So it is tough.  I was reminded of this today when I saw a patient who had liposuction and a tummy tuck a month ago.  She looks fantastic and is back to normal life, but still doesn’t feel quite back to her old self.  She gave me a beautiful card and present (thank you!!! So so lovely of you!).  What she said I think is particularly poignant and insightful:

“Dear Dr. Greenberg,

Thank you for everything.  It’s been a tough month, but well worth it.  Thank you for your care and support. It has been awesome.”

On the same day I got a card from another tummy tuck patient who is 3 months out.  Her card read,

“I wanted to show and say my appreciation for your services.  I feel like a million bucks and like that I can do just about anything.  Thank you for being such a great doctor.  And thank you for helping me look better than I did 10 years ago!.” 

I warn all patients regardless of how fantastic they may look in the future to expect buyers remorse the first week after abdominoplasty.  Why?  Even if they look great and their friends and family can see a significant change, it is a big surgery and a tough recovery for the first few days in particular.  You are bent over, you have drains, you are wearing a garment, your skin is likely numb, and it hurts.  It is common for you to not “feel” like you look better.  It is common for you to feel weird, puffy, pudgy. 

So what to do?

• know it is normal to have mixed feelings the first week after surgery.  It is a tough recovery, big surgery, and unlike some other big surgeries, it is elective- you chose to do it. 
• know it is going to hurt.  To help with this, I use the pain pump which I implant during surgery, which drips numbing medication along your muscles to minimize the pain.  Also pain pills and muscle relaxants help.
• know you won’t feel “normal” until at least 4-6 weeks out.  At 3 months you will feel even better.
• look at your preop photos.   It is easy to forget what you looked like which drove you to seek help.  Our minds are gentle, and I think the mind freeze frames us at age 29, pre kids and other life tolls. So look at the preop photos to remind yourself.

Talk to your doctor.  If there are things which are bothering you, let them know.  Anxiety of what is normal or not, what is going to stay versus what is normal post op stuff is all important to address.

“I went to Dr. Greenberg about 6 years ago. She was the last of the 6 doctors I interviewed in search for a doctor to do my breast augmentation. She was the ONLY one who said she would not do it. I had lost about 100 lbs at the time and had not yet had kids. She said, she would not do the tummy tuck I was considering either as I should wait to have my kids and see her when I was done. She did offer to do some other work on me at the time that would not be damaged by a pregnancy weight gain and would help my overall look in the meantime.

It was a very intense procedure called a Medial Thigh Lift but the results I believe were phenomenal. She did some lipo too to help contour my shape a bit more. It wasn’t to lose more weight, as I had done that already but it was to take out the extra skin I had on my legs and inner thighs and stretch marks that were always very embarrassing.

My scars healed very well and are almost unnoticeable. I have since had 2 kids and now am ready for my “mommy make over.” Again, I interviewed other doctors because I really wanted the “gummy bear” implants. Dr. Greenberg doesn’t do them but does the cohesive gel implants and she did explain the difference to me.

I chose to go with Dr. Greenberg again for this surgery because I knew what her bedside manner was, she was straight forward with me last time about the expected results and she is always more cautious and looks long term for you.

I would highly recommend going to Dr. Greenberg if you are considering any plastic surgery, she is professional and is constantly educating herself as you can read in her blogs. I met with her twice for a consult already before my pre-op and she said to call or email if I have any further questions. We’ve chatted through email and on the phone and for a busy surgeon that says a lot. ”

SB, Inner thigh lift and liposuction patient, San Jose, CA

Now found in the filtered section of Yelp

A study was published in the general surgery literature.  It was a good study on 12,600+ patients in Sweden looking at smoking (and obesity) effect on surgery.  Sweden has nationalized health care, so they are able to study many things well.  The surgery was an inguinal hernia surgery- small potatoes relative to a lot of what I do as a plastic surgeon.  An inguinal hernia is a tiny incision, tiny location, usually an hour surgery, and not a flap.

Findings?

34%

Current smokers had a 34% increased risk of a complication relative to nonsmokers.

We doctors talk talk talk about the negative effects of smoking.  But when I talk about this to my patients before surgery, it is for a real reason.  Your risk of an issue goes up if you are a smoker.  The risk of infection, poor wound healing (and therefore poor scar), wound breakdown, tissue and skin loss, and others.  I won’t do certain surgeries on current smokers because the risks are too high.  Breast lifts, breast reductions, tummy tucks, and facelifts are all very dependent on blood supply.  I specifically address this in my consent.  I had one patient at her preop become very agitated – turns out she was a closet smoker, denied it to me, but when she had to sign the consent form and saw in black and white clearly spelled out what smoking does, she knew she couldn’t do the surgery.

