The “Mommy Makeover” is a complementary blend of plastic surgery procedures that can be performed to restore or improve a woman’s body after pregnancy. For many women, the joy of having children can be accompanied by a feeling of loss for her original pre-baby body. Most people realize that pregnancy changes a woman’s body for nine months, but for some women the changes become permanent in predictable ways.

Abdomen

During pregnancy, the abdomen is stretched to accommodate a growing new life, but when the skin is over-stretched the skin cannot snap back to its original form. The skin has three layers, the epidermis (outer layer), dermis (middle layer), and subcutaneous fat (inner layer). Once the dermis is damaged, it leaves marks called “striae.” The presence of striae, or stretch marks, is an indication that the overstretched skin has lost its elasticity, and no amount of exercise will cause the skin to revert to its original shape. Sometimes these stretch marks will become less noticeable over time, but they cannot be erased through creams or lotions.  

In many women, the changes in the abdominal shape after pregnancy are not just limited to the skin. Often, women also develop an abdominal bulge because the rectus abdominis muscles are pulled apart. The separation of the rectus abdominis muscles is called a “rectus diastasis,” and is due to a thinning of the connective tissue. A rectus diastasis usually leads to weakening of the abdominal muscles, and can make it difficult to lift objects. It can also cause lower back pain, weakened pelvic alignment, and altered posture. Unfortunately, abdominal exercises do not improve the bulge; instead the protrusion usually becomes worse when the abdominal muscles are tensed. In order to correct a rectus diastasis, the stiff wrapping around the muscles, called the “fascia,” are sutured or “plicated” during the abdominoplasty. The resulting internal corset also has the additional benefit of improving the patient’s waistline.

In order to remove the excess skin and eliminate the stretch marks, many women will choose to undergo an “abdominoplasty,” or tummy tuck. An abdominoplasty involves resecting the excess skin and striae from the lower abdomen, leaving a permanent scar that is located from hip to hip. During the abdominoplasty, the patient’s abdominal skin is lifted off of the abdominal wall. This makes it possible to sew together the gap between the abdominal muscles to improve the patient’s waistline. In addition, the patient’s belly button, or “umbilicus,” is isolated, and a new opening is created for the umbilicus to come out. 

Prior to surgery, we advise our patients to bring a bikini bottom that they would like to wear so that we can try to design the scar within the borders of their clothing. If the patient’s body habitus allows it, the scar can be placed low enough to be hidden under their clothing. Furthermore, all scars eventually fade over the years, but some patients have a genetic tendency to scar very well so that their scars are difficult to see. Ultimately, however, patients who undergo an abdominoplasty are accepting a permanent scar in return for an improved shape. 

After surgery, patients will typically have drains for 1-3 weeks. Patients should be able to walk immediately after surgery. Depending on how much extra skin and fat is removed, however, and how tight the plication is, patients may need to walk hunched over to allow their skin and fascia to stretch before they can stand up straight again. Sometimes, patients will feel numbness in their abdominal skin, but normal sensation usually returns after several months.

BREASTS

After pregnancy, a woman’s breasts will engorge with milk to allow for breastfeeding, or “lactation.” Again, this stretching of the skin during lactation can cause permanent changes. When the skin is over-stretched it cannot snap back to its original form. The skin has three layers, the epidermis (outer layer), dermis (middle layer), and subcutaneous fat (inner layer). Once the dermis is damaged, it leaves marks called “striae.” The presence of striae, or stretch marks, is an indication that the overstretched skin has lost its elasticity. Sometimes these stretch marks will lighten over time, but they cannot be erased through creams or lotions.

 When breastfeeding stops, the breasts will shrink as the milk ducts dry up, a process that is called “involution.” If the dermis of the skin is damaged, the remaining breast tissue will droop to the bottom of the breast while the top of the breast appears flat and empty. The appearance of sagging breasts is called breast “ptosis.” Depending on the patient’s body and preferences, there are multiple ways to correct ptosis from post-pregnancy breast involution.

Breast Augmentation

After a woman has completed breastfeeding, her breasts may seem smaller than they did while she was nursing. When the milk ducts are no longer filled with milk, the breast tissue itself will appear to shrink. Furthermore, if the breast skin has overstretched, the top portion of the breast may appear empty with skin flat against the chest wall. Women who would like to fill the superior pole of their breast may opt for breast augmentation to make their breasts appear fuller.

Breast augmentation involves the placement of either saline or silicone breast implants to increase the size of the breasts. Saline implants are filled with salt water, and usually feel firmer to the touch. Silicone breast implants typically feel softer, but should be monitored with breast MRIs every 2-3 years.  Either way, the breast implants can be placed under the pectoralis muscle or on top of the muscle, but under the breast tissue.

In order to determine the appropriate breast implant size, a patient should bring in a soft supportive bra with no inserts. We will have different size breast implants for you to try on over your breast and in your bra. Some women will also want to try on their clothes over the implant. You will try on many different size implants until you reach a size that you feel is too small and a size that is too big. This is the range of breast implant size that you feel is right for you. Every woman has a different idea of how she wants her breasts to appear. In addition, every bra company has a different sizing system so that a C cup in one company may be equivalent to a B cup in another company. Thus, the best way to determine the right size for you is to try different implants on for size yourself. It may also be helpful for you to bring in photos of breasts that look like the breasts that you want.

