THE MOMMY MAKEOVER: RESTORING (and even improving) WHAT PREGNANCY CHANGES
How to choose a plastic surgeon for a Mommy Makeover.
The miraculous privilege of bringing new life into the world and creating a family carries with it one particular consequence that for most of human history has been something that a woman just had to accept and live with: the changes in body contour that result from pregnancy. Deflated and/or droopy breasts, excess abdominal skin, weakness in the abdominal wall; all the issues that can be minimized or concealed with appropriate attire and supportive undergarments, but that are an unavoidable reality in an intimate setting.
It is only the last two generations of mommies that have had the luxury of surgically improving, if they so desire, the post-pregnancy changes in body contour about which they are self-conscious. And it is really only in the last ten to fifteen years or so that the simultaneous surgical treatment of breast contour and abdominal contour - what we now refer to as a 'mommy makeover' - has become a universally accepted and widely practiced technique amongst board-certified aesthetic plastic surgeons.
SURGICAL AND ANESTHETIC SAFETY - THE FIRST AND FOREMOST CONSIDERATION
For me as a surgeon, the most important consideration is safety. This is elective surgery to treat an appearance issue, often on a person who usually has very young or school-age children and a spouse or partner counting on them, so it is not worth taking any chances related to patient safety. Other patients seek this surgery later in life.
So in making decisions regarding all aspects of the endeavor, from the design of the surgery center to the surgical team to the anesthesia personnel to the actual plan for the surgery, I do for my patients what I would want to be done for my family member if they were the patient. We don't cut corners because we're not related to you.
If you are (or your spouse/partner is) considering a mommy makeover, you are considering what is usually a four- to seven-hour procedure in the operating room for the sake of improving appearance (and in doing so, of course, improving the quality and enjoyment of your life in general and your intimate relationship in particular). So in the process of evaluating physician practices and selecting one for this major elective surgery, you must examine a number of important factors.
The most important factor is the surgeon and his/her training, experience and outcomes as demonstrated by 'before and after photos'. But you must also carefully examine the practice - the support staff, the environment, the surgical facility, the overall attention to detail - for your experience as a patient is shaped not only by the surgeon but also by the people and environment that supports the surgeon.
CHOOSING YOUR MOMMY MAKEOVER SURGEON
The following are critical issues to review as you evaluate surgeons and their practices for this major, surgical procedure with significant recovery considerations:
Surgeon training and experience - Did the surgeon train at a prestigious university medical center? Has the surgeon performed a large number of combined breast and abdominal contouring procedures? Are there more than a few 'before and after' images to review, and do they show results that are appealing to you?
Consultation process - Did you get a great deal of helpful information from the Cosmetic Surgery Consultant before your physician appointment? At your MD consultation appointment, did the physician spend a significant amount of time with you and attentively listen to your concerns? Is the proposed surgical plan carefully customized to your particular needs? Was the rationale for the proposed surgical plan clearly explained to you?
Supporting medical personnel - Is the surgeon supported by knowledgeable and caring medical professionals such as Nurse Practitioners (NPs), Registered Nurses (RNs) and Physician Assistants (PAs)? Are these medical professionals easily available to you by phone and email? Do they appear to be experienced in caring for patients undergoing the surgery you are having?
Surgical facility - Does the surgeon operate in facility accredited by the Joint Commission (JCAHO), AAAASF or AAAHC? Were you provided an opportunity to see the surgical facility in advance of the date of your surgery? Does the facility appear pristine from a cleanliness perspective, uncluttered in terms of organization and layout, and state-of-the-art from an equipment and technology perspective?
Preoperative process - Once you have scheduled surgery, are you provided with a preoperative appointment with the physician and supporting medical personnel a few weeks in advance of the date of your surgery? Is the surgical plan reviewed with you by your surgeon and all of your questions answered in detail? Is the pre-operative education process specific and thorough?
Anesthesia staff - Does your surgeon employ a board-certified MD anesthesiologist to provide your anesthesia care on the day of surgery? Is the MD anesthesiologist present in the operating room for the entire surgery? Has the type of anesthesia been thoroughly explained to you preoperatively? Is the surgery center equipped to handle any and all anesthesia emergencies (they are rare, and can be managed effectively if the center is prepared)?
