How Does Pregnancy Affect the Various Types of Tissues?
Mommy make over is a term used to encompass different combinations of surgical procedures aimed at reversing the changes in the mother’s body that occurred during pregnancy.
During pregnancy the skin stretches resulting in an increase in surface area. Sometimes after delivery the skin does not recoil back to the “pre-pregnancy” state and can hang loose. Moreover, if the stretching occurs beyond the elasticity of the skin, then stretch marks appear. These stretch marks are cracks in the dermal layer of the skin.
It is not only the skin that can stretch during pregnancy, but also the suspensory ligaments. The suspensory ligaments are the fibrous strands that connect the top layer of the skin to the muscle and fascia underneath. During pregnancy these ligaments will stretch due to the pull created by the increase in weight. The laxity of these ligaments can result in an increase in cellulite, drooping of the breast (ptosis), as well as laxity of the inner thighs and abdomen.
During pregnancy, the abdominal muscles are stretched to accommodate the volume of the baby particularly when twins are present. While the muscles might regain their tone on their own, that is not always the case.
- During pregnancy the rib cage expands and increases the chest circumference to aid the lungs in oxygenating 2 persons.
- Other structures that widen during pregnancy are the pelvic bones and hips. This occurs in response to the increase in size of the uterus.
- Diastases recti is a relaxation of the fascia between the abdominal muscle. During pregnancy the stretch is exacerbated and results in a pseudo-hernia.
- If there is a pre-existing umbilical hernia it can become larger and more noticeable after pregnancy.
- In cases of pre-existing lordosis (forward curvature of the lower spine), the weight of the baby results in a forward pull increasing the abdominal bulge. The alteration in appearance may not be reversed after delivery.
All of these changes can have a significant impact on the appearance of the trunk.
Pregnancy unequivocally affects fat deposit. We know that all fat cells in the body are not the same. The pregnancy hormones will affect each type differently. We know from observation that fat cells in the bra roll, posterior waist and inner thighs store more than fat cells in other part of the body.
Breast increase in volume with pregnancy and after delivery the gland can remain hypertrophic (enlarged). In some cases, when breast feeding ends, they can become smaller resulting in involutional atrophy. In most cases, there is also relaxation of the suspensory ligament of the breast along with stretching of the skin envelope.
What Are the Procedures Available to Us to Correct the Changes Described Above?
Abdominoplasty is a procedure specifically designed to correct the changes of pregnancy in the abdomen. It is the most common procedure in the difference variations that consist of a mommy makeover. The procedure can take anywhere from 2 hours to 4 hours depending how extensive the needed correction is, and whether liposuction for the upper abdomen and sides is going to be part of the procedure.
It is an extremely rewarding procedure that rejuvenates the patient the most. It makes the mother an empowered, confident, and vibrant woman.
Please visit the abdominoplasty page on our website and read about the management of the umbilicus and the section on ‘dog ear’.
There are multiple procedures available to address specific effect of pregnancy on breast tissue. One of the most frequent complaints after pregnancy is breast deflation. If it is strictly a volume loss from involutional atrophy (breast gland shrinks) than augmentation will address the problem.
In this context however, one has to first decide on the implant location: place it with gland and above the muscle, or below the muscle, meaning in the undersurface of the glandular tissue of the breast itself.
If there is significant amount of glandular tissue present, then over time gravity will have its effect and the gland will drop even if it is only a small amount. If the implant is placed with the gland (i.e. just behind it), then it will move down with the gland and the soft tissue, but the breasts will remain attractive because the nipple the gland and the implant moved together.
If the implant is placed behind the muscle it usually does not drop over time, and with the migration of the gland down, the patient may end up with an implant mound superiorly and a breast mound inferiorly. This is what people call a ‘double bubble’ deformity or a ‘Snoopy’ breast.
If the decision is to place the implant behind the gland, then thee next step is to choose between a saline implant and a silicone implant. The plastic surgeon’s wisdom requires at least 2 cm of breast tissue covering a saline implant to avoid palpability and rippling. If that is not available than a silicone implant should be used as it is more forgiving in this situation.
The next issue to consider is the nipple areolar complex (N A C). When placing an implant, the surgeon has to estimate where that complex is going to end up on the breast mound. If it is felt that the NAC is going to be too low it will need to be elevated.
This areolar lift is the simplest form of a breast lift. It results in a scar around the areola. It can be done at the time of the implant placement or later on when tissues have settled and an accurate position can be established.
If there is more significant breast tissue laxity, both the NAC and the gland need to be elevated. This is a level II breast lift. It results in a lollipop scar and can be done with or without implant placement. In this lift, the nipple areolar complex is repositioned much higher and glandular tissue is elevated as well. The vertical component of the scar allows tightening and elevation of the glandular tissue and better distribution of the excess skin produced by the elevation.
A level III lift is done when there is significant glandular drooping particularly on the outside of the breast and/or significant skin excess is present. This excess skin will not be sufficiently addressed by placement of an implant. The scar used in this situation is in the shape of an anchor, (a circle over an inverted T). The glandular and fatty tissues are elevated, a reduction can be done, and the excess skin removed. Patients, understandably so, are concerned about the scar, but many times these heal quite well and are barely noticeable.
These are complex decisions and help from an experienced surgeon like Dr Makhlouf, is very important. A technically satisfactory procedure in the face an inadequate decision will lead to an unsatisfactory outcome
Many women gain weight in the inner thighs, for some it is a specific bulge right below the groin fold. Some complain that even after losing the “baby weight” the generalized fat deposit does not go away. If it is just fat, then liposuction can address the problem. However, if the skin is severely stretched, particularly with a bulge below the groin fold, then skin excision is required and the scar can be hidden in the groin crease. If a full thigh lift is needed, please visit the thigh lift page on our website.
We mentioned earlier that during pregnancy there is an increase in the width of the chest with lung expansion. We also talked about an increase in the hip width due to the weight of the baby. Between these 2 areas are the stretched abdominal muscles. This can result in a square looking trunk and the waistline is gone.
One cannot change what happened to the chest or the pelvic bones, so a proper abdominoplasty with good repair of the muscle is paramount. For that reason, Dr. Makhlouf does a 3-layer repair of the abdominal wall. The first 2 layers are independent sutures:
The first repair brings the muscles together. The second repair provides further tightening, and the last repair is two continuous sutures one going from the pubic area to the umbilicus and one going from the upper umbilicus area to the xyphoid. The role of these sutures is to even up the tension and ‘burry’ the independent sutures so as to render them unpalpable.
During pregnancy the impression is that fat does not deposit evenly throughout the body. One of the areas of predilection seem to be the flanks. It is very difficult to lose fat in that area after the baby is born. Luckily liposuction is a suitable option for this problem.
What is less suitable is correction of the bra roll. Only 50% can be expected to improve with suction. For that problem, direct excision or radiofrequency are options. This would be addressed in the future once their role is clarified.