Dr. Houssock (00:04):
You are listening to another episode of Perfectly Imperfect. Hello, Valerie.

Val (00:10):
Hello, Dr. Houssock.

Dr. Houssock (00:11):
All right, well, here's part two because you and I, you know too much to say.

Val (00:18):
This is one of my favorite of topics to talk about, so I need part time part two.

Dr. Houssock (00:26):
Alright, so we had kind of dived into mothers and mommy makeovers on our last episode of Perfectly Imperfect. And so today we're going to dive a little bit farther into the idiosyncrasies of it all. So we kind of talked about the emotional side, all that. Alright, now we're here. We're at the surgical side. And one of the things that grinds my gears the most is the amount of pressure and unreasonable expectation there is for women to bounce back when it comes to the changes that happens to the abdomen. So we know the words because I think social media has made it fancy enough. So we talk about our diastasis recti or diastasis recti, I think it's diastasis, you'll hear everybody say it the way they want, whatever, potato, potato. But anyway, that is a just reality for pretty much anyone who undergoes pregnancy. Everything in our body, so our hormones release and we kind of alter to naturally accept the growth of a human into our abdomen.

(01:41):
And all of our joints are stretchy, our hips get stretchy, everything kind of maneuvers its way to leaving room for the growing human, but also, hey, we need to still stay alive and our organs need to still have space. And so our body naturally creates space.

Val (02:02):
We're like Gumby.

Dr. Houssock (02:03):
Yes. Oh my gosh. So true. And it can get a little crazy because it happens everywhere, even in your back. And so it's a good and bad thing because some women go through some issues with that. But that being said, generally speaking, it's for good reason. But here's the thing, when we finally deliver our children, yes, there are things that kind of shrink back and do their thing and they were stretched and they come back and we start to feel more of ourselves again. We get stiff again.

Val (02:34):
God do we.

Dr. Houssock (02:35):
In our joints, but there are parts of our body that don't. And so one of those areas is the abdominal wall. So the abdominal wall is highly complex. There are many layers to the abdominal wall. There's the skin you see, underneath that skin is two layers of subcutaneous fat. In between those layers is a very superficial fascia, something strong that keeps the skin strong. Underneath that second layer of fat is where your muscles lie. And so you have your muscles and in between your two rectus muscles is something called the linea alba, and that is the fascia or strong kind of material that is splitting the two six pack muscles, the rectus abdominis, that sit in between. And then underneath those, once you dive underneath the muscle and the fascia, then you're looking at a couple other layers of muscle coming laterally. And then finally to something called the preperitoneal fat.

(03:33):
It's fat that hugs and is very cozy around our organs. And then underneath that is what's called the peritoneum, which is a very fine layer. And then there's your organs, that's where your intestines are, your liver, all the things that matter. And so all of those things need to be protected. But while your uterus grows, the muscles which are super strong, and that fascia which is super strong, has got to stretch to allow the space for that beautiful human you're making. So then they come back together and you end up with two muscles and the fascia in the middle just isn't that great at bouncing back. It just isn't. It's like you picture, how does it feel? Kind of like a canvas leather strap canvas, leather strap.

Val (04:18):
Ooh, that's a good way to describe it. Yep.

Dr. Houssock (04:20):
 It doesn't have pull, like if you pull on it, it doesn't have elasticity. And so it's not the kind of thing that if you pull it, it just comes back. If it pulls, it's kind of being tore and then it's going to just kind of stay there. So because of that concept, it doesn't just snap back. And so when we talk to patients about how they've been told that they can do all of this physical therapy to improve their diastasis, it's a misnomer. It's not really true. You can't make that stretched canvas heal, but you can certainly strengthen the core, whether it's your rectus abdominis or the muscles, there's several layers of muscles that come around the abdomen in your core, you can certainly strengthen them to support you, but it will not repair the center linea alba and where things stretch.

Val (05:17):
So are you saying, I can't fix my diastasis recti with exercise?

Dr. Houssock (05:21):
I am saying that I saying that, I am saying that ifs, if it's extreme enough and there are levels of extreme that you may require for ultimate function support and improvement of discomfort and also aesthetics, you may have to have a surgical repair.

