What a Mommy Makeover Actually Is (And Isn’t)

Dr. Kuruvilla (00:11):
Welcome back to Behind the Double Doors. I'm Dr. Shannon Kuruvilla. I'm a plastic surgeon at Basu Aesthetics and Plastic Surgery in Houston, Texas. We're talking about one of the most rewarding procedures that I do, and that is a mommy makeover. So a mommy makeover is not just a single definition. It is actually a customizable combination of procedures designed around what pregnancy and motherhood specifically can change about a woman's body. I want to walk through what's actually in it, talk about sequencing, what recovery looks like when you have kids at home and how to know when the timing is right for you. Okay, so why is mommy makeover just a category and not a single procedure in a specific operation? It's actually a customized combination of procedures designed a woman's anatomy, goals, lifestyle, and then also recovery priorities. So no two pregnancies are identical and no two mommy makeovers should be either.

(01:04):
So as both the plastic surgeon and a mom, I kind of know firsthand that pregnancy changes every woman differently and so treatment should never be a one size fits all. There are kind of four standard anatomic changes that happens in our bodies with pregnancy. So we do know that pregnancy affects the body in predictable ways, even though the degree of that can vary from woman to woman. The four changes that I see are skin laxity. So what that means is stretched abdominal skin that might not fully recoil or retract back. Also, same thing for the breasts, fat redistribution. So kind of new fullness around the abdomen, waist, the flanks. If you had a C-section, maybe some of that fat is like producing a little bit of a C-section shelf that you're seeing. Muscle separation, so that is your diastasis recti, so the separation of your rectus abdominis muscles.

(01:54):
And what actually happens is weakening and widening of the fascial connection between those two muscles, so kind of widening of your whole abdominal wall. And then breast changes. So deflation, sagging, some loss of upper pull fullness and in some women, some prolonged kind of enlargement and heaviness. So diastasis recti is when your rectus abdominous muscles separate. So it's not simply weak abdominal muscles and you're seeing that in this picture. So in both pictures, those abdominal muscles look the same size and they can very well stay the same size. You can keep the same strength or even be stronger in them after pregnancy. The anatomic change that happens is actually the widening of the fascia or connective tissue between it. So that middle line going between the two sets of muscles will become stressed with pregnancy or with any sort of increase in your intra abdominal pressure.

(02:48):
Exercises and core strengthening activities will strengthen these muscles. Maybe by strengthening those muscles, you can narrow that gap a little bit, but it will not restore any sort of stretched connective tissue. The main way to fix that is to put sutures in and to bring those two muscle edges together. So that is what I do in abdominoplasty. I do find that for patients that get it repaired, they often notice an improvement in their reduced back pain because they have a stronger core. It's a more supported core. Even sometimes improvement in your pelvic floor strength and decreased urinary incontinence can sometimes be improved upon by this. But I just as a mom myself, I can kind of understand the frustration women feel when they're exercising and still see that doming or feeling weak just because the issue isn't necessarily your effort, but it's the anatomy that's there.

(03:40):
So I have seen patients with diastasis recti that's so bad that they still look pregnant and that's just because no matter the amount of muscle strength that they have, they cannot overcompensate for that stretched fascia. And so all of the intra abdominal contents kind of push out against it and it can be very hard to constantly be sucking in and fighting that intra abdominal pressure. And I think that sometimes patients will misunderstand that round abdominal bulge for fat that just needs to be liposuctioned away, but the majority of that is intraabdominal pressure. So we obviously can't liposuction or remove intra abdominal contents. And so the way that you can really help improve that contour is by bringing those two muscle edges together. So there's a couple ways you can tell. Usually if you lay flat on your back and you either do a crunch or lift both of your legs up at the same time and place your fingers kind of along the midline, either below or above your belly button and you'll be able to push down and feel a gap.