The breast implants are usually placed through one of two scars. For patients with very small breasts, the best scar is usually a periareolar scar, which is a small curvilinear scar that is placed along the edge of the “areola,” or the dark circle in the middle of your breast. Women with small breasts usually have small areola with sharp borders, so that their scars are well camouflaged when placed at the border. For patients with larger breasts, a periareolar or an inframammary scar can work well. This is a scar placed at the bottom edge of the breast border. Since the weight of larger breasts causes them to fall below the bottom border of the breast, or the “inframammary fold,” a scar at the inframammary fold is often well-concealed.

After a breast augmentation, patients usually do not need drains. There are dressings on the incisions, which remain in place for at least 48-72 hours. After the dressings are removed, the patient can shower. Sometimes, we will give patients an elastic band to push the implants down for shaping. Many patients can return to work in 1-2 weeks. Patients should avoid heavy lifting for 6-8 weeks. The breasts will be swollen initially, but the swelling subsides and the breasts settle over several months.

Mastopexy

After breastfeeding, some women may realize that their breasts have reverted to their original size but their breasts are in the wrong place. They may be happy with their breast size, but their breasts need to be lifted so that the breast tissue is higher on the chest wall. The dermis of the skin is damaged, and the breast skin has stretched irreversibly. The remaining breast tissue has fallen to the bottom of the breast while the top of the breast appears flat and empty. When a woman does not want larger breasts but just wants her breasts to be lifted, she needs a “mastopexy.”

Depending on the degree of breast lift needed, a mastopexy will involve removing excess skin and moving the nipple-areola complex (NAC) higher on the breast mound. For breasts that only need a very minimal lift, the scar will only be around the areola. This type of lift is called a Benilli-style mastopexy, and it tends to flatten the breast. Most mastopexies require more skin reduction. When the nipple is pointed straight down or the breast tissue itself needs to be repositioned higher on the chest wall, for example, there will need to be a scar around the areola and a vertical scar from the areola to the inframammary fold. This lollipop-shaped scar will create a more conical breast that appears more youthful and perky.  

After a mastopexy, drains are occasionally needed if a large amount of tissue has been moved around. There are dressings on the incisions, which remain in place for at least 48-72 hours. After the dressings are removed, the patient can shower. Many patients can return to work in 1-2 weeks. Patients should avoid heavy lifting for 6-8 weeks. The breasts will be swollen initially, but the swelling subsides and the breasts settle over several months.

Augmentation Mastopexy

Sometimes, the patient feels that her breasts have become too small after breastfeeding, but the skin has stretched so much that her breast tissue is left hanging at the bottom of her breast. In these cases, the patient may need a breast implant (described above) and a breast lift (also described above). This can be a complex procedure sometimes is best staged over two separate operations. 

Breast Reduction

For some women, breast engorgement from lactation leaves them with larger breasts even after involution. That is, even after they stop breastfeeding, their breasts still feel large and uncomfortable. Their large breasts, or “macromastia,” leads to lower and upper back pain, shoulder grooving from their bra straps, headaches, neck aches, arm pain, and even rashes under the breasts, or “intertrigo.” For women who want smaller breasts, the solution is a breast reduction, or “reduction mammoplasty.”

A breast reduction involves removing excess breast tissue and skin, and repositioning the breast tissue and nipple-areola complex higher on the chest wall. The patient will have a lollipop scar that consists of a scar around the areola and a vertical scar from the areola to the inframammary fold.  Often, a breast reduction will make a woman look like she has lost weight, even if only a small amount of breast tissue has been resected. It will also make her breasts look younger and perkier.

After a breast reduction, drains are sometimes needed. There are dressings on the incisions, which remain in place for at least 48-72 hours. After the dressings are removed, the patient can shower. Many patients can return to work in 1-2 weeks. Patients should avoid heavy lifting for 6-8 weeks. The breasts will be swollen initially, but the swelling subsides and the breasts settle over several months.

Liposuction

Liposuction is an adjunct procedure that can finesse the result of many breast and body procedures involved in a mommy makeover. Most commonly performed with an abdominoplasty or a breast reduction, liposuction can smooth out the final contours to remove additional unwanted fat accumulated during pregnancy. During liposuction, warmed tumescent fluid is infused into the patient’s fat to liquefy it and minimize bleeding. After tumescence, the liquefied fat is aspirated and removed. Small 3-4 mm incisions are made for the insertion of the liposuction cannulas. The incisions are usually placed in areas where they may be camouflaged, such as in the groin crease, the belly button, or previous scars. Liposuction is performed to sculpt the body to the desired shape.

Liposuction does not involve any skin resection. If a woman has excess skin due to overstretching from pregnancy, liposuction will not solve her problem and may even make it worse. For example, if she has excess overhanging skin and stretch marks on her abdomen, liposuction may make it look like she has even more overhanging skin after the fat is suctioned out. Thus, for post-pregnancy body contouring, liposuction is best used as an adjunct procedure.

After liposuction, drains are not needed. The patient will need to wear a compression garment to mold the tissues and squeeze out the excess fluid. The dressings on the incisions remain in place for at least 48-72 hours. After the dressings are removed, the patient can shower. Most patients can return to work in 1-2 weeks. Patients should avoid heavy lifting for 6-8 weeks. The liposuction sites will be swollen initially, but the swelling subsides in the first couple of weeks and settles over several months.