(05:42):
And in that surgical repair, we are taking the fascia in between the two rectus muscles and we are suturing it together to bring them back.

Val (05:50):
Sounds like a corset.

Dr. Houssock (05:50):
Internal Spanx baby, internal Spanx. You got it. So anyway, this is like an absolute pet peeve of mine. Yes, you can do your part and you should, you absolutely need to think about strengthening the core to the best of your ability, strengthening those muscles because no repair will do that. I can't provide you with additional strength. I can only put the muscles back where they should be. And then it is your responsibility to take it from there and tighten and strengthen the muscle. That makes sense.

Val (06:25):
Would you say if a patient got their core strength up before surgery would make their recovery a little bit easier?

Dr. Houssock (06:34):
I don't know if it would make your recovery easier, but it would definitely make your functional life easier. You're going to have less back pain, you're going to have more support when you're lifting your child. You aesthetically are going to have a tighter tummy. So even though I can tighten you with bringing the muscles back together, you'll see with a patient who has severe, severe diastasis, they can look like they are severely overweight. And when you tighten up just the diastasis, it flattens everything out. Because quite frankly before that time, your organs are almost protruding out of the abdominal wall. That's what you're seeing. And when you tighten it up and bring that Spanx like behavior to the fascia, it flattens you right out. So aesthetically, if it's stronger, it's going to be even flatter, I would say. But I will have patients who will still, even with a diastasis repair, will return and say, my stomach is still rounded, there's still a little bit of roundness. Why am I not perfectly flat? And I'll say, when is the last time you did a crunch? And they'll say, what's a crunch? So yes, you have to play your part too, right? I mean that's true, but I think the opposite is the most important to understand is that you cannot work out in the gym and do a million, trillion, trillion crunches and do a ton of core and then just think it's going to make your diastasis heal. That's impossible. So did I hit that home well enough?

Val (08:01):
Yes, you did. Definitely.

Dr. Houssock (08:02):
Do you get my point? Do you get my point?

Val (08:04):
I get what you're putting down. So with the patients that have had C-sections or they have a current hernia on their exam, do you suggest that they have that repaired before moving forward with an adominoplasty?

Dr. Houssock (08:16):
Oh, so C-section scars, very common. Obviously a lot of women have had C-sections. It doesn't bother me at all if you've had one. I just usually when we are talking about the tummy tuck, we make our incision just below it typically, or if this doesn't happen often, but if a c-section scar is higher, I just go where my incision I want it to go. And usually it's just a couple of centimeters above the vagina. We make a really low incision, so I'll just remove the C-section scar with the tummy tuck. That's easy.

Val (08:46):
That's awesome.

Dr. Houssock (08:46):
Get rid of it completely. Yep.

Val (08:48):
Amazing.

Dr. Houssock (08:48):
Gone. Totally gone. And so is the shelf, if you have one. A lot of people will have an adherence, this is another good kind of thing too. Why do patients get C-section shelves where their scar adheres to the abdominal wall and then they get the skin hanging over it?

(09:04):
Why don't people get that from tummy tucks? And the answer is because we don't go through all the walls of the abdomen. There's a lot of scar tissue that's gets created with a C-section. You're cutting through all those layers. I just went through that sciencey thing I started the podcast with. All those layers, when you are having a C-section, the doctor or the surgeon, the OB is cutting through all of those layers to get to your baby. And so when they scar down, they really scar down together and they create that tight shelf where the skin then kind of hangs over. When we do a tummy tuck, I'm only cutting through your skin and subcutaneous tissue. So it has the mobility to flatten out and straighten out and it doesn't adhere to the abdominal wall the same way.

Val (09:44):
So it blends better.

Dr. Houssock (09:45):
Definitely blends, definitely more aesthetic will have patients who just, and I'm one of 'em actually who just have their c-section scar revised because I had a little mini shelf that adhered, and so the surgeon just got rid of that and I'm totally flat now.