(04:40):
And if you can get your fingers to kind of sit in a depression, you'll feel the two edges of your muscle if you are able to fit your fingers in between there. So when I'm meeting with somebody who's coming to me for a consultation for a mommy makeover, I never have in my mind that I'm going to automatically plan certain procedures. I always start first by listening. So I first just want to hear what changes they've experienced and what's causing them discomfort and what they want to address. Most commonly, it has something to do with breast changes and then something on the trunk, sometimes something in like the mom's area or labiaplasty. So I first listen to them, I ask them kind of what bothers them the most, what she is hoping to regain and then also what matters most for them in terms of recovery and timing.

(05:24):
Do they still have like a 15 month old that they're chasing around the house and they have to lift them up multiple times a day? So once I kind of narrow it down in terms of procedures, are they looking for a breast lift? Are they looking for improved volume, both? Is this just liposuction or is this a tummy took abdominoplasty? I'll jump to an exam. In my exam, I'm looking at skin quality, muscle separation, any sort of fat distribution and then breast volume and physician as well as any existing scars. In terms of the consultation, I think that's very personal. I don't think it's ever wrong to gain information about something and especially if you're trying to plan how this fits into your life. So consultation anytime if you're pregnant and you're like, "Hey, this is my last pregnancy and I know that after this kiddo I'm going to want something done." I think it's great to gather information.

(06:12):
But in terms of actual surgical timing, usually I do want your weight stable or within 10 to 15 pounds of your goal weight for at least six months. I would like the mom to have been finished breastfeeding for at least three months. Actually, I don't want milk coming out for at least three months. So even once you stop breastfeeding, you'll still continue to produce milk for a few months after that. And I would like you to be finished having children. Are there accidents later on? Yes, but you just would have to accept that you're going to have likely a recurrence of these anatomic changes. And then obviously I want you to be healthy and medically cleared for surgery. And then also ready logistically. Do you have help set up at home? Do you have a good support system? Do you have somebody that can help drive you around, get you to and from appointments?

(06:54):
So being a mom of two and soon to be three, I feel like this genuinely changes how I approach these conversations with these patients because I truly understand where they're coming from in terms of frustration with body image changes after pregnancy, physical changes that don't necessarily respond to effort, or you just feel like you don't have time in the day to put in the effort. The emotional kind of complexity of wanting surgery, feeling guilty for wanting the surgery and then just the reality of really busy family schedules and feeling like you can take the time to recover. So honestly, this isn't really like a cosmetic consultation in isolation. It's a conversation about your identity, your confidence and just feeling good in your own body. Even after my second child, I had stubborn baby weight that I was just feeling really frustrated with and I went on tirzepatide.

(07:44):
And even by losing a few of those extra pounds, I felt like I was feeling more social and wanting to show up better for my kids, being more active with my kids. So I can truly come from an empathetic place of understanding where they're coming from and a non-judgmental place as well to contribute to any sort of feelings of guilt that they might be having. If you are having trouble losing weight and you want to get a mommy makeover or a tummy tuck, but still feel like you're not at your goal weight and you're really struggling to get to shed those last few pounds, Basu Aesthetics and Plastic Surgery does have a med spa and we have a weight loss program. So it's run by the physicians here and nurses will monitor your weight loss. We can prescribe our skinny shot, tirzepatide or semaglutide and this is monitored.

(08:28):
We make sure you lose the weight safely. However, you have to be done breastfeeding and not pregnant. And then there's a few other clearance questions that we'll ask you, but that is a very great option for patients to get to their goal weight, especially losing some of that intraabdominal fat that can be more stubborn to lose with just diet and exercise. So yes, it's awesome that we have that option for patients to help get them to their goal. I plan to have a body makeover someday. I think the one thing that holds me back from that, committing to that logistically and there's other surgeries I've considered in the past is like the recovery and what that looks like with my kids. And right now I don't have children that would tolerate not being picked up by me, but I would consider it, yes. So a lot of patients come to me and they ask me, "Is it safe to do this altogether?

