Mommy Makeover Consultation and Physical Exam

Health History

All cosmetic surgery consultations begin with a thorough health history. Tummy tucks and breast surgeries are almost always done under general anesthesia because of the extensive amount of tissue undermining necessary. For this reason, it is especially important that your health is optimized. Prior to meeting with Joseph T Cruise, MD, you will be given a health history questionnaire to fill out in the waiting area. There are five areas of your health you will be asked about. Be sure to answer it with detail so that Joseph T Cruise, MD and anesthesiologist can be optimized for you.

General Health

General health problems are important to discuss so that your surgery is as safe as possible. Be sure to mention any chronic illness. Of particular concern are high blood pressure, diabetes, heart problems, liver and kidney disease, stroke, cancer, bleeding problems, and wound healing problems.

What will Joseph T Cruise, MD do if I have medical problems?

In short, he will make sure your health is optimized as much as possible to ensure your safety. This may mean referring you to your private physician.

If you have a health problem you can often save yourself time by getting a letter from your private physician prior to your cosmetic consultation stating what the health problem is, how it is being treated, and whether or not you are able to tolerate general anesthesia safely.

If you are seeing any specialist (cardiologist, kidney doctor, psychiatrist, etc. ) be sure to bring a letter from them stating you are able to tolerate surgery.

Be sure to let Joseph T Cruise, MD know if you have ever had a blood clot. Abdominoplasties have a higher incidence of causing blood clots compared to any other cosmetic procedure.

Past Surgical History

On your questionnaire, you will be asked about previous surgeries. Be sure to identify any problems you may have had with anesthesia. Of particular concern are previous cosmetic surgeries especially if you do not like the result and are interested in revision. With abdominoplasty, it is especially important to mention all abdominal surgeries including C-section, gallbladder, and hernia operations. With breast augmentation, it is especially important to mention all breast surgeries including breast biopsies.

Medications

Be sure to list all medications you take including aspirin and over-the-counter medications. These are important as they may increase bleeding and affect your surgery. It is extremely important to stop taking aspirin and aspirin-containing products at least 2 weeks before surgery. Tylenol is a good alternative. 

Allergies to Medications

Information about medications that cause allergies is very important so that these medications can be avoided. Of particular importance is the reaction you had, especially if you had trouble breathing. Be sure to include this information! Nausea is not an allergy but it is important to mention as well.

Smoking, Drinking and Drug Use

These will certainly affect your surgery and MUST be mentioned so that your surgery can be optimized. Smoking causes a profound decrease in wound healing and will lead to worse scarring and a less favorable result. With large procedures such as a facelift, neck lift, tummy tuck, and breast lift smoking must be stopped at least 6 weeks before and after surgery. Otherwise, the results could be disastrous leading to non-healing wounds, poor scarring, and/or infection. With smaller procedures such as eyelid surgery, nose surgery, breast augmentation, and liposuction smoking will hurt the overall result but this may or may not be noticeable. In this case, smoking cessation is strongly advised but is not mandatory.

Specific Abdominal Issues

During your consultation, you must be very accurate with abdominal problems. Of particular concern is a history of an abdominal hernia. This problem must be addressed during your consultation. If a hernia is present it can often be fixed during the surgery or if it is large it may need to be fixed with the help of a general surgeon. Another issue that complicates abdominoplasty is previous abdominal surgery. The scars may affect the blood supply to the skin. Once again, any history of blood clot must be discussed.

Physical Exam 

The key to the abdominal physical exam is to determine exactly what is causing the problem. Some problems can be treated with liposuction while others require a tummy tuck. Sometimes a combination of the two is best. This section will help you decide what is best for you. Abdominal cosmetic surgery can be broken down into the following 5 categories: liposuction alone, mini-abdominoplasty, standard abdominoplasty, extended abdominoplasty and circumferential abdominoplasty

Liposuction

Liposuction alone is excellent when skin excess is not a problem and there is a localized excess fat deposit. Liposuction requires that the patient's skin has the ability to shrink back once the fat is removed. Patients with poor skin quality, demonstrated by many stretch marks and cellulite, are not good candidates for liposuction. This is better discussed under the liposuction section. Often, patients convince themselves that 'If I could just suck this fat out then my stomach would be flat. 'This may be true, but if they have a lot of excess skin or their skin quality is poor then they will be disappointed. Liposuction may leave them with loose, hanging skin often with waviness.