How much smoking is ok?
None.

• A history of smoking, even remote, will affect your ability to heal, though some of the ill effects do reverse with time.
• Smoking just on weekends, the “oh I don’t really smoke… oh you know… sometimes I do socially… when I have a few drinks…”  is not okay.
• Smoking things other than tobacco is not ok either.

What happens?
Increased infection, poor healing, tissue loss.

Can you give me some good news?

Stopping smoking can reverse some of the bad effects of smoking.  If I know you are an ex smoker, I do things more conservatively to try to avoid issues. Honesty is the best practice here.  I am not your mom.  I am not here to lecture you on the yellow teeth, expense, aging of your skin, etc.  I am your surgeon.  I am here to work with you to get the best surgical outcome we can.

Hernia. 2007 Apr;11(2):117-23. Epub 2006 Dec 6.
The effect of tobacco consumption and body mass index on complications and hospital stay after inguinal hernia surgery.

A single, beautiful, perfect red rose.  It came from the husband of a woman I met yesterday.  This woman came to me for a  tummy tuck consult.  I didn’t do surgery on her.  In fact, I was the only one of many consultations she had who didn’t recommend she do surgery.  “Everyone else was ready to book me for surgery immediately.” 

And I said no. 

So when she told me everyone else was ready to sign her up, I admit, I had to take another look.  And I poked and pulled and prodded again.  Nope. I stick with my original advice.  Not worth it.

I’ve been thinking about her a lot.  How could others advise so differently? This was a woman in the grey zone-  no excess skin when she is standing, a little when she is sitting.  I don’t know if it is because I am a woman, I think about the scar a lot, the cost, the recovery, how much change you will have, what is your expectation, the recovery.  Do I weigh the pros/cons differently?  I don’t know.

. 

But I do think there are women whom surgery is not the right choice for.  And I will tell you.  ”No surgery” was the right advice for her.  And I think they both knew it.  She hugged me, and told me she knew I was right.  And her husband, who fantastically thinks she is perfect as she is, clearly agrees.

Thank you lovely couple for the beautiful rose.

Full abdominoplasty.  Also called Tummy tuck. Two scars: one incision from about hip to hip and one around the belly button.  The muscles are tightened and usually all of the skin between the pubic area and belly button is removed. This can be combined with other procedures like liposuction of the flanks.  Cannot be combined with liposuction of the belly itself.  If you have hanging skin, volumes of loose skin, or loose skin above the belly button, this may be what you need.

Mini abdominoplasty.  Also called a mini tummy tuck.  The incision for a mini can be placed as low as you want to go.  The scar length can vary– from short like a C-section to longer from hip to hip.  The longer the scar, the more skin is removed.  (and most are not the short C-section kind.  Sorry.) Does not have an incision at the belly button. (Good for bikinis and low rider jeans) Does minimal to no tightening of the skin above the belly button.  It does tighten the skin of the lower belly. You can combine with liposuction of anywhere you want.  You can also combine with tightening of the muscle, though it can be difficult to reach the upper muscle near the ribcage if you are long waisted.

Floating belly button.  This is not a common surgery.  It involves no scar on the skin of the belly button, just one in the lower abdomen.  Your belly button is like a mushroom.  During a normal tummy tuck the belly button does not move- the skin does.  In this surgery, the stalk of the belly button is cut, and the belly button floats down toward the pubic area attached only to the skin.  This allows tightening of the upper abdomen and lower abdomen skin.  The issue is it lowers the position of the belly button, so it is only good for those with high belly buttons to begin with, and the belly button is no longer connected to the stalk.  If you ever need a laproscopic procedure, they cannot use the port through the belly button as this connection is gone. 

Muscle tightening only.  This is for the women who have good skin tone, no fat, but have loosened muscles after babies. (When you aren’t sucking it in you look 5 months pregnant, and when you suck it in you go FLAT.)  A lot of my Bay Area women fall into this category.  The skin incision can be short when you do this.  NOTE:  If when you suck in your belly the skin hangs and is wrinkled, then you likely need some form of skin tightening.  The more skin tightening, the longer the scar.  See mini tummy tuck description above.