(09:19):
Should I do this all together? Should I have this in two separate procedures?" It's very personal. So sometimes a combined operation is ideal. You get one anesthesia event, one recovery, although it might be a little bit longer, and then kind of a faster time to your final results, like a faster transformation. But then I think staging can make more sense for some patients financially if you're just wanting to kind of stage that financial stressor or event in your life based off of the patient's height, weight, and what procedures they're getting. If I feel like that operative time is going to be too long to do safely, then I might recommend to stage the whole mommy makeover. And that would look like doing your time tuck first, coming back and doing your breast or vice versa, whichever your priority is. Recovery demands are going to be overwhelming.

(10:05):
So if say you want to just get the breast implants first because you only have four weeks to recover and not six weeks versus like if we were doing breast and body, I'd probably push it more towards that six weeks asking for a full recovery or a patient just prefers a more gradual approach, they want to see how they do from a pain standpoint, anesthesia standpoint before kind of committing to that big long recovery. So the priority is safety, but those other factors are things I definitely consider for the patient. The internal bra technique is something that I learned from Dr. Basu during my fellowship time here. And so he's an expert in this and he taught me all of his techniques. And so what the internal bra technique is is where we use a piece of resorbable mesh. It's made out of suture material.

(10:51):
It's resorbable because it will dissolve over the course of the next several years and your body will replace that material with your own collagen. The reason we call it the internal bra is that it is used as a support structure, almost like a bra to hold either implants up or your breast tissue up and take the weight of implants breast tissue off of your skin because why do people have sagging breast gravity. So any sort of heaviness or weight that's put on that skin is going to stretch the skin and things are going to fall. So the concern putting implants into weak skin is that that skin will then fall again. And so we use internal bra as a way to kind of increase the longevity of your results. I do offer this to patients frequently, especially if on exam they have loss of elasticity in their skin, their skin seemed very thin.

(11:40):
There's some stretch marks. They've had significant weight changes. I use it more commonly in breast implant cases where I'm putting an implant in there, but it is an option for just your standard breast lift or even a breast reduction and just kind of depending on your anatomy and goals, I might recommend it. So it is commonly used in our money makeover procedures because we're doing breast procedures on patients who have had changes in their collagen and their breast skin. So getting into the procedure itself and the day of surgery, all of our surgeries are performed in our state licensed ambulatory surgical center. It's state licensed, meaning that it meets hospital grade standards for quality and safety as determined by the Texas Department of Health. All of our cases have an MD anesthesiologist board certified. We have dedicated nursing staff in our ambulatory surgical center and we have comprehensive cardiac monitoring.

(12:29):
I think patients really feel less anxious when they understand the process. So arrival and check-in, you're met with one of our nurses. We take this time to explain every single step to you in the preoperative area. You'll meet our anesthesia team in the pre-op area and then I'll explain my markings to you just to make you feel like you really understand exactly what's going to be happening while you're asleep. I'll also go over discharge planning and recovery with you in the pre-op area and your care partner will be receiving consistent updates from our team while you are in surgery. So I want you to feel cared for and informed the entire time, not feel like you're getting rushed around and thrown into the operating room and just put to sleep.You are really understanding every step of it. So we are very proud of our anesthesia team here.

(13:12):
Dr. Mary Ellen Firat is a gem and usually when I walk into the pre-op area and I ask my patients if they're nervous and they say yes, I say, "Just wait till you meet Dr. Firat." She's going to calm you down in every sense because usually that's the main concern is there's people feeling uneasy about anesthesia. It's been a long time since they've had anesthesia. They've never had anesthesia and she is just so experienced. She's so smart. She knows how to give the perfect cocktail for you to have a smooth both anesthetic period as well as recovery. So patients, they're not asleep for hours after and without being able to wake up, our patients recover within 20 minutes, they're up eating and drinking. So she is amazing and she is a gem to our practice. For anyone who wants to meet our anesthesiologist, there's an entire episode dedicated to meet Dr. Firat and you will get to hear her lovely Southern twang and she'll explain the entire anesthesia process to you.