(10:02):
So that's always an option. If you don't have a lot of extra skin, you might just need the C-section scar revised. But anyway, so that's a c-section scar. And then hernias are a totally different animal. When you think about that diastasis, you see how you have a thinness to that wall. You'll see how it's almost like that canvas area, that fascia area has thinned out. You definitely are at higher risk for hernias and the hernia means a literal hole. So a diastasis is a thinning, a hernia is a hole. And now underneath that fascia, the pre peritoneal fat can come through, intestines can come through, God forbid, organs can come through. And so that hole becomes a problem. And it can be very painful. So depending on where the hernia is, we can oftentimes repair them at the same time as a tummy tuck. Now that depends.

(10:57):
Everything is a depends, sorry, it's medicine. There's never a

Val (11:03):
Depends, dot, dot, dot.

Dr. Houssock (11:05):
Yeah, I mean every patient's different. So I will find patients who have incidental findings, meaning that I didn't know they had one and along their abdominal wall in that diastasis, I'll find a little hernia and that's easy, I'll just repair that. And that happens a couple of times a year, I would say it's not super common, but it can happen.

Val (11:24):
Yeah, I agree.

Dr. Houssock (11:24):
A lot of people have hernias in their belly button and when you have a hernia in your belly button, it does complicate a tummy tuck a little bit because when we cut around the belly button, we cut around the blood supply of the belly button and now all it's being held onto is with a little stalk of blood supply. And if you have to cut that open to repair the umbilical hernia underneath it, it could really compromise the tummy tuck. So I do not like repairing umbilical hernias with tummy tucks. If it's significant enough, I usually suggest they have it repaired laparoscopically by a general surgeon first and then we will proceed with our tummy tuck and that will maximize the result. It will minimize the risk of losing the belly button intraoperatively and it definitively repairs your hernia.

(12:15):
So it depends and I'm standing to it. So if you have one, we absolutely are happy to see you and then we can talk you through where you are in that spectrum and whether or not we can repair it with the tummy tuck and why or why not makes, I might suggest one or the other.

Val (12:29):
Before a patient goes through with having a mommy makeover, do you suggest that they're done having kids?

Dr. Houssock (12:34):
I mean, here's the thing, right?

Val (12:35):
Yeah.

Dr. Houssock (12:39):
You don't want to do this again, right? Financially and physically it's a lot of investment. So I do highly encourage that patients have their children first. However, I have seen a lot of patients over the years that are very young in their early twenties who have no plans for children anytime soon. They may have children in the future, but know anytime soon and they will have a tummy tuck after massive weight loss, significant amazing weight loss. And in my mind I absolutely support that plan because I would rather a young person really be able to embrace their youth and enjoy their body.

Val (13:26):
Absolutely.

Dr. Houssock (13:27):
And feel good about themselves especially yes, especially after doing such an amazing thing as losing that kind of weight, that I think it's worth it for that patient population to go ahead and remove the skin, and understand that we may be back together in 10, 15, 20 years after pregnancy and you may have additional skin that needs to be taken care of. So that's the one population where I think it makes sense. But if you're in the prime of your life, you just had a kid, you're not sure if you're going to have another one, I say make sure before you go ahead and get a tummy tuck. I've only had one patient who went out and got pregnant then that following, she looked so good, I mean, that's the problem.

Val (14:10):
That's so true.

Dr. Houssock (14:12):
She went ahead and got pregnant again.

Val (14:15):
Well, we're here when you're ready.

Dr. Houssock (14:18):
So yeah, it happens. I mean it doesn't happen often, but yeah, it's smart just for that reason.

Val (14:24):
That makes sense.

Dr. Houssock (14:25):
It's not going to be necessarily dangerous or anything for you to go through a pregnancy after it, it's just you're kind of starting from ground zero again.

Val (14:34):
We talked about tummy tucks being part of mommy makeovers. What else can you do at the same time of the mommy makeover?

Dr. Houssock (14:39):
Yeah, so obviously we talked about the breasts last time being a really big part of the whole thing. And when it comes to, especially being early in your motherhood, you may still be breastfeeding and so we have to figure that all out. But generally speaking, you may or may not want something done to your breasts at the time of your tummy tuck. So definitely it's very common for Val and I to do surgeries that are combined breast and body. It just makes sense because it doesn't add recovery time, it is a kind of one hit one and done. And so a lot of women, yeah, they'll opt for that. They'll opt for just doing it all at once and that will depend on what they want. Do they need a lift? Do they need a reduction? Do they need an augmentation? They all could be part of a mommy makeover. It just depends on you and what happened during pregnancy and really what you want now. Some patients, I find this one to be the funniest of all, it's like patients will come in and they'll do their tummy and then they sometimes will feel like they need to justify to me that they don't want to do their boobs. And just so you know, I know they're blank, but I don't want to, and I'm like, I don't care. They're great. Whatever, you don't need,

Val (15:40):
If you're happy and comfortable, then that's all that matters.