If there is a significant amount of excess skin then the only way to get rid of it is to cut it out via a tummy tuck. Frequently, non-plastic surgeons will perform liposuction and these patients end up with disappointing results. The scars caused by a tummy tuck are very long but this is almost never a complaint. Satisfaction is uniformly high. Once it has been decided that skin excision is necessary the next question is how far to the back should the excision go. The answer is relatively straightforward.

Mini Abdominoplasty, AKA Mini Tummy Tuck

If your problem is limited to a small amount of loose skin and excess fat below the belly button then a 'mini-abdominoplasty' may be all that is necessary. As the name implies, a mini-abdominoplasty creates a smaller scar. The tradeoff, however, is that it may not obtain the results you are looking for. Generally, if you can only pinch an inch or two then this will probably suffice. The incision stays inside the hip bones and the belly button is not transplanted like in a standard abdominoplasty. It is merely pulled downward toward the pubis. Abdominal muscle tightening is performed up to the level of the umbilicus. This markedly improves the abdominal pooch.

Standard Abdominoplasty, AKA Standard Tummy Tuck

If there is more than an inch or two of excess skin then a standard abdominoplasty is probably necessary. This does an excellent job of removing loose skin, excess fat, and creating a flat stomach. It also helps to create a curvy waist but not as dramatically as an extended abdominoplasty does. Below are the components of an abdominoplasty:

• • Skin Excision

In general, you can expect the scar to extend from hip to hip. The scars do not fade until about 6 months and will always remain visible. Hydrocortisone cream does a good job of limiting the redness. The good news is that the scar can easily be hidden by underwear or a bikini; patients rarely complain about it. The tradeoff is more than worth it. Another big advantage with skin excision is that the stretch marks located below the belly button will be gone forever! The better quality skin located above the belly button is brought down in its place. Keep in mind, it takes 1-2 years for an abdominoplasty scar to soften and lighten. Joseph T Cruise, MD uses a topical combination of Silicone, Vitamin E, and Steroid to minimize scarring.

• • Abdominal Muscle Tightening

Often, with age, weight gain, or pregnancy the stomach muscles separate in the midline causing a diastasis. This leads to additional bulging. Therefore, muscle tightening is very helpful in obtaining a desirable, flat stomach. The stomach muscles are tightened during the procedure by suturing them together in the midline.

• • Belly Button Transposition

It is usually necessary to transplant the belly button because of the large amount of skin that is removed. Failure to transplant would lead to an unnaturally low location that would look strange. Plastic surgeons create different types of belly buttons. You should be sure to discuss with Joseph T Cruise, MD your preference. Do you prefer a small vs. moderately sized bellybutton? Would you prefer a round one or one that is slightly longer vertically than horizontally? In some patients, it is possible to create a “hooded” appearance which some people find attractive.

• • Liposuction

Performing liposuction on the abdomen at the same time as the abdominoplasty can be dangerous. Many plastic surgeons will not perform them together as it may jeopardize the blood supply to the skin. In some patients limited liposuction is possible. These are generally patients with good skin quality and who do not smoke cigarettes. If you have a significant amount of extra skin then liposuction may be too dangerous to perform concomitantly and would have to be done as a second procedure. Liposuction of the flanks is possible at the same time if a patient needs it.

Extended Abdominoplasty, AKA Extended Tummy Tuck

When the redundant skin goes around toward the back, then there is no other way to remove it but to extend the excision to include this area. This can be identified by grasping the skin over the lateral waist and around to the flanks. Extending the excision to include this skin and fat does a spectacular job of creating an “hour-glass' figure. In doing so, the waist becomes much smaller. This makes the buttocks appear much more attractive and curvy. Furthermore, the breasts appear larger. The reason for this is that the waist is the focal point of the body around which everything else is evaluated. A smaller waist significantly impacts both the breasts and buttocks.

The downside of the extended abdominoplasty is the additional operating time necessary, the additional cost, and of course the longer scar.

