LISA J. KORUS MD MPH FRCSC PLASTIC AND RECONSTRUCTIVE SURGERY EDMONTON

Thinking about that summer body?  One of the most common procedures that we perform is abdominoplasty surgery, aka the “tummy tuck”.  It is important to realize that undergoing plastic surgery is a partnership.  Not only do you place your trust in your surgeon, but your surgeon also trusts you that you will closely follow instructions they provide to help you obtain the best results possible.  But are there things that you can do before surgery to make sure you can achieve the best result possible?  Absolutely! 
 

• Being in good health and obtaining your ideal body weight.  Surgery is not a weight loss tool and often people are surprised how little the removed tissue weighs!  While being overweight when undergoing surgery is associated with a higher chance of complications there is no set “target” that is the same for everyone. Most important is that your weight is stable.  If you achieve a weight before surgery that is not sustainable, then if you gain that weight back after surgery, it can impact your results.  It is also important to be in good health.  Smoking or uncontrolled diabetes, for example, can drastically increase your chance of complications.

 

• Work on core and pelvic strength. If part of the reason you are seeking surgery is to repair a rectus diastasis (splitting of the muscles in the middle of the belly – usually due to pregnancy), it is important to know that a tight tucked looking tummy comes from both great core strength and repair of any diastasis.  While we can fix the gap, surgery does not strengthen your core muscles.  So basically if you want abs – you need to build up muscle strength first and then we just bring those muscles together!

 

• Do your homework.  Understand what is involved with surgery.  No surgery is without trade-offs.  Other than the recovery period, the biggest trade off with tummy tucks is usually the scarring.  Usually this means a scar along the lower abdomen and around the belly button.  While these scars are fairly minimal once healed, they will always be visible. We often keep these scars quite low however this means if you are wearing a high cut bikini the scars might be visible.  You may need to adjust the clothing you wear after surgery if you wish to keep these scars hidden.

The choice to both undergo breast augmentation as well as breast implant removal is an intimately personal decision.  In either decision it is important to understand the process and any potential risks.
 
While breast augmentation is a safe day procedure that has a very high satisfaction rate, a woman may go on to have their implants removed or exchanged.  Reasons for this vary.  Some women decide that implants are just “not for me” anymore.  In the absence of any complications, they may decide that they do not wish to worry about monitoring for the long-term complications.  While long term complications such as rupture and capsular contracture can occur, they are uncommon (you are more likely to never have to deal with them than you are to have to deal with them) however implants are ultimately not guaranteed as lifelong devices.   Additionally, women’s priorities can change over time and they may no longer wish to have the volume associated with implants or wish to change to smaller implants.  A certain type of breast implant has also been associated with a very rare form of lymphoma.  While these implants have been pulled off the market there has not been a “recall” on implanted devices. Many women, however,  wish to take control of their health and are choosing to have these implants taken out or replaced for peace of mind.
 
Factors to be considered when removing or exchanging implants include what the implant is filled with (saline or silicone) and if a breast lift might be required.  It is not always possible to determine if someone will need a lift when the implants are still in.  With saline implants, the option to deflate the implant in clinic allows time for the breast tissue to retract back into position over a period of a few weeks to months and if no lift is required, then often the saline implants can be removed with local anesthetic.  Silicone implants, on the other hand, are often better removed in the operating room – especially if there is concern about a ruptured implant.  If it is very obvious that a breast lift is required, this can be done at the same time as either the exchange or removal of breast implants.
 
The biggest changes to the breast after implant removal are a loss of volume and “upper pole fullness” or fullness on the top part of the breast.  If the breasts have additionally become droopy over time, then a lift may be required which results in additional scarring on the breasts.  As with any surgery, there are risks of infection and bleeding.  You are also more likely to require drains compared to when implants are put in.  For women that choose to have their implants taken out, satisfaction tends to be quite high despite the recovery time required and the risks associated with surgery.
 
Every situation is unique depending on the type of implants you have and the changes with your own body.  For this reason, it is important to discuss this surgery with a board certified plastic surgeon so they can help you navigate what is the best choice for you!
 
 

Depending on what your concerns and problem areas are, there are different ways that the abdomen can be rejuvenated.
 
Liposuction– Occasionally the abdominal skin can collect deposits of adipose tissue (also known as fat). Liposuction can be used to remove this tissue.  It is important to note however that liposuction only works if your skin is tight and of good quality.  Liposuction does not fix loose skin, especially if there are stretch marks.  Additionally, liposuction can make cellulite worse and should not be used as a tool for weight loss.
 
Mini-tummy tuck-  A mini-tummy tuck involves cutting out loose skin on the lowest part of the abdomen (around where a C-section scar would be).  It does involve the creation of a lower abdominal scar that is much longer than a C-section scar.  A mini-tummy tuck generally does not fix any loose skin above the belly button or any rectus diastasis (where the rectus muscles have split, usually after childbirth).
 