(14:10):
So everybody worries about pain after surgery. I think especially with a tummy tuck, there's this huge stigma that is just the most uncomfortable experience ever and thankfully we have amazing pain adjuncts and a multimodal approach to pain management that has really mitigated this and because we want patients up and walking and keeping your blood flowing after surgery, I do not want you bedbound and putting you at risk for a blood clot because you're not up and walking. So we do use a multimodal approach to pain management for our patients. One is I will do blocks where I block the nerves in your abdominal wall and I use a long acting numbing medicine called Exparel. This is a special numbing medicine that will gradually release into your system over the course of about 72 hours to give you almost three days essentially of a numbed abdominal wall.

(15:00):
And that's important because the most uncomfortable part of a tummy tuck is that muscle tightening. And so by keeping you comfortable and having that pain mitigated, you are still up and walking and able to get yourself water, use the restroom. We also will prescribe you anti-inflammatories, a nerve pain medicine that helps reduce the need for opioids. I will prescribe a narcotic as well just for you to have for breakthrough pain, but we really coach you how to take non-narcotic pain medications to help you just get off the narcotics because it makes you constipated, you can't drive, you feel out of it, can make you nauseous. And so those are the main ways we manage pain for our patients. So what does recovery look like? And this will be very different for everybody, but in general, that first week you're going to notice the most swelling.

(15:49):
You're taking it easy. I don't want your heart rate getting up. I don't want your blood pressure getting up. I encourage you to walk very slowly, just keep your blood pumping, but you're not lifting anything heavier than about 10 pounds, including your children. And you're also kind of walking bent over for a little bit, kind of a skier's posture for about seven to 10 days. By week two, usually you're feeling a litle bit more mobile, your drains are probably out around that point. You're not taking narcotic pain medications and usually patients feel up to driving by week two and you'll notice that kind of that swelling is starting to improve. From a work standpoint, a lot of patients that work from home I find are kind of back to work within that first week, like even the first three to five days, but definitely by week two to three, most patients have returned to work.

(16:38):
And then at about the six week mark, if you got that tummy tuck, that's when I clear you for return to lifting, exercising, lifting your kids. But this does happen in stages. You're still going to swell when you go back to the gym and you kind of have to be conscious of that and maybe take it a litle bit easier next time you get back to exercising. So in terms of how often you see me after surgery, I will see you at the one week mark. I call all my patients the night of surgery to check in. So I'll give you a call that evening, answer any questions, make sure that you're eating okay, not feeling too nauseous. And then our team will check in with you the next day, either via text or phone. And then if you're doing fine, I see you at one week.

(17:15):
If anything comes up before then, I'm always here. The next time I see you or you see someone from our team is usually around the three to four week mark. We do use a tension offloading tape called silk tape and this stays on for at least three weeks. It helps our incisions heal incredibly faint. So we'll usually see you back for that tape to come off. Somewhere in between that one to three weeks, you will probably come back for a drain removal. So those first three weeks are seeing us a lot. You're getting kind of tired of us. And then after the three week mark, you're free from us for about three weeks. And then I'll see you again at your clearance appointment, which is around six weeks. At your clearance appointment, we assess your scars. We see if you might benefit from some laser lightning, some microneedling.

(17:58):
We go over scar management protocols, so scar massage, scar taping. And as long as everything's healed well, I clear you. So back to exercise, back to lifting your kids, back to swimming, bathtubs, hot tubs. And then I do love to see all my patients again at around the three month mark just to see how everything is kind of finally settled now that all the swelling's kind of gone and also just to address any concerns or questions that have since come up from being cleared. I do feel like there is a huge emotional component to the one week appointment. I think a lot of times patients are feeling a little bit more uncomfortable. They're feeling stir crazy in their house, especially patients who are used to exercising every single day, you're swollen. And so that is when I usually expect patients to not necessarily feel regret about their procedure, but it does involve a lot of just encouragement and like, yes, you're swollen.

