Sydney

Post Pregnancy Surgery

Six months after your last baby is the usual minimum. By then your weight, your breast volume and the tissues of the abdomen have had time to settle, and a settled body gives a more predictable result. Plenty of women are better off waiting longer than that, especially if breastfeeding has not finished or your weight is still moving.

Six months is a floor, not a target. A lot of women are still changing shape at nine months, or at twelve, and tissue that has not settled makes it much harder to judge how much skin should come away, or where the breasts will end up sitting. Timing has a practical side too. Four weeks off work and six weeks of no lifting is not easy to arrange with a baby in the house. There is no upper limit at the other end. Some women book in a year after their youngest, and others come in a decade later.

The usual advice is to finish having children, and to finish breastfeeding, before you book anything. Another pregnancy can stretch a repaired abdominal wall and reshape the breasts a second time, undoing part of what the surgery achieved. Breastfeeding should be well behind you too, because breast tissue takes time to settle once feeding stops.

None of that is a rule. Falling pregnant after an abdominoplasty is possible and poses no danger to the pregnancy, though it can alter the surgical result, and some women then ask about revision surgery. If you are genuinely unsure whether your family is complete, say so at your consultation. There is no right answer to give. Breast surgery can also affect your ability to breastfeed later on, and that is worth working through in detail while more children are still a possibility.

An abdominoplasty with some form of breast surgery is the common pairing. On the breast side that might be a lift, an augmentation with implants, a reduction, or a lift and implants together. Liposuction is added in some cases. Which version suits you comes back to what actually bothers you: loose skin, lost volume, the position of the breast, or the muscle separation.

Briefly, what each one does. An abdominoplasty takes away excess skin and fat and can repair separated abdominal muscles. A lift raises the breast and the nipple without adding any volume. An augmentation adds volume using implants. A reduction removes tissue where the size of the breast is causing symptoms. Put two of these into the same anaesthetic and they are still two operations carrying two sets of risks; the combination does not shrink into something smaller. Ask for each part to be explained on its own, including what it will not do for you.

Both approaches are defensible, and the trade-off is a real one. Doing everything at once means one anaesthetic, one admission and one recovery to get through. It also lifts the complication rate. In a study of more than 25,000 abdominoplasties, major complications occurred in 3.1 per cent of operations performed alone, and in 4.3 per cent where a breast procedure was added.

That paper appeared in Plastic and Reconstructive Surgery in 2015. It put the overall major complication rate for abdominoplasty at 4 per cent, against 1.4 per cent for other aesthetic procedures, with haematoma, infection and venous thromboembolism the problems seen most often. Stack more procedures on and the figure climbs: abdominoplasty combined with liposuction and a further body contouring procedure reached 10.4 per cent, and having multiple procedures was itself an independent risk factor. Numbers like these are pooled from thousands of patients and cannot predict your own outcome. Your health, your weight and the likely length of the combined operation all feed into the decision, so ask for both pathways to be explained and costed before you choose.

The reported risks include bleeding and haematoma, infection, blood clots (deep vein thrombosis and pulmonary embolism among them), wound breakdown, fluid collections, scarring, altered skin sensation, asymmetry or a result you are not happy with, complications of anaesthesia, and the possibility of needing further surgery.

Blood clots are worth singling out. Abdominal surgery under a long anaesthetic raises that risk, and in the study above venous thromboembolism made up roughly a fifth of all major complications. The published risk factors are age 55 or over, a body mass index of 30 or above, smoking, and having several procedures at once. If implants form part of your surgery, the risks specific to implants apply on top. Numbness across the lower abdomen is common in the early weeks and does not always go away. Chest pain, breathlessness, or pain or swelling in a calf after surgery are all reasons to seek medical help straight away. Do not sit on them until your next appointment.

Plan for about four weeks away from work. Driving is off the table for the first fortnight, and heavy lifting and strenuous exercise for six weeks. You wear a compression garment over the abdomen and a surgical bra while everything heals. Three to five days in hospital is typical, which allows you to be monitored closely early on.