Full tummy tuck (aka abdominoplasty)– This involves making a cut along the lower abdomen and around the belly button so that all the skin can be lifted off the abdominal wall.  Once this is done, any gap in the rectus muscles is repaired.  Excess skin is then amputated (usually this means cutting off all the skin up to the bellybutton) and then the remaining skin is stretched down to close the belly. A hole is then made for the belly button to come out through.  This leaves a scar along the lower abdomen slightly longer than a mini-tummy tuck scar and a scar around the belly button. A full abdominoplasty results in tighter skin both below and above the belly button in addition to flattening and tightening the belly through muscle repair.

As with any procedure, it is important to discuss your goals with a board certified plastic surgery in order to better understand what each option can address, as well as their  limitations and possible complications.

One of the most common questions I am asked during breast augmentation consultations is what is the recovery like.  Ensuring you have enough time to properly heal after surgery is key to help you get the best results possible while at the same time minimizing the risk of complications.
 
Day of Surgery
 
When you go home the day of surgery you will be sore and your chest will feel quite tight.  Special measures are taken to ensure that you are as comfortable as possible.  These include using anesthetics and medications that decrease the risk of nausea after surgery, atraumatic technique during surgery to minimize pain and early use of non-steroidal anti-inflammatories to decrease drowsiness.  Most people will feel pretty good after a day or two.
 
Week or Two After Surgery
 
This is when most people will feel pretty great and almost back to normal after surgery.  Often people will go back to work at this time, provided that your job is not too physically demanding.  Even though you may be feeling great at this time, it is still important to remember to take it easy so no heavy exercise such as running or weight lifting just yet. 
 
Six Weeks After Surgery
 
This is when you are technically unrestricted and can return completely to “regular life”.   Your scar tissue will have its maximum strength and you are allowed to exercise again and can return to work if it is very physical.   This does not mean, however, that you will have your final cosmetic results.
 
Three Months to One Year
 
By this time we expect your implants to have completely settled however sometimes it can take up to a year (or even two!) for the scar tissue to completely mature, meaning for the redness in the scars to go away.   Young healthy people will often take the longest for the scars to fade (meaning for the redness to go away and the scar to have a minimal appearance/flesh colored tone)
 
As you can see recovery from surgery is a process and is an important thing to understand when choosing to undergo breast augmentation.

​There is no question that breast implants can help improve a woman’s body image in cases where the breasts are small or undeveloped, deflated after breast feeding or when used for reconstruction after breast cancer.  Although implants are generally considered safe and most women are very happy with their results they are not considered lifelong devices and may require further surgery down the road.  What are important considerations when choosing to undergo breast implant surgery?
 
Postsurgical complications
 
Although rare, any surgery comes with a risk of complications.  After surgery, these complications include infection (which is why you are given antibiotics at the time of surgery) and bleeding (which is why you should not perform any heavy or intense exercise for six weeks after surgery).  It is important for your surgeon to discuss these with you so you know how you can do your part to help prevent these from happening.
 
Aging of the breast
 
Having breast augmentation does not freeze your breasts in time (unfortunately!).  Sometimes as the breasts age they can become larger and droopier.   This means you might need repeat surgery for cosmetic reasons, such as lifting the breast back up again. Things that accelerate aging of the breasts include fluctuations in weight (especially gaining weight) or pregnancy.  To get the best results from your surgery it is best to maintain a stable weight.
 
Long-term complications
 
Long term issues with breast implants include implant rupture and capsular contracture:
 

• Implant rupture is when the shell breaks.  With a saline implant this is very obvious as the implant will deflate. With a gummy bear silicone implant a break may be less obvious.  In both cases, however, the implant should be replaced.
• Capsular contracture is when the capsule (layer of scar tissue around the implant) becomes very hard and very tight.  It is still not clear exactly what causes this, but given that it can be uncomfortable and make the breasts look strange it should be treated.  

 
Patient satisfaction is very high after breast augmentation surgery and while the above possible complications are overall rare, with any surgical procedure it is very important to discuss with your plastic surgeon the pros and cons of surgery to make sure that you pick the procedure that is right for you. 

​WHAT ARE WE DOING TO KEEP YOU SAFE?
 