Immediate postoperative care - Does the surgeon provide postoperative overnight observation at the surgery center following your surgery, or will you be sent home on the day of surgery? Is overnight care at the surgery center provided by experienced surgical nursing staff? Will there be more than one nurse with you at the surgery center for your overnight stay? Will the surgeon see you in the morning before you are discharged to go home?
Postoperative pain control measures - Does the surgeon have a comprehensive plan for postoperative pain control that will allow you to be ambulatory (on your feet and walking) later on the day of your surgery? Does the surgeon use a local anesthetic infusion device (pain pump) or long-lasting abdominal nerve blocks to provide the maximum possible pain control for the abdominal wall? Are non-narcotic oral anti-inflammatory pain medications prescribed as the primary oral pain medication post-op? Is there a plan to limit and potentially eliminate the need for postop oral narcotic pain medications (Vicodin, Percocet, etc) postop? Will you be able to return to routine, non-strenuous activities of daily living within 2-3 days postop?
Follow-up appointment schedule - Will you be seen again in the office one or two days following discharge from the surgery center? Will you be seen in the office at least once a week during the two weeks following the week of surgery? Are regular appointments scheduled for you following the immediate postoperative period, for example at 1, 3, 6 and 12 months?
THE SPECIFIC MOMMY MAKEOVER SURGICAL PROCEDURES
The specific procedures that comprise your mommy makeover should be completely customized to your individual needs. The breast procedure may be any of the following:
Auto-augmentation mastopexy (breast lift with upper pole augmentation using lower pole breast tissue)
Likewise, the abdominal procedure may be any of the following:
Reverse upper / modified lower abdominoplasty (skin excision below breasts and in lower abdomen)
Lower abdominal skin excision and liposuction.
This is not 'cookie cutter' surgery. No two patients are exactly alike, and therefore no two mommy makeover surgeries should be exactly alike. Thoughtful preoperative planning is one of the most important keys to a successful outcome. As a surgeon, the patient evaluation and surgery planning process is interesting and challenging, both from a medical and artistic perspective. A talented surgeon enjoys this process, and that should be evident to you at the consultation appointment.
Obviously there are a lot of issues for the surgeon to consider at your consultation appointment when examining you and formulating your customized surgical plan. This takes time, and for this reason in my practice we extended the consultation time from one hour to one hour fifteen minutes. Putting the plan together, explaining the rationale for the plan (I draw on patients - with their permission of course - using dry-erase makers to explain my thinking and to outline the surgical plan and location of incisions, scars, etc), and providing important information about the recovery and the means by which complications can be avoided cannot be accomplished in less than an hour. So if you do not receive this kind of evaluation at your physician consultation, you may want to think twice about going forward with surgery in that practice.
HOME AND WORK CONCERNS, COMBINED VERSUS STAGED SURGERY
There are other, non-medical considerations that may impact your decision to have your breast and abdominal surgery performed on a single day, or performed in stages. How old are your children, what level of care do they require, and what arrangements are you able to arrange for assistance at home? Are you employed outside the home, and how much time will you be able to take off for recovery? The specific nature of the surgery understandably has an impact these family and work-related concerns. Of the two procedures, the abdominoplasty is in most cases the major recovery issue, and adding a mastopexy or breast reduction to that procedure does not necessarily prolong the recovery time or add significant recovery considerations. On the other hand, a subpectoral breast augmentation or augmentation mastopexy requires additional pain control measures and may add somewhat to the time it takes to return to full activity.
You should not feel pressured to do both an abdominoplasty and a breast surgery on the same day for any reason. There certainly are advantages to having a single surgery recovery period, but if for any reason you are not certain that you want to do it all at once, then make a plan to have the surgeries performed in stages. Perhaps the worst form of pressure is financial, and if you find that you are being encouraged to have both surgeries performed on the same day in order to save a significant sum of money, then find a practice where that kind of pressure does not exist. In my practice we structure the cost so that there is little or no difference between having both surgeries on one day and having the surgeries performed in stages, so patients can make their decision based purely on the basis of the approach with which they are most comfortable.