The hybrid adominoplasty is a trademarked name of a procedure done by Dr. Moelleken from Southern California.  It is most like the muscle tightening only procedure listed above.

Communication with your doctor is SO important.  When you don’t like your belly, it is important to figure out why.  I think this woman’s question could have been better written- Communication 101: Make sure you and your doctor are on the same page.

Is it

• stretch marks?
• hanging skin?
• loose skin when you sit?
• the muffin top?
• wrinkling around the belly button?
• you look pregnant?
• loose muscles?
• is the problem mostly above the belly button? Below?

You need to be very clear about what bothers you. This patient was bothered by loose skin above her belly button.  She then had her first tummy tuck, a mini tummy tuck.   Ug.  She was destined to be unhappy with her results, as a mini tummy tuck does not tighten the skin above the belly button.

This communication is a dual thing- your surgeon should be blunt in their communication and let you know what will be improved.  There is a lot of verbage out there.  What I call a mini tummy tuck may not be what Dr. X calls a mini.   I have had patients who think they had “full tummy tucks” who only had a mini.  Ask your doctors for specifics.  “By doing a mini tummy tuck,  the scar will be on the abdomen here.  There will be no scar around the belly button.  Your belly button will move down a bit.  This will not tighten the skin above the belly button at all.  This will not tighten your muscles.” 

There are all sorts of variations.   Is your issue Fat? Skin? Muscle?  In what order? Tummy tucks involve removing skin, tightening muscles, and sometimes liposuction.  There are things which are not safe (full tummy tuck and liposuctioning the anterior abdomen).  And again, the names are confusing: full tummy tuck, mini tummy tuck, mommytuck (what is that?), hybrid tummy tuck (a trademarked name for what is likely a mini tummy tuck with muscle tightening by Dr. Moelleken), lipotuck (those that overestimate the tightening effects of liposuction), etc etc.  You get my drift.

Expectation is everything.  If this patient is considering a third surgery, I would recommend sitting in front of the mirror and write down her ultimate wish list.  Some things are not achievable.  (Where is that fairy godmother and her wand?)  Also I would recommend getting a second opinion, just to have two board certified plastic surgeons looking at the same thing.  If there is controversy, consider a third opinion. 

There is a law of diminishing returns with multiple surgeries.  Many times the enemy of good is going for the “better.”  And some things can’t be done.

We don’t like this. 

So if you have a headache what can you take?  Tylenol is okay.  It does not cause an increase in bleeding.  Aspirin, Motrin, Ibuprofen are all bad.  But it is tough to know what is “aspirin” or a nonsteroidal antiinflammatory, and what is safe.

For a partial list of Aspirin and NSAID products, read below.  These are all  NO NOs for the two weeks ahead of surgery.  I also have another blog on herbals to avoid.  In general, anything which is “heart healthy” means it makes you bleed more.

• Advil, Advil cold and sinus, Advil PM 
• Aleve
• Alka Seltzer
• Anacin
• Arthritis Pain Formula
• Aspergum
• Aspirin
• Axotal
• Bayer, Bayer plus, Bayer Children’s
• Bufferin
• Cama Inlay Tabs or arthritis pain reliever
• Celebrex
• Congespirin
• Cope
• Coricidin Decongestant tablets
• Damason
• Dimetapp Sinus
• Dristan
• Ecotrin
• Empirin
• Emprazil
• Equagesic
• Excedrin, Excedrin Migraine
• Feldene
• Fiogesic
• Fiorinal, Fiorinal with Codeine
• 4 way Cold tablets
• Gelprin
• Goody’s Headache Powers
• Ibuprofen
• Metabolife
• Midol, Midol PMS
• Motrin
• Naprosyn
• Norgesic, Norgesic Forte
• Nuprin
• Nyquil, Nyquil PM
• Pacaps
• Panalgesic
• Panasal
• Pedrazil
• Percodan
• Persistin
• Quite World Analgesic
• Robaxisal
• Salflex
• Salicylic acid
• Soma
• St. Joseph cold tablets
• Stanback analgesic
• Supac
• Synalgos
• Talwin compound
• Tecnal
• Triaminicin tablets
• Vanquish
• Vioxx
• Viro Med tablets
• Zorpin

Dr. Greenberg Discusses Plastic Surgery at Mommy Night Out Event

The Palo Alto Mothers Club recently hosted a “Mommy Night Out Talk” to welcome board-certified plastic surgeon Lauren Greenberg, MD. Designed to be an informal, real discussion about Bay area plastic surgery, Dr. Greenberg covered a variety of topics spanning the spectrum of cosmetic enhancement, from BOTOX Cosmetic® to breast augmentation.