Dr. Houssock (15:43):
Yeah, there's no one size fits all. If you are happy with your breasts, no matter what, they are too big, too small, too droopy, who cares? None of this stuff has to be done. I would argue the only part of this that has a significant functional advantage is someone who has a significant diastasis.

Val (16:02):
Absolutely.

Dr. Houssock (16:03):
In those instances, I think it is worth considering. But that spectrum is so wide that, no, just because you have a diastasis does not mean you have to have an operation. Does it affect you? Do you not like it aesthetically? And does it create functional problems, then yes. But none of the stuff that Val and I do are absolutes. You can live without surgery. I know, listen, we're amazing and you love us. We get it. But you can live without us.

Val (16:33):
We always say what we do is life giving.

Dr. Houssock (16:35):
Yeah, definitely life giving.

Val (16:37):
For sure.

Dr. Houssock (16:37):
But you'll be okay. You'll be okay without us, promise.

Val (16:40):
Absolutely. If a patient is planning on doing their breasts at the same time as their abdomen and they're breastfeeding, how long should they stop before moving forward surgery?

Dr. Houssock (16:49):
This goes back and forth. I would say it's somewhere between three and six months. And the reason for that is just the timetable of when you will start to dry up, generally speaking. So you want to not be still producing significant amount of milk and you can have a tummy tuck. You certainly can have tummy tuck or liposuction when you're still breastfeeding because I'm not touching your breasts. We do sometimes suggest that if you're still breastfeeding, you may hold on pump and dump. So you might just because of anesthesia, you might hold off on feeding your baby the milk of the day of surgery or something like that. But you can absolutely have a tummy tuck or liposuction while you're still breastfeeding. But you're going to need to wait three to six months after stopping to be safe for something for your breasts. And again, those are, just to go back to that, we did talk about that a little bit for, we want to make sure there's not milk production, so you don't develop a pocket of milk or galactoele around an implant or in your lift, but also so we know what the final end kind of where's your breast going to end up? You know, the boobs change so much. We don't know what they're going to do.

Val (17:54):
They do. I was just going to say they change quite a bit when you're pumping and breastfeeding. I think that's very smart to be done for sure. During the time of mommy makeover, is vaginal rejuvenation an option? I feel like that's something that is not talked about a lot because I don't know if people feel ashamed of it or embarrassed of it, but I feel like that's something that we really need to cover and just help everyone realize that you're not alone. We have options for this.

Dr. Houssock (18:26):
It looks different for everybody.

Val (18:27):
It does it.

Dr. Houssock (18:29):
We have some women who have very little change to the aesthetic appearance of the vagina, but they may have some internal changes or we might have vice versa where they haven't had really any internal issues, but they aesthetically might have excess tissue or skin or whatnot. And so a hundred percent we're going to do an entire different podcast on just kind of women's wellness. But yes, you can, if it is a concern of yours, you definitely can add that into a mommy makeover. A mommy makeover is whatever you need or want. And even further than that, you may want something that has nothing to do with the fact that you were pregnant. You may want us to do something facial while you're getting the tummy done or get a laser done. And so yes, you can have a lot of different things to combine. And so yeah, and will talk about the women's wellness side of it because there are nonsurgical options that are out there for us too, because I don't know a woman who has gone through pregnancy and doesn't have an issue with sneezing and peeing.

Val (19:35):
Ain't that the truth? Holy Moly.

Dr. Houssock (19:38):
Now, very interestingly though, and I would tell you this makes sense as the core gets stronger and as you are repaired to have that support in the core, patients will describe some improvement in their urinary symptoms. And so that's just one of the many other reasons why repairing your diastasis might be beneficial to you.

Val (20:00):
Sounds like the core is everything.

