Jana K. Rasmussen, MD (retired)

A tummy tuck helps 3 problem areas of the abdomen. First is removal and tightening of the excess skin. Usually all the skin from just above the belly button down to the pubic bone is cut away.  Second is the removal and/or thinning of the fatty layer.  All the fatty tissue beneath the removed skin mentioned above is also cut away; then the remaining tissue, including fat in the upper abdomen is stretched downward, ultimately making the fatty layer thinner. Finally, the paired rectus muscles which extend the length from the bottom of the breast bone to the top of the pubic bone is tightened. There are various techniques, but usually an "imbrication" stitch is placed in the "fascia", or strong, thin covering of the muscle, such that when the ends of the stitch are tied, the edges of the separated muscles are brought closer together. No cutting of the muscles is performed.  Personally, I place a "figure of 8" stitch made of a strong synthetic non absorbable suture that feels similar to a heavy duty cotton or polyester thread you use for sewing.  It comes in different sizes, and a size that is strong enough to hold, but not so big to cause a foreign body tissue reaction is generally selected.  Every surgeon has their own particular preference. Typically, those stitches are never felt below the skin. And eventually, scar tissue bonds the "imbricated" tissue, so that even if a stitch would break, the scar tissue holds the fascia/muscles together.

Some women have very little "diastasis" (separation) of their rectus muscles, and don't need significant muscle tightening.  But anyone that has had at least one pregnancy will have some separation of the muscles and the only thing that brings them closer together is surgery....all the abdominal exercises in the world will NOT correct diastasis. I hope this has more than answered your question!

 

A standard tummy tuck lifts the skin and fatty tissue off the underlying abdominal muscle from the top of the pubic bone up to the bottom of the breast bone, almost like lifting up an apron. As a result, all of the lymphatic channels are damaged and so swelling is a given. It's just a matter of how long it will last, sometimes as long as 3 to 6 months. There are certain things we do intra-operatively to minimize lymphatic disruption, and there are things we recommend to our patients post-operatively to help reduce swelling, such as compression garments or massaging techniques.  The problem is that when a patient is in an upright position, the lymphedema cannot cross the fresh incisional scar to drain into the inguinal lymph glands in the groin, so it tends to get "hung up" in the lower abdomen, producing more swelling above the scar.  At night time, while lying down, the swelling drains dependently around to the back, but the cycle resumes when the patient  wakes up/stands up the next day.  And unfortunately, chronic lymphedema (swelling) can turn into chronic fibrosis (scar tissue) resulting in a bulge or step off above the scar.

I first started offering Endermologie (aka LPG) to my abdominoplasty patients in 1996, when it was first introduced to the US. Those that had the "rolling and sucking" treatment  twice weekly for about 6 weeks had significantly less swelling and better results than those that didn't.  Because of that, I chose to incorporate the fee of 12 LPG's into my tummy tuck estimate, since in my experience, the patient would have faster resolution of swelling and ultimately have better results. Sometimes patients who have had tummy tucks elsewhere are referred to my office for treatment when they are concerned about prolonged swelling.  Delayed treatment can be effective, but I like to implement the treatments about 5 days post-op.  Patients tell me it makes them feel better, too, presumably due to less tension on the nerve endings from less swelling. It also enhances scar softening/maturing.

