of the breast involves the following: Converting the flattened breast to a more rounded and globular structure; elevating the nipple-areolar complex to a point at or above the inframammary fold; down sizing of the widened areola; elevating and projecting the breast parenchyma; maintaining or improving the nipple sensitivity.
Preparation and Assessment
Of paramount importance is the proper preoperative education of patients and obtaining a truly informed consent. Investing time up front with patients will maintain realistic expectations, improve patient satisfaction, and decrease the possibility of litigation in the face of complications.
A thorough history and physical examination must at the very least address the following important issues: Cardio-respiratory status; prior breast surgery; prior abdominal surgeries; family history of breast cancer; medication history; breast and abdominal skin thickness and quality including presence of stria; degree of breast ptosis; presence of infra and/or supra umbilical rectus diastasis; distribution of excess skin; presence of hernias; distribution of flank, back and abdominal fat. Careful measurements of the chest, waist and hips as well as height and weight are mandatory. Patients are also measured and fitted for a postoperative surgical girdle at this time. I feel that a girdle manages postoperative swelling far better than an abdominal binder.
It is important to mention that discussions with the patient must include suction lipectomy (traditional and ultrasonic). Assessment of flank and back fat is extremely important. Contouring of these areas can provide dramatic three dimensional changes to the patient's entire lower body and a significant change in clothing size. It is worthwhile having this discussion, if only to advise the patient that a tummy tuck alone will improve appearances and make existing clothes fit better, but will not significantly decrease size. Emphasis of this point is extremely important to avoid unreasonable expectations from an abdominoplasty alone.
Prior to surgery patients are advised to stay well-hydrated and a simple bowel cleanout with magnesium citrate is performed the day prior to surgery to avoid issues of constipation.
Surgical Technique - mastopexy/augmentation
Post partum changes can be broadly categorized as volume loss and expansion of the skin brassiere, the combination of which causes ptosis. Options include removal of skin to accommodate existing volume or volume expansion to accommodate the existing skin brassiere, or a combination of these procedures. If both are required, my preference is to stage the two procedures with the mastopexy performed first to create the shape of the breast and augmentation performed 6-8 weeks later to add volume. The rationale for staging is that the two procedures done together work against each other with the mastopexy lifting and tightening and the augmentation expanding and placing downward pressure on the breast. Staging the procedures allows for preliminary healing and less tension on the inferior suture lines.
There are many variations with respect to mastopexy, the choice of procedure is dictated by the skin excess of the individual patient. Mastopexy is a continuum from periareolar to vertical to a traditional Wise pattern (figure). As the need for skin removal increases, one progresses to the next stage.
Periareolar lifts are useful for pseudoptosis or early ptosis and in conjunction with augmentation. These lifts tend to flatten the breast and can result in long term expansion of the areola if too much skin is removed or a purse string type suture is not used.
Addition of the vertical component (aka vertical mastopexy) balances the flattening of the periareolar excision by narrowing the base and coning the breast. A concomitant narrowing at the base of the breast gland with judicious nonabsorbable suture placement and release of the inferior glandular attachments helps to stabilize the shape and elevate the inframammary fold. For patients with significant amounts of skin excess, adding the horizontal component at the base of the vertical excision helps to better tailor the residual skin and prevent the scar from extending below the new inframammary fold. It is an important concept to emphasize that each procedure can only accomplish a limited amount of improvement. Each should be utilized in sequence as an extension of its predecessor to assure proper shape and scar healing. Attempting to overreach with a particular procedure will result in a poor outcome and an unhappy patient.
The indications for augmentation are for patients in whom there is minimal ptosis (stage 0/1) and the desire for increased breast size. Saline implants require placement under as much tissue as possible to obtain a natural look and feel. As the size of the implant increases relative to the breast tissue, the contour and firmness of the implant becomes more evident. Additionally, complications such as malpositioning and loss of sensitivity become more prevalent.
Post operative motion exercises and physical therapy techniques are used to improve circulation and reduce edema about the pectoralis muscle. In situations where an augmentation is performed alone, this reduction in edema decreases pain and allows most patients to be managed on Ibuprofen alone.
Surgical Technique - Abdominoloplasty
Abdominoplastry has an infinite number of variations on the technique. In considering how to approach a particular patient, one should pay attention to the pattern of skin laxity and be prepared to alter the skin pattern based on the distribution of the skin excess. In some cases this can be a high lateral tension style abdominoplasty that contours effectively in the horizontal as well as vertical vector as opposed to the standard abdominoplasty pattern. One should not forget the skin inferior to the incision as the mons, anterior thigh, and groin area stretch considerably during pregnancy. Again, tightening in the horizontal vector with a central "V" excision (with or without z-plasty) can add an extra dimension to the rejuvenation. Liposuction of the flanks with abdominoplasty is routinely performed to obtain typically dramatic results, however most agree that anterior abdominal suction should remain subfascial and limited to preserve blood supply in the central segment of the flap. The abdominal wall repair takes into consideration the degree of abdominal wall stretch and the quality of the tissue. Nonabsorbable sutures are mandatory and are usually placed as a two-layer type repair along the midline. Liberal use of Marlex Mesh especially at the lower abdominal midline where the forces are typically the greatest and the failure rate is more common can preserve the repair in patients with poor tissue quality. Lastly, be sure to emphasize the long-term nature of the recovery. It took nine months to create the pathology and that is approximately the time for optimal recovery and results to be visible. Patients typically will require some form of "cheerleading" at about 4-8 weeks, as they will not feel their progress is fast enough. Showing them the pre-op photos reminds them of the extent of the problem and how significant the improvement.
The traumatic effects of pregnancy can be remedied, all that is required is a committed patient, an organized plan, and thoughtful execution. ah, that it should be so easy!
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Kirk A. Churukian, M.D., F.A.C.S.
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