Dr. Lauren Greenberg, a board-certified plastic surgeon in Palo Alto, recently joined the Palo Alto Mothers Club for an educational discussion on cosmetic enhancement. Topics ranged from how to pick a plastic surgeon and common misconceptions concerning plastic surgery to specific procedural questions addressing different types of breast surgery and the combination of procedures known as the mommy makeover.

Along with a talk about professional image and style consultancy, and another focusing on wine appreciation, Dr. Greenberg offered the “Girlfriend’s Guide to Plastic Surgery,” to focus on the educational aspects of plastic surgery and how she strives for subtle, natural-looking results. In addition to her plastic surgery training and experience, Dr. Greenberg says she also relies on her experiences as a mother of three because it allows her to better understand her patients’ cosmetic enhancement expectations and goals, whether considering a facial rejuvenation, a breast lift, or a tummy tuck.

Dr. Greenberg says she looks forward to future events such as the “Mommy Night Out Talk” because it provides her a chance to connect with like-minded women and forge meaningful relationships centered on improving the lives of mothers in Palo Alto and across the U. S.

About Dr. Greenberg

Lauren Greenberg, M. D. earned her medical degree from Northwestern University Medical School, and completed her general and plastic surgery residencies at Stanford University. She also completed a fellowship in breast and cosmetic surgery in Nashville, TN, where she trained under several prestigious plastic surgeons. Dr. Greenberg is a member of the American Society of Plastic and Reconstructive Surgeons, the Santa Clara Medical Association, and the California Medical Association. She is an avid blogger on all things plastic surgery, and participates in discussions like the “Mommy Night Out Talk” whenever possible.

Dr. Lauren Greenberg’s office is located at 750 Welch Rd. Suite 117 in Palo Alto, CA 94304, and can be reached at (650) 617-9907, or found online at http://www.laurengreenbergmd.com/, http://wwww.bodypostbaby.com , or the Lauren Greenberg, M.D. – Cosmetic Plastic Surgeon Facebook page.

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http://www.bodypostbaby.com/belly/can-a-tummy-tuck-help-back-pain/

That tummy tucks help with back pain is not new news.  When you have babies you will stretch out your abdominal muscles.  Frequently this leads to separation of the rectus muscles, what is called a diastasis.  This midline separation cannot be fixed with situps.  The only way we have of fixing it is to corset the muscles back together during a tummy tuck. 

So why would fixing your belly help your back?  Your back and your abdominal muscles work to stabilize your body and help you stand up straight.  If your abdomen is blown out or loosey goosey (I know, highly technical terms here), then your back must work overtime to stabilize your body.  This can lead to pain.

What is common folk wisdom in plastic surgery often leads to scientific papers which support it.  A multitude of papers have emerged which support that tummy tucks are not a just-to-make-you-look-pretty surgery, but a functional one.  The latest appeared in the January 2011 issue of Plastic & Reconstructive Surgery Journal .  It is a study out of the University of Michigan, “Wide Abdominal Rectus Plication Abdominoplasty for the Treatment of Chronic Intractable Low Back Pain.” 

In it, they point out some ideas I would like to reiterate:

• Most surgical treatment for chronic back pain is directed at the spine.  In a study by Toranto, who first championed the wide abdominal rectus plication, he gave relief to chronic back pain in 24 of 25 patients by addressing the belly, not the back.
• A tummy tuck for back pain is only useful in patients who present with significant abdominal wall weakness and laxity.  All of the patients in this study had one or more pregnancies. 
• Conservative treatment is always good first. 
• For those with neurologic damage of the spine, you need to make sure there is no radiographic or clinical evidence of the damage being caused by an identifiable structural lesion in the spine.

The study postulates that the rectus muscle forms a “sheath” of tissue connecting to the thoracolumbar fascia.  “This forms a structure that biomechanically influences the mechanics and stability of the lumbar spine.”  The “wide” abdominal plication doesn’t just realign the rectus muscles, it brings it in tighter.  The thought is to increase the intraabdominal pressure and put the muscles at a more efficient place in the force-length curve to increase their force generating capacity. In this small study of 8 patients, all were improved. 

Small studies can be discounted, but this study had a very thorough evaluation preoperative and postoperatively by a physical medicine and rehabilitation specialist with specific expertise in management of chronic low back pain.  100% of them were better.