Circumferential Abdominoplasty, AKA Body Lift

As its name implies, this goes completely around the body. This procedure is commonly performed in patients who have lost massive (greater than 100 lbs) amounts of weight. This is not uncommon with patients who had gastric bypass surgery and are left with a significant amount of hanging skin that goes completely around the body. Another name for this procedure is a body lift. This is useful to lift the buttocks and thigh skin back up into an attractive position. This is usually performed in two settings.

Specific Breast Issues

During your consultation, you must be very accurate with breast problems. Of particular concern is a history of breast masses and/or breast cancer. If you are over the age of 40 Joseph T Cruise, MD will require that you have a mammogram. Bring the results with you to your consultation so it can be documented. If you haven't had a mammogram yet, you will be sent to a lab pre-operatively. If you, or a family member, have a history of breast cancer then this age may be moved up to 35 or even 30. Breast augmentation has no effect on breast cancer. The only potential problem is mammogram screening. Mammograms are harder to read when there is an implant. This problem is minimized by taking special mammogram views called Eckland views. Eckland views show the breast tissue in multiple planes to see around the implant. It works very well but there still is a small (less than 10 percent) amount of breast tissue that remains unseen. Mammograms work better when the implant is placed under the muscle. This allows better visualization.

Physical Exam

Typically, your exam will begin with your height, weight, and bra size. You should be as accurate as possible. If you have been pregnant or have had a significant weight change be sure to let Joseph T Cruise, MD know. Tell him what you would like to be after surgery. For example, I am a 34 A and would like to be a 34 full C. While cup sizes are highly variable depending on manufacturer, this still gives Joseph T Cruise, MD an idea of what you are looking for.

Once again, a picture of someone with breasts that you like is helpful. Be sure that this person has a similar body type as yours. Point out what you like about the picture, i.e. I like her size, I like her cleavage, I like her fullness up high, or her natural appearance, etc.

• Observation

The second part of the exam involves evaluating the breasts for size, shape, and symmetry. It should be pointed out that all breasts are asymmetrical. Some are extremely asymmetrical while others have only minimal differences. These asymmetries will persist postoperatively.

Common causes of asymmetry include size differences, sagginess, nipple location, areola size and shape, scoliosis, chest wall asymmetries.

• Palpation for masses

Typically, your plastic surgeon will perform a quick breast exam. Monthly, self-exams are extremely important and are the best way to catch early cancers that are easily treatable.

• Measurements

Joseph T Cruise, MD will take measurements. This helps to objectively determine what would best obtain your goal. Measurements will determine which breast procedure is best suited for you, which implant size and style. 

Here are the most important breast measurements: 

Distance from sternal notch to nipple - this distance determines sagginess of the nipple. Normal distances are less than 21-22 cm. Over 22 cm usually means there is some component of sag. Minor sag can be corrected with augmentation but usually needs some type of breast lift in conjunction. See the section on Breast Lift for more information.

Distance from nipple to inframammary fold (IMF) - this distance determines if there is a bottoming-out of the breast. It increases as the breast tissue falls downward. Typical lengths are less than 8 cm in the ideal breast but may be more in large breasts and still be acceptable.

Relationship of the nipple to IMF - this is, perhaps, the most important measurement. It determines whether the nipple is on top of the breast or has fallen. The ideal breast has a conical shape with the nipple on the top. The nipple should be at least 1 cm above the IMF. When the nipple falls below the IMF it should be lifted. Nipples that are at the same level as the IMF may, or may not be, corrected by augmentation alone. This must be determined by your plastic surgeon.

The width of the breast - this measurement is important in determining the maximum size of an implant that will fit on the chest wall. This measurement can be anywhere from 11 cm to over 16 cm. If someone has a thin chest but desires a large augmentation she may need to use a high profile implant to accomplish this.

The gap between breasts - this is the distance between the breasts. Most people relate it to cleavage but cleavage also is dependent on breast size as well. Typical separation is about 3 cm. This distance can be made smaller by elevating the pectoralis major muscle along its medial border. Point this out to your plastic surgeon if this is important to you.

Areola size - the areola is the colored area around the nipple. It often enlarges after pregnancy as well as changes shape. Ideal areola size is subjective. Areola reduction is often done at the same time as breast lifting, but not routinely, with breast augmentation. Reduction requires a scar that goes all the way around the margin of the areola.