Dr. Houssock (20:01):
Dude, it is everything. I've had women who are extremely fit, they've done all of the right things, they've done a ton of core, and then we repair their diastasis and they have this unbelievable improvement in back pain they never knew they had. Meaning, all of a sudden they're like, wow, my back feels just totally different than it did before. And it's all based on having that core, that core is back where it's supposed to be. So instead of laying outward out here, it's now back up to the front. It's supporting the back and then you've got your back here and your abdomen here and everything's working together. So I can't say enough about the repair of the diastasis. And while I don't take it lightly that it's a big operation, it really is probably the most functional thing besides labiaplasty that we perform.

Val (20:51):
One of my favorite things about our patients during follow-ups is the progression of week by week, seeing them stand up straighter. Cuz they always have the tummy tuck lean the first week just because things are so tight. And then week two, they come in for their second drain removal and they're sitting a little bit more up. I'm like, look at that.

Dr. Houssock (21:11):
So cool. Yeah.

Val (21:12):
It's amazing. So I agree with you. That's definitely one of the biggest changes and most rewarding things with the tummy tuck is repairing that separation.

Dr. Houssock (21:23):
Yeah, I mean, listen, we're not going to deny that there's an aesthetic component to this. It's what we do. But there is such a functional improvement in that particular part of your tummy tuck. And before we go, just as far as how we do it in our practice, it's not like you have to pay extra for a diastasis repair, it's just part of the tummy tuck. So the way that Danielle and I have decided to do it, and it makes sense for us, is I look at you as that cylinder and whatever you need is what you get for your tummy tuck. So it's all included. If you need liposuction for contouring, you get it. If you need a diastasis repair, you get it. If you need just the tummy tuck alone and you don't need a whole lot of lipo, that's fine, you get it. If I find a hernia intraoperatively, you are not charged extra. It's all included. So when you come in, you don't have to worry about picking what you need and what you want. When we say full adominoplasty, whatever you need in that area is what you get. And that's just how we've always done it because it just takes all the guesswork out.

Val (22:25):
Ain't that the truth?

Dr. Houssock (22:26):
Yes.

Val (22:28):
I don't know what else we got? Anything else? We covered everything. Seriously. We were, so

Dr. Houssock (22:35):
Oh, we talked about this last time, but finally, and just to reiterate, every mother has a feeling of guilt during this recovery time.

Val (22:42):
Yes, yes.

Dr. Houssock (22:43):
So just keeping in mind, if you have young children and when you decide to undergo plastic surgery, the one thing Danielle and I will always say in consultation is make sure that you do this at a time that makes the most sense for your family. And that means when you can have support to help you.

Val (23:00):
Absolutely.

Dr. Houssock (23:03):
And you won't have to worry about your child as much and someone else can help you do that. And that's important. And if that means you have to wait a couple years, then you have to wait a couple years. But we're not going anywhere.

Val (23:11):
No, timing is everything. And stress really can impact your recovery and your head space. And you definitely, and you invest a lot of time and money in this, you want the results to be everything that you want. So I agree with Dr. Houssock, if it's not the right time, we're here. And then we're also happy to do a follow up and review plans if we need your body changes as we get closer to actually doing it. But I agree, definitely wait for the wait time for sure.

Dr. Houssock (23:38):
Yeah. Yeah. And it's not cute to try to be tough and start doing stuff too soon because it'll just lead to complications and bad outcomes. So encouraging you just to think about doing it at the time that makes sense for you and your family, and that will always lead to the absolute optimal results.

Val (23:55):
For sure. Yep. You nailed it. Alright, carry on Dr. Houssock. Have a good day.

Dr. Houssock (23:59):
Love you. See ya.

(24:01):
Perfectly Imperfect is the authentically human podcast navigating the realities of aesthetic medicine. JEV Plastic Surgery is located in Owings Mills, Maryland. To learn more about us, go to JEVplasticsurgery.com or follow us on Instagram @Dr Care Houssock, spelled D-R-C-A-R-E-H-O-U-S-S-O-C-K, or just look in the show notes for links. If you enjoyed this episode, please share it and subscribe to Perfectly Imperfect on YouTube, Apple Podcasts, Spotify, or wherever you like to listen to podcasts.