In Great Shape

Created on 25th September 2008

Miss Lisa Sacks, consultant plastic surgeon at the Nuffield Hospital Bristol, discusses the option of combining breast and abdominal surgery to give you the contour you desire

The appearance of a woman's abdomen and breasts change during the course of her lifetime. Pregnancy and weight fluctuations are mostly to blame. In the abdomen, loss of muscle skin tone contributes to poor posture and loss of self-esteem. In the breasts, stretched skin and loss of volume alter the shape forever. More women nowadays are seeking help to reconstruct their bodies, after completing their families, rather than just accepting the consequences of child rearing as their mothers did.

When women look in the mirror they see their breasts and abdomen in one view. It is therefore not surprising that requests for joint operations arise. Women who are generally fit and healthy and are able to give up smoking before and after surgery are good candidates for combined operations. Others are best advised to have breast and abdominal surgery done separately.

A tummy tuck involves removing the apron of skin and fat that may hang over the pubic area, but the real bonus of this procedure is tightening of the abdominal wall muscles (equivalent to the six-pack in men). This muscle tightening helps with core stability and stops that dragging feeling that a woman may have after intercourse or around the menses.

Muscles never really knit back together again in the midline after pregnancy or after excessive weight gain and then weight loss. A gap remains and can cause an arched back when standing, giving the appearance of a potbelly even in relatively thin women. When lying down this gap may form an actual gutter in thin patients that one can put one's hands into and feel the strong pulsation of the aorta. If it is not possible to press one's hand into the abdomen and feel this pulsation because there is a tummy mound, then the patients is probably too fat for this operation and needs to lose some weight beforehand.

The scar may be short but if a large amount of tissue needs to be removed then it usually extends from hip to hip. If designed correctly, most panties and swimwear can usually hide the scar. After about six months to a year there may be small points on the hips called ‘dog ears'. A small touch up usually done under local anaesthesia is necessary to improve the final result. This involves cutting out a small ellipse of skin at each end of the scar to help smooth it out.

It is important to communicate with your surgeon and find out exactly where the scar is going to lie. Fashions change and low cut trousers may mean that a lower scar is needed. High leg swimsuits may mean the scar needs to raise up like bicycle handlebars. A scar that is too high over the pubic area may prevent you from showing off a nice flat tummy in a bikini. Little can be done to resite the scar once it is there. So discuss it before, not after, the operation.

Some breasts may become enlarged after pregnancy and breast-feeding and remain too large for comfort afterwards. While in others, breasts become smaller and left floating in a large sack of skin. Matronly- ooking breasts can leave women feeling old before their time, and damage their confidence. Breasts can be lifted and reduced or just lifted thus rejuvenating their appearance enormously. This can be done through an anchor (inverted T) scar or even through short scars. It is also possible to enlarge breasts at the same time, although this is less common than lifting or reducing breasts at the same time as tummy tucks. Breasts that are saggy and have lost a lot of volume may need a combined lift and augmentation. This is often done on separate occasions or can be combined. Complications from breast surgery include loss of erogenous sensation, loss of nipple and/or areola, scarring and asymmetry. In good hands though, these complications should all be quite rare.

When breast surgery is combined with a tummy tuck, it is the less painful of the two procedures and therefore less trouble to the patient. The advantage of combining breast and tummy operations is one hospital stay, one anaesthetic and one recovery time. Combined surgery may also reduce the overall cost. Two nights in hospital is usual for a tummy tuck alone and three if the breasts and tummy are
operated on together. Breast surgery alone is usually a one night stay, but may require two nights.

Recovery takes three to six weeks depending on the extent of the tummy tuck. The more tissue excised and the more extensive the muscle repair, the longer the recovery period. Driving can be resumed by three weeks and full activities, including tummy muscle exercises, by twelve weeks.

The combined operation takes between five and six hours therefore the major risk is deep vein thrombosis and pulmonary embolus. Stopping oral contraceptives before the operation, stopping smoking before and after, and wearing compression stockings before, during and after the operation are all necessary precautions to minimise complications. Different surgeons have different thresholds for operating on overweight patients. Tummy tucks carry the highest risk of deep vein thrombosis and therefore pulmonary embolus, amongst all plastic surgery procedures. Postponing surgery until the desired weight is achieved is often advisable. The patient who can obtain their ideal weight before an operation is planned enhances the results of any surgery. Unfortunately breasts can sometimes be so large and uncomfortable, precluding any type of surgery.

After these operations, individually or combined, the improvement in the silhouette and posture is usually dramatic. Posture is improved by altering the effects of gravity on the breasts and by restoring core stability. Patients often tell me that the overall feeling of well being is paramount and that "looking better is the icing on the cake". CSMUK