Drains are used in some cases to clear excess fluid. Short walks and deep breathing exercises start early, since both cut the risk of clots and chest complications. Organise someone to drive you home and to stay and help once you are there. Prescriptions and loose clothing are far easier to sort out before surgery than in the days afterwards. How long recovery takes depends on which procedures were combined and on how you heal, so ask for timelines built around your operation instead of working from general figures.

Sort this out before surgery, not afterwards. Six weeks of lifting restrictions means six weeks of not picking up a toddler, and not lifting a child into a car seat or a cot. Line up help ahead of time, above all for the first two weeks, when you cannot drive either.

Some things that do help. Teach a toddler to climb onto a lowered couch or bed rather than being lifted. Have a second adult around for school runs and bath time. Cook and freeze meals before the surgery. Women tend to underestimate this part, and a lot of them say it was the hardest thing about the whole recovery. If you cannot line up reliable help for those first weeks, it is better to push the surgery back than to struggle on and put your wound healing at risk.

Yes, and they are permanent. An abdominoplasty leaves a long horizontal scar across the lower abdomen, usually with a second scar around the navel. Breast surgery brings scars of its own, in a pattern set by the operation you have. Where your anatomy allows it, incisions are placed so that clothing covers them.

The abdominal scar usually runs hip to hip, sitting low enough that underwear covers it in most cases. Lift and reduction scars circle the areola and run vertically down from it, sometimes with a horizontal line along the breast crease as well. Scars look their worst in the first few weeks. They then flatten and fade over the following months, and most keep changing for something like 12 to 18 months. Ask to see the planned incisions drawn on before the day, because the total length across a combined procedure catches some patients off guard.

Sometimes, and only in part. Anything done for cosmetic reasons attracts no rebate. If your abdominal muscle separation meets the criteria set out in MBS item 30175, that portion of the surgery may be rebatable, and a breast reduction can qualify separately under its own item where the criteria for it are met.

Item 30175 covers radical abdominoplasty with repair of rectus diastasis after pregnancy, and its criteria are tightly drawn: a diastasis measuring at least 3 cm on diagnostic imaging taken before the service, moderate pain or discomfort at the site during functional use and/or lower back pain or urinary symptoms, and a failure to respond to non-surgical treatment, physiotherapy included. A lift or an augmentation done for appearance draws no rebate at all. Ask which item numbers, if any, are being claimed for your surgery, then take those numbers to your health fund and confirm your cover before you book.

If your surgery is being done for cosmetic reasons, the Medical Board of Australia’s cosmetic surgery guidelines apply to it. Those guidelines include a cooling-off period of at least seven days after informed consent, before surgery can be booked or any deposit paid. Either way, you need a GP referral to see A/Prof Bish Soliman.

The same guidelines call for a referral from an independent medical practitioner, at least two pre-operative consultations with one of them held in person with the surgeon who will operate, and screening for psychological conditions using a validated tool. Where part of the operation is medically justified, diastasis repair that meets the Medicare criteria for instance, the position for that component is different. Given how much a combined procedure involves, taking considerably longer than the seven day minimum, and asking for another consultation, is a perfectly reasonable thing to do. Check which pathway applies to you at your first appointment.

Swelling and bruising have to settle before there is much to see. For most patients the result starts to show itself around the three month mark, and the last of the settling takes longer still. What you end up with is long lasting without being permanent, because weight change, another pregnancy and simple ageing all keep working on the body.

Skin and fat that have been removed will not return, and a muscle repair holds unless something stretches it again. The two things most likely to visibly change your outcome are significant weight gain and a further pregnancy. Do not judge the result at six weeks. Swelling is still present at that stage, and the abdomen tends to feel tight and look fuller than it eventually will. Results differ from patient to patient, and no particular shape or size can be promised to anyone.