POSTOPERATIVE PAIN CONTROL FOR MOMMY MAKEOVER PATIENTS
Your surgeon's approach to postoperative pain control will be the difference between a few days of moving slowly and a few weeks of significant pain and discomfort. There are number of non-narcotic medications, some in forms only recently available, that can be used in combination with local anesthetic infusion devices (or injection of sustained-release local anesthetics) to make the recovery from this major surgery quite tolerable for the majority of patients.
Effective postoperative pain management begins preoperatively. In our surgery center we administer a combination of non-narcotic medications that have been shown in scientific studies to reduce postop narcotic requirements. Another preop measure that contributes to reduced postop pain is patient warming (using a forced-air warming gown) in the preop area. A peaceful and reassuring environment in the preop area also contributes to pain control, as anxious patients tend to report higher levels of pain postoperatively.
Patient warming should be continued intraoperatively by means of a warmed O.R. while the patient is prepped for surgery, an under-patient warming pad and/or a forced-air warming gown. Local anesthetic is injected in every location that a surgical incision is made prior to the incisions, a pre-emptive measure also shown to reduce pain and narcotic use postoperatively.
For subpectoral breast augmentation and augmentation mastopexy, we inject a sustained-release form of a long-acting local anesthetic, Exparel, peripherally around the breast prior to breast implant placement. For patients having breast augmentation alone, this has helped to make surgery recovery without postop oral narcotic use an achievable outcome. For the abdominal wall, the primary source of pain following all forms of abdominoplasty, the insertion of local anesthetic delivery catheters underneath the outer layer of abdominal wall on each side allows continuous postoperative administration of a long-acting local anesthetic. The catheters are connected to a reservoir filled with local anesthetic, and this 'pain pump' system reduces postoperative pain to a level that is more easily controlled with oral medications, primarily non-narcotic medications.
Acetaminophen (Tylenol) has recently become available as an intravenous solution, and the IV administration of this agent (the trade name is Ofirmev) prior to the end of surgery has also been shown to reduce postoperative narcotic requirements.
Our goal is for postoperative mommy makeover patients to report a pain level of 0 to 2 on a scale of 0 to 10 in the recovery room. Using a combination of a relaxing and reassuring environment, preop oral non-narcotic medications, patient warming from the preop area to the recovery area, the pre-emptive use of local anesthetics, Exparel and Ofirmev administration, and continuous postoperative local anesthetic administration we have been able to achieve this outcome for most patients.
One of the greatest advantages of a comprehensive approach to postoperative pain management is the fact that it allows patients to return to mobility and the routine, non-strenuous activities of daily living almost immediately. Early mobility significantly reduces the risk of postoperative complications, and your surgeon should be able to describe to you in detail their plan for helping you to achieve that outcome.
The primary postoperative oral pain medication used at our center is a non-narcotic, anti-inflammatory pain medication called Celebrex, which patients take twice a day for five days. Patients are also given a few Percocet or Vicodin to use for 'breakthrough pain', however in most cases patients use them intermittently for the first two to three days postop but are no longer using them by the weekend.
OVERNIGHT OBSERVATION FOLLOWING YOUR MOMMY MAKEOVER
I feel that postoperative patient observation at the surgery center is a critical part of the care of mommy makeover patients. The first few times a patient gets out of bed to ambulate, a nurse (or two) is present to provide assistance if needed. With an IV in place, effective medication can be administered for immediate relief of symptoms if patients experience pain or nausea. Vital signs are monitored and issues such as elevated blood pressure can be immediately and effectively controlled.
Patients who are sent home after this kind of surgery usually have no nursing care, and have to rely on oral medications only. If a patient is nauseous and vomiting, none of those oral medications are ever absorbed. Fending for yourself at home after a surgery of this magnitude can be an extremely unpleasant experience, and patients who are miserable for the first few days postop often have a prolonged and difficult recovery.
On the other hand, patients who have effective pain control and a pleasant, comfortable first 18 hours or so following surgery are set up to have a faster and more pleasant recovery overall. The attention to detail regarding pain control immediately preop, during the surgery and immediately postop is the key to providing patients with a positive surgical experience. If the primary means of pain control is postoperative oral narcotic tablets, then patients have no choice but to use them heavily and endure the consequences of that approach which are inadequate plain control and the side effects of oral narcotic medications: nausea, constipation, headaches and altered mental status.