As a general rule, implants will not look bigger after they "settle", BUT, there are several factors in considering how your final breast size will appear.  First, the breast lift creates tension in the skin and breast  that will eventually "settle" with time and that will be affected by the underlying implant.  Second, the implant will "settle", both with respect to the overlying lifted skin and breast envelope, but also due to the accommodation of the overlying muscle. Since this is not a saline implant, you won't have the usual "relaxation" of the saline implant that occurs with time, so the size of silicone implant, as it appeared when place on the operating room table, will not change. Finally, you have the natural occurrence of the body's response to trauma (surgery), so there will be swelling of all the tissues affected (skin, fat, breast, and muscle), and then there will be some element of retraction of this swelling....some skin types don't retract back as well as others.  All of these factors effect the final breast appearance (size, shape, symmetry), and as surgeons, we hope that our expertise allows us to accommodate for all of these factors during the surgery so the final appearance on the OR table is a prediction of what to expect after several months of healing.  Remember, the acute healing phase takes about 6 to 8 weeks, before transitioning into a chronic healing phase. So time and patience are important to achieve the final result we had planned to achieve. Of note, many times patients in the very early time frame (first week), get used to the appearance of the large, swollen breast, and then when it "settles" they think they are "small"....this is when reviewing your pre-op photos are helpful, because you can clearly see that, indeed, you are "bigger" but hopefully well proportioned. A 450 cc gel implant is fairly large, depending on your height/weight/stature.  So presumably you will be happy with your outcome with that large of an implant once the healing process is complete. Remember, breasts look differently in a frontal view than they do from the side view....if you are "rounding" from the side, you are probably "big enough" and didn't need to go with a larger size. And be sure to follow you surgeon's post-op recommendations to prevent problems as you heal!

Marketing may be ahead of science, particularly in the case of stem cell-based cosmetic surgery, including breast augmentation and facelift. Although laboratory and clinical studies are encouraging, the science does not yet support some advertising claims being made.  A joint task force comprised of members of the American Society of Plastic Surgeons(ASPS)  and the American Society for Aesthetic Surgery(ASAPS) said plastic surgeons should refrain from offering stem cell-based cosmetic procedures until studies prove they are safe and effective (May, 2011).  So consumer beware of those entrepreneurial plastic surgeons for the time being. For more info on the joint report, go to the ASPS or ASAPS websites.

First of all, the latest statistic  I read is that about 80% of women have some degree of Fibrocystic Breast Disorder (it is not a "disease"). Secondly, FCBD is not linked with breast cancer.  While breast augmentation is not contraindicated in women with FCBD, there are a couple of factors you should consider.  You did not mention if the reason you get an annual breast ultrasound is if you have palpable masses in your breasts. If a woman has a breast mass on exam, it is the burden of the physician to rule out cancer.  Usually a mammogram is performed, but it may not be diagnostic unless "suspicious".  In addition, very youthful breasts may not be the best way to image the breasts since they tend to be very "dense" on a mammogram.  So an ultrasound is helpful to image dense breasts, and it particularly helpful to determine if a mass is"cystic" or "solid".  If it is clearly a simple cyst, nothing has to be done, but often a needle aspiration is performed to remove fluid to minimize the size or symptoms of tenderness. A solid mass can be benign (fibroadenoma, more common in young women, not imperative to remove, but can grow to be large, so often removed in the operating room), but because of the possibility of something suspicious, it is usually biopsied, many times by way of a relatively non-invasive ultrasound guided needle aspiration procedure under local anesthesia.

What does this mean to you.....well, in part, it is related to your age.  You didn't mention how old you are, but since you are having regular ultrasounds, presumably you are "young" and your breasts are "dense. You didn't mention that you have had any biopsies, so presumably all the masses in your breasts have been "simple cysts". You didn't mention your breast cancer risk, but unless you are at "high risk" (positive genetic testing or strong family history despite negative genetic testing), breast augmentation should not be a contraindication.  Some plastic surgeons will tell you that saline implants under the muscle will be the ideal option for mammogram imaging, but I have discussed this with top-notch radiologists who inform me that as long as the implants are soft and mobile without capsule contracture, that it probably doesn't make any difference as long as the radiology tech is very good at the Eklund technique...the tech compresses the implants away from the breasts in order to get the most breast tissue on the xray cassette.

So your answer about FCBD  is somewhat based on your answers to the other questions that I posed above. Of course, a thorough consult including your breast history and exam with a reputable plastic surgeon is imperative.  Regarding future pregnancies.....no problem and in fact if you could normally breast feed, the surgery should not impair this, and pediatricians encourage it.  There are no plastic surgery contraindications to breast feeding after breast augmentation.  Long term, over the course of aging, gravity, loss of elasticity, weight fluctuations, pregnancies, breast feeding, and hormonal changes, your own natural breast tissue will change, your implant typically will not, with the exception of the possibility of capsule contracture and rupture.  Good Luck!