While we are excited to return to operating and see patients in our clinic, the safety of our patients is our utmost priority.  These are the steps that we are taking to ensure your safety:
 
Before your visit:
 
We are screening patients as well as our own office staff BEFORE they attend our facilities to ensure that:  
 

• They have not travelled outside of Canada in the past 30 days
• They are not currently feeling ill or have not felt ill for the past 14 days
• They have not cared for someone feeling ill in the last 14 days or have been contact with someone being diagnosed with COVID19
• Are not immunocompromised
• Do not have body aches, fatigue, loss of taste and/or smell and do not have a fever

 
Additionally, we are asking that patients:
 

• Arrive with a mask if possible
• Attend their appointment by themselves is possible
• Arrive at the time booked

 
At your visit:
 

• We are currently booking under capacity to decrease the number of people in the facility at a time and have spaced out our waiting room to comply with social distancing
• We have posted visible information in regards to social distancing and hygiene to remind both office staff and patients alike of precautions that must be taken
• We have hand sanitizer available for use when arriving and leaving the facility
• Common areas are being sanitized with increased frequency and common use items (such as magazines) have been removed
• All surfaces that come into contact with patients through their visit are being sanitized between patients using Health Canada approved disinfectants
• Our staff will be either behind physical barriers (sneeze guards or shields) or be wearing medical grade masks during their interactions with you

 
As Alberta relaunches, it is our duty to ensure that we are able to continue to provide the highest level of patient care while additionally doing what we can to help decrease the spread of COVID19.

While a variety of women come into my office seeking breast augmentation surgery, they tend to form two groups - young women with smaller breasts who have not yet had children and women who have finished child bearing and are seeking to rejuvenate their breasts.  If you have already finished having children – congratulations on experiencing one of life’s miracles!  If not, then read on: 
If you are considering having breast implants and wish to have children in the future, what important things to do you need to know?

1. What are the current recommendations on breast feeding and breast surgery?
2. What is the evidence on women being able to breast feed after breast augmentation surgery?
3. What does this ultimately mean to me?

1. The World Health Organization currently recommends EXCLUSIVELY breast feeding for the first six months after birth.  After this breast feeding is recommended up to two years (or longer) in combination with nutritious food (1).  Advantages of breast feeding include lower risk of gastrointestinal infections for the baby and long-term benefits such as a lower chance of Type-II diabetes and performing better on intelligence testing.  Benefits for the mother include faster weight loss and decreased risk of developing breast cancer (2).

2.  Current evidence suggests that many women can breast feed after breast augmentation however are more likely to have to supplement, i.e. not be able to EXCLUSIVELY breast feed.  (3,4) There has been some suggestion that certain techniques may impact the chances of being able to breast feed more, such as a using a peri-areolar incision (5,7), or putting the implant in a subglandular plane (7).  The biggest issue with these studies is not knowing if these women had implants put in because of a lack of breast development, meaning that they would have had difficulty breast feeding regardless of whether they had implants or not.  There is no contraindication to TRYING to breast feed if you have already had implants put in.

3. While women may not choose to breast feed their children or encounter difficulty, we do know rates of breast feeding have been increasing throughout the years as the health benefits become better understood, going from about 25% in the 1960s to 85% more recently.  Only about 50% of women breast feed their children for six months or more and even less do so exclusively.   Reasons for stopping breast feeding include not enough milk, the child weaning itself, having to return to work/school or fatigue (8).   While the science suggests that most women should be able to breastfeed after breast augmentation, they may have difficulty producing milk and will have to supplement with other sources of food.  Again, we do not know if this is a result of having less breast tissue to begin with versus the result of having a breast implant.  

The bottom line is we do not 100% know.  If considering breast augmentation and potentially having children down the road, it is important to know that there are health benefits to breast feeding your children and that your ability to breast feed MAY be affected, most likely meaning having to supplement.  The technique of breast augmentation such as using an incision under your breast versus around your nipple and the decision to place the implant under the muscle could help minimize issues with breast feeding.  That being said, if you have already had breast implants,  there is no contraindication to trying to breast feed!  As with any surgical procedure it is important to discuss the risks and benefits with your doctor to decide if this surgery is right for you.

REFERENCES:

1. https://www.who.int/mediacentre/news/statements/2011/breastfeeding_20110115/en/
2. https://www.who.int/features/factfiles/breastfeeding/en/
3. Schiff M et al.   The impact of cosmetic breast implants on breastfeeding: a systematic review and meta-analysis.   International Breastfeeding Journal.  9(17): 1-8.
4. Cheng F et al.  Do Breast Implants Influence Breast Feeding:  A Meta-Analysis of Comparative Studies.  Journal of Human Lactation.  34(3): 424-432.
5. Hurst NM. Lactation after augmentation mammoplasty. Obstet Gynecol. 87: 30-3
6. Neifert M et al.  The influence of breast surgery, breast appearance, and pregnancy-induced changes on lactation sufficiency as measure by infant weight gain. Birth 17:31-38.
7. Bomby et al.  Impact on Breastfeeding According to Implant Features in Breast Augmentation.  Annals of Plastic Surgery.82(1).  11-14.
8. Maclean H, Millar WJ. Breastfeeding practices [Internet]. Ottawa (ON): Statistics Canada; 2005 [cited 2018 May 14]. 54p. Cat. No.: 82-003. Available from: http://publications.gc.ca/Collection-R/Statcan/82-003-XIE/0020482-003-XIE.pdf.