(18:49):
Yes, we still need to wait for the swelling to go down. This is all very normal and very expected and a normal response your body is having to the stress of surgery. So in terms of that emotional first week visit, I have had patients tear up, cry to me. They're just feeling a little bit overwhelmed. They're probably not sleeping well. They're maybe feeling some guilt about the procedure about not holding their kids. And I do feel like I offer a very non-judgmental comforting presence for those patients to kind of let out their emotions if they feel like they can't necessarily do that at home. I do feel like that's a little skill that I have to offer for the psychology of plastic surgery. Of course, one of the biggest questions patients have about this procedure is how are they going to pay for it? So investment in financing pricing for a mommy makeover procedure will vary depending on the procedures that we select, how long that surgery will take, are we adding some breast implants to it?

(19:45):
I said the operative time and then also just the complexity. Have you already had a breast surgery before? Is this a revision procedure? Most patients are budgeting for a combined surgical investment and financing options like patient buy can be used to make treatment more accessible. So we do want to meet you where you are. I don't want this to be a financial strain on your family. I totally respect that this is an investment and that is why we're pretty strict on those postoperative instructions are taking care of this surgical result, but we will go over individualized pricing and planning at your consultation. We'll make it very clear for you to understand. We always have price ranges on our website and it's very easy to find out if you qualify through patient by. Also, when you call our patient care coordinators to get that consultation set up, they can usually give you an idea of probably what procedures you're going to be looking into and also give you a litle bit more of a specific price range at that time.

(20:39):
Okay. When patients come back to me at three months or beyond, if they come back to me for some other procedure that they want to add on, I feel like maybe this is recently buys. I had a lady yesterday who was, they're just like, "Thank you for giving me the cutest belly button." And just usually they're feeling so much more confident in their clothing and they have enjoyed the process of getting to kind of treat themselves as some new clothes that fit better. They are very excited to wear a bikini in the summertime and a lot of times they're saying, "This was the best decision I ever made. I regret not doing it sooner." Okay, if you are ready to take that first step in coming and having a mommy makeover, and don't feel like this is a huge commitment just because you're making a consultation, you're just information gathering.

(21:23):
But in terms of what I really like for you to bring as a list of questions, goals. Photos are very helpful, especially for breasts because I think patients all use different words to articulate what they're looking for in breasts and photos can make it more clear to me what the patient is looking for. And then also an open mind. So a lot of patients come in thinking like all they need is liposuction and I have to be the person to say like, "No, liposuction's not going to take care of this for you. It's going to be a litle bit more of an invasive procedure to really get you the goal that you want. " And then in terms of what to expect, so we are going to do an exam. I'm going to go through your anatomy pretty extensively with you. I'm going to go through options, what I think is best for you.

(22:04):
We'll go over recovery. I do go in depth about risks. This is an elective procedure and I want you to be very well informed about risks that come with surgery. Plastic surgery is real surgery and then just whether surgery is even the right choice for you if we need to work on some weight loss first if you're unsure about if you're still having kids later on. So those are all kind of important conversations for us to have, but there's a ton of value in understanding what your options are even if you're not ready to move forward. So where can you find me online? You can find me primarily at our Instagram page, Basu Plastic Surgery. I do have my own personal Instagram page, Dr. Shannon Kuruvilla, and then of course @basuplasticsurgery.com.

Announcer (22:47):
Basu Plastic Surgery and Aesthetics is located in Northwest Houston in the Towne Lake area of Cypress. To learn more about the practice or ask a question, go to basuplasticsurgery.com/podcast. On Instagram, follow Dr. Basu and the team @BasuPlasticSurgery. That's B-A-S-U Plastic Surgery. Behind the Double Doors is a production of The Axis, T-H-E-A